Current and Future State of Ancillary Serivces in Urologic Practices

1. Current and Future State of Ancillary Serivces in Urologic Practices • Juan A Reyna MD • President Emeritus-Urology San Antonio

2. Ancillaries Definition • For the future, lets call these integral services • Services which historically were sent out of your office or were out sourced • Services that historically never brought you any income or sometimes created another trip for you patient • Services where the group size and financial position determined if they could be brought back in house

3. History For USA • First came research. Clinical trials that would could fill with our volume of patients. We started this with 4 partners • Second was from our associations in our research division. The sons of Don Gleason (pathologist) who had begun research consortiums. We had previously belonged to a different litho consortium and then decided to get our own and we lease it to a surgery center on our property • Our professional fee remained the same

4. History for USA • Well, you guessed it, the volume we had now reached allowed us to purchase and strip center which just happened to be located in the medical center. We stopped outsourcing revenue to pay the rent and paid it to ourselves • We then all became limited partners in the surgery center. In retrospect, a mistake to not completely own and run this ourselves

5. History for USA • Why, well because we had just purchased a CT scanner for the group and were growing too quickly to handle the administrative load. Ultrasonography was already in house • The ideas for the rest of our integral services grew out of attending meetings in Chicago with other large groups-LUGPA • Advantage of LUGPA was that we could get straight information from other big groups who were not threatened by competition and were going through the same growing pains

6. History for USA • Several groups came together and formed UroPath. This was a pod lab idea which allowed us to do pathology in “our” lab whether it was on site or not. Stark changed this but we lucked out from being one of the sites that had 15 lab sites. Being on your property allowed us to self refer and only lost the profitability of our smaller peripheral clinics

7. History for USA • The next obvious investment was in our own in house clinical lab which is where we send all our PSA’s, CBC’s BMP’s etc • We bought our own cryo unit for treating CaP and leased it to hospitals on a per click arrangement. Admittedly, we have stopped this due to infrequent use • Next was the developed a full blown urodynamics lab with video and bio feedback, PTNS and hired a dynamo of a nurse practitioner =Home Run

8. History for USA • Our last, and without question, the most profitable was the addition of a cancer with a single IMRT vault that grew to two vaults in 18 months • Most recently, a reverse integral idea of out sourcing our billing and collections

9. State of Integral Services • Research-break even at best-solution pending • Lithotripsy-very profitable • Land purchase for clinics-sitting on a huge return • CT scanner/ultrasound- very profitable • Pathology-very profitable despite Pete Stark • Clinical lab- mildly profitable

10. State of Integral Services • Cryo-dead • Urodynamics-very profitable • Cancer center/IMRT-very profitable • At present the sum of our take home revenue is large based on these service. In fact 50% • The split is evenly split based on legal language • Out sourcing billings and collections was a terrible idea. This cost us big. Lesson learned

11. So The Obvious Question • Have your referral patterns changed because of ownership • The answer is yes, no no and no • During the ramp up yes • Our referral pattern has been flat to lessened since purchase of these services • Path-down CT-flat IMRT-flat

12. Future of Integral services • The future of other integral services is constantly under attack • I need not speak to CMS, SGR, potential changes in payment methodology under ACA • But our doctor friends in Radiation Oncology, Radiology and Pathology have lobbied hard against us and continue to do so

13. Radiology and Pathology • The IOAE is constantly being lobbied hard to suggest that self referral is inherently a bad thing and would suggest that cost have risen dramatically because of this • Dr. Jean Mitchell is trying to get an article published that suggest that doing 12 biopsies for the diagnosis is purely for financial reasons • The radiologist lobby would suggest that CT’s are ordered more frequently for the same reason

14. The Battle Wages On • Dr. Mitchell went so far as to pick out 10 groups and suggest that their data showed less positive biopsies than other non pathology owned groups • Unfortunately 7 of those groups are LUGPA members and we have solid data and evidence to prove her dead wrong • She is currently suggesting that her information is based on peer review data vs a lab rag journal

15. Radiation Oncology • Far and away the largest bucks and most heinous efforts have come from ASTRO • LUGPA has been very effective at shutting down these efforts in all three areas protecting the in office exception Stark rule • However, ASTRO is now attacking very briskly at the state level and this very state (Florida) is the perfect example

16. Watch Your Back • Last year, in Florida in a last minute effort largely funded by Century 21st Oncology, language was secretly entered into an otherwise inocuous bill that would have stripped 9 Florida urology groups of their ability to perform IMRT • By a stroke of luck someone happened to notice this as it passed through the house without any exception • When found LUGPA mobilized all its attorney and political clout and was able to defeat this in the senate

17. Watch Your Front • The AACU is being very vigilent about tracking state by state legislation • Make sure your state organizations are being as vigilent • You and your integral services are a tremendous resource to your patient and your community. Do not let “turf” battles dictate what you can offer

18. Thank you • Questions