ASC Specialty to Watch: Urology in 2012

This is part of a series on the five ambulatory surgery center specialties to watch in 2012. The five specialties are gynecology, ophthalmology, orthopedics and spine, pain management and urology. These specialties have a favorable outlook in terms of case volume, revenue and new procedures moving into the ASC setting.

Herb Riemenschneider, MD, staff urologist and founder of the Knightsbridge Surgery Center in Columbus, Ohio, discusses five points on the outlook for urology in ambulatory surgery centers in 2012 and beyond.

1. Demand for urological procedures is increasing. As the population ages, more people will develop urological problems and require treatment, he says. This increase in demand can be beneficial for the specialty.

"I think that the practice of urology has benefits because there are relatively few urologists relative to the population of patients that we treat," he says. "There are demand issues, and if we can address them appropriately, the patients and urologists can benefit. Urology is actually in a good position relative to the other specialties because of this supply and demand."

The American Urological Association currently has about 10,000 members, and that is not enough. Many of those urologists are over 55. The ultimate solution is to train more urologists, but until that can happen, he thinks the stop-gap solution will be physician extenders, such as nurse practitioners and physicians assistants. The controversy will be over which procedures physician extenders should be able to perform, and which procedures should be performed exclusively by urologists. Procedures, such as cystoscopy to determine bladder pathology, prostate exams and biopsies, should be done by a urologist, Dr. Riemenschneider says.

"I think the person that does these should be the person who uses the results," he says. "I can't see an extender taking those cases to their completion."

According to VMG research comparing same center benchmarks from 2009-2010, urology case volume increased 6.8 percent from 2009-2010. The only other specialty to have a higher increase in volume was plastic surgery with 9.4 percent. The net revenue for urology cases also increased 3.4 percent for the same period, an average increase of $63 per case.

2. New procedures are moving into the ASC setting.
Dr. Riemenschneider sees several procedures moving into the ASC setting over the next few years. Although there has been resistance from the hospital lobby, the safety and efficiency of the ASC as a delivery system will demand this change, he says. One such procedure is female pelvic floor surgery.

"Every time a woman has two or more children, she will likely develop pelvic floor weakness," he says. "This leads to problems such as bladder leakage and reproductive organs not being supported as they were earlier in life. Pelvic floor support can be significantly enhanced with surgery that is well suited to the ASC. The current mesh controversy alters the availability of some of the methods that makes this level of surgery quite appropriate for the ambulatory environment."

Minimally invasive treatment for prostate cancer such as focal cryoablation for carefully selected cases not only addresses the problem of overtreatment for many men with the diagnosis of prostate cancer but is a good fit for the ASC delivery environment, Dr. Riemenschneider says. Other procedures such as lithotripsy are growing and are very effective for management of urinary tract stone disease and the number stone cases treated with other techniques will continue to grow.

Treatment for male sexual problems, such as surgery to correct curvature of the penis, prosthetic implantation for treatment of erectile dysfunction, sling implantation for male urinary leakage and placement of an artificial sphincter for more severe cases of leakage, are all ideal cases for the ambulatory surgery center. Dr. Riemenschneider thinks the volume and efficiency of these types of urology cases will grow significantly over the next few years for the simple reason they are done safely with time efficiency and clearly cost significantly less in the ASC than any other delivery system.

3. Lithotripsy can be profitable for an ASC. The reimbursement rate for lithotripsy, the procedure to treat kidney stones, has remained stable and is expected to continue that way, Dr. Riemenschneider says. Because the equipment can be rented for the day or on a per-case basis, the capital expense is lower than other procedures. He also notes that lithotripsy ownership by physicians is a Stark exemption, so physicians who refer and perform cases can have ownership in the lithotripsy company.

Dr. Riemenschneider says centers should encourage physicians who perform lithotripsies in the center to do other procedures as well.

4. Hospital employment threatens the ASC. Dr. Riemenschneider thinks the biggest risk to urology in ASCs right now is the employment of urologists by hospitals. He thinks hospital employment looks good to young urologists now, but as time passes, they will become bored with the hospital employment and direction. Because they will be locked into long-term contracts with hospitals, eventually this will lead to significant unrest in this group of physicians.

He sees this as a trend over the next decade and thinks urologists will move again toward independent practice. The ASC industry should take an active role in marketing itself to young urologists and encourage them to join independent practice and the ASC setting.

"The private sector of urology should be much more vocal about private sector urology simply because that’s where the innovation comes from," he says.

Dr. Riemenschneider thinks one way ASCs can be more vocal is though a targeted marketing strategy.

"Marketing is very important to every business large or small," he says. "In medicine and urology, education about our rapidly expanding field of treatment options and the sophisticated diagnostic techniques are not understood by our patients. Potential patients are a great business opportunity. Education about these aspects in an honest and insightful manner that focuses on quality, cost containment and an efficient delivery system is a win-win situation for all concerned."

5. Reimbursements are being squeezed. Like other specialties, urology faces an uncertain reimbursement future.

"It's going to be tough for a while," Dr. Riemenschneider says. "Profit margins are going to be squeezed. It's going to be about understanding the cost of what you do. The people who can deal with that for now will keep their head above water in this unfortunately murky area until a change of leadership stimulates economic growth and eliminates the overhang of ever changing regulation the field of healthcare. The opportunity of 2012 is before us. We must be active, bold and support change that will lead to economic growth and realistic healthcare reform that embodies the physician as an integral part of that change."

More Expertise from Dr. Riemenschneider:
Dr. Riemenschneider: Top Urology Issues for ASCs
Presentation on Key Thoughts on ASC Urology From Dr. Herbert Riemenschneider Now Available for Download and Viewing
Dr. Herbert Riemenschneider, Urologist and Surgery Center Owner, Shares His Thoughts on the Healthcare Reform Process

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