Dr. Keating opened a urology practice in Columbus, Ohio in about 1940.  A few years later, Dr. John P. Smith (JP) joined the practice.  This was the beginning of Urological Associates.  The third partner to join was Dr. Mark Saylor.  Mark Joined shortly following WWII.

 

Urological Associates leased office space on the 3rd floor of a building on the near East side of Columbus, Ohio at the corner of Broad and Grant Streets.  This was strategically close to Grant Hospital, White Cross Hospital (closed in 1961), and Children’s Hospital.  Mount Carmel Hospital, on the near West side of Columbus was about 2 miles away.

 

Dr. Keating lived fast and hard, but he didn’t live long.  I never met Dr. Keating, but I have been told that he was a drunk and a womanizer.  He was known to stay up all night gambling and drinking, then take a late train back to Columbus to see his patients.  His death left JP and Mark to run the practice for many years.

 

JP was one of the first pediatric urologists.  At Columbus Children’s Hospital, he performed many life-saving urinary diversions on children with meningomyelocele. He wrote textbook chapters on childhood urologic disease.  He also cared for adults.  He was a nationally recognized urologist.  He was also a demanding personality who sometimes brought surgical nurses to tears.

 

Mark was a general urologist.  Mark was a respected member of the regional section of the American Urology Association.  Mark also managed the business side of Urological Associates.  Mark was my father’s classmate at OSU School of Medicine and my Godfather.  He was a kind and soft-spoken gentleman.

 

At some time prior to my involvement, Urological Associates incorporated to become Urological Associates, Inc.

 

Steve Smith joined Urological Associates in 1978.  Steve graduated from the University of Maryland School of Medicine, and he had fellowship training for pediatric urology in Chicago.  Steve was JP’s son.

 

I joined the practice in 1980.  I was welcomed into the practice, but it was unclear if the practice was generating enough revenue to support an additional urologist.  My starting salary was $36,000 per year.  This was far below prevailing standard compensation for a starting urologist, but I was allowed to share in any bonus that would result from increased practice revenue.  There was no guarantee of eventual partnership, but partnership was a near certainty.  JP and Mark were both over 60 years old, so the practice would eventually belong to Steve and me.  The future and options greatly outweighed the low starting salary.

 

When I started, our only office was the small, leased space on Broad and Grant.  This was inadequate for 4 urologists.  Also, the neighborhood was deteriorating and the building was in dis-repair.  My secretary worked from inside a closet.  Steve used JPs office and I used Mark’s office.  The staff needed to go from our 3rd floor office to the basement to use a copy machine.  One of our nurses was once confronted by a “flasher” in that basement.

 

In 1980, we used 4 different hospitals, but most of our patients were at Mount Carmel Hospital (later to become Mount Carmel Medical Center then Mount Carmel West Hospital).  White Cross Hospital had closed in 1961, and they had moved to become Riverside Methodist Hospital (RMH) located several miles north of our office.  Both Grant and RMH had other good urology groups that practiced exclusively at those hospitals.  Steve and JP took care of almost all the pediatric patients, so I rarely went to Children’s Hospital.  It was common for me to see patients at Mount Carmel, Riverside, and Grant Hospital before coming to the office in the morning.

 

In the early 1980s, Mercy Hospital, a small hospital on the South side of Columbus requested for us to see patients there.  We complied, and I saw patients at that facility almost every day.  Our patient volume at RMH and Grant slowly faded away, while we developed a thriving practice at Mount Carmel and a good practice at Mercy.  Eventually, Mercy Hospital merged with St. Anthony’s Hospital on the East side of Columbus, and years later Mercy closed.  Small community hospitals were becoming obsolete in large cities.

 

Our thriving practice quickly eliminated any concerns about my small beginning salary.  My first-year bonus greatly exceeded my offered salary.  After one year in practice, I became a full partner.  After 2 years, Mark turned over the checkbook and management responsibilities to me.  He was glad to no longer have the responsibility.  I managed these responsibilities during my entire remaining time at Urological Associates and until they merged to become Central Ohio Urology Group.

