Integrated Urologic Services: A Community–Academic Partnership
William See, MD, Professor of Urology, Chairman, Department of Urology
Healthcare delivery is changing before our eyes. Healthcare systems are positioning themselves for the future by building vertically integrated delivery systems based upon employed physicians. Beginning with a foundation of primary care physicians, systems are subsequently overlaying specialty services in a manner that provides a continuum of care and maximizes patient and revenue retention. The final piece of the strategic puzzle — geographic distribution — results in the need for a buy-it/build-it approach that further drives provider consolidation around care systems.
The implications of this process for the historic model of community-based specialty care delivery are profound. The independent specialty physicians group is rapidly going the way of the dinosaurs. System employed primary care physicians are “incented” to prevent patient leakage. No longer are the “three A’s: affable, available, able” relevant to patient referral. The supreme “A” is now “aligned.”
As such, specialty groups are under tremendous pressure to join systems as employed specialists lest they lose access to their referral base. The disconcerting part of this process is that patients are kept “in system” regardless of whether the optimal specialty care provider works within that system.
Arguing the merits of market consolidation serves little purpose. The pragmatic question is “can market consolidation be engineered in a way that meets the needs of the patient and the enterprise?” I suggest that health systems incorporating academic medical centers coupled with intra-specialty horizontal integration across geographically distributed sites of service represent the ideal model. In this model, community-based specialty practices are aligned with academic subspecialty practices in a manner that serves the interests of patients and the needs of the health system. Specialty physicians linked to local communities and their system referral base can continue to provide high quality, on-site care. Community-based specialists can take advantage of the expertise of academic specialists for tertiary/ quaternary needs in a manner that serves the best interests of the patient, and does so without disadvantage to the organization.
Through this model, the patient and the community specialist have access to the full range of care delivery sites and expertise. One would anticipate that the majority of care would be delivered by the community specialist at a community site. On those occasions where care can be delivered within the community, but the involvement of a subspecialist benefits the patient, the subspecialist and community specialist can partner for on-site treatment. In instances where technology or resources are limited to the academic medical center, the community specialist and academic subspecialist can partner for patient care at the academic medical center. Ultimately, the community specialist can choose to refer complex patients for whom the provision of care by the academic subspecialist is warranted.
We are in the process of putting this philosophy into action. As of September 2011, in partnership with our Clinical Ventures Group, we have put in place a Community Division of Urology supported by two Medical College urologists Jeffrey Bejma, MD, and John Lacey, MD. These outstanding urologists will provide care to patients in Menomonee Falls and West Bend in affiliation with Froedtert Health Community Memorial and St. Joseph’s hospitals respectively. With Jeff and John functioning as the cornerstone of urologic care at these sites, patients who are referred from them, or who have already seen an outside urologist and desire a subspecialty opinion, will have local access to a urologist with focused expertise in cancer care, voiding dysfunction, female urology and infertility. Patient care may be coordinated between community and subspecialty urology faculty in a way that links physician skills, hospital resources, and patient needs to serve the best interest of the patient.
By providing the right care, at the right location, by the right physician, this model is patient-centric and cost effective. It leverages economies of scale, prevents the need for duplicative services, limits the extent to which financial incentives drive care decisions, and allows for “just-in-time” expansion of provider inventory, while providing the full breadth of expertise within the system. Finally, an acknowledgement of and respect for cultural differences between community and academic components is being integrated into the model in a way that values the importance of different roles.
Our world is changing; how we confront that change is up to us. I would argue that it is our professional imperative to participate in a way that serves the interests of our most important constituency – our patients. Our ongoing efforts to provide seamless urologic care across the community/academic continuum in southeastern Wisconsin are intended to meet this imperative.