 

Patient Records

Before 1980, JP and Mark kept minimal records on cardboard sheets.  Patient charges were unrelated to records, so there was no external standard or requirement.  An office visit was often documented with only a few words or a single line.  The charge for an appointment was usually $20.  A cystoscopy in the office cost $35. There was no formal problem list or list of prescriptions.  Ruth, JPs nurse/secretary, typed up letters to referring physicians without specific physician input and based on her perception.

 

When I began, I instituted a practice of placing records in a folder that included the problem list and list of medications.  I began using the SOAP method (subjective, objective, assessment, plan) for documenting visits.  Eventually, we used small Dictaphones to dictate letters to referring physicians. 

 

Medicare decided to control the amount of payment for office appointments.  They developed a CPT system of requiring specified documentation corresponding to levels of office visit.  This required us to use a dysfunctional format to chart patient visits (rather than the more functional SOAP system).  Urological Associated resisted the transition to electronic medical records until they merged with other groups to form the Central Ohio Urology Group in about 2005.

 

In about 1990, we took about 35,000 old patient charts and moved them into boxes in my barn.  Rarely did I need to retrieve a record from this archive.  All these records were unused for decades.  Eventually, we contracted a shredding service to destroy these old records.  When we transitioned to electronic medical records (EMRs), we scanned over 100,000 patient charts and destroyed the paper copies.

 

 

Innovations

I was an innovator when I joined the practice.  In 1980, computer technology was primitive by current standards.  There was no user software, and the first Apple Computers were a recent development.  I used an Apple 2 personal computer and a 10-megabyte hard disk the size of a shoebox.  I wrote my own >1000 command database program using Applesoft programming language to catalog patients’, birthdates, diagnoses, and treatments.  EMRs for general use were decades in the future.

 

Another early initiative was to create video education films for office patients.  I purchased a tape-cassette recording camera and a screen.  I recorded my own films to instruct patients in such procedures and vasectomy and urethropexy.  I would instruct my staff to show the film to appropriate patients after which I would come into the room to answer any questions.  Very few other physicians were doing this at the time, but it has now become common.

 

Other innovations, discussed later, were electronic urodynamics and office urine culture testing

 

 

Adding partners

Mark retired in about 1985 at the age of 65.  He claimed that his health was poor, but he lived for another 35 years and died at about 100 years old.  I guess that retirement was good for his health.  JP worked until 70 years old.  His wife had died from a heart attack years earlier, and he had little else that he wanted to do.  JP probably should have retired sooner based on his declining capabilities.  His retirement left just Steve and me responsible for too much work for only 2 urologists.  We needed to hire.

 

Dave Stewart was our first addition.  Dave had his urology residency in Cincinnati where I had trained and where he knew me by reputation.  He was a great fit for the office.  Next, we hired Mark Byard from OSU.  This was followed by George Ho from Harvard, Evan Cohn from the University of Chicago, Brad Pewitt from Northwestern, Rashmi Patel from Case Western Reserve in Cleveland, Jeff Carey from Detroit with pelvic floor fellowship in California, and Adam Weiser with pediatric urology fellowship in New York.  Each new partner brought new capabilities that could be shared with the entire group.

 

We had no female physicians.  George was Taiwanese-American, and Rashmi was Indian-American.  We had no LGBTQ physicians.

 

The above partners were added at a rate of about 1 every 3 years.  We had no difficulty in recruiting partners and no difficulty in attracting enough patients to keep everyone busy.  All new hires had the opportunity to become partners with equal compensation and full voting rights after only one year.  Our maximum number was nine before we merged with other groups to become Central Ohio Urology Group.

 

During my years at Urological Associates, 2 partners left the practice.  Because the reasons are personal, I will not provide details except that the remaining partners were pleased that they left voluntarily.

 

 

Offices

The original office on Broad and Grant was never adequate for more than 2 urologists.  Because Mount Carmel Hospital was our primary hospital, we decided to relocate there.  Mount Carmel had constructed a new office building connected to the hospital (POB2), so we decided to lease there.  I had the pleasure of designing our floor plan.  After about 15 years, we had outgrown this space, and there was no room to expand in this building.

 

When we needed to expand, Mount Carmel was in the process of building another medical building on their campus (POB3).  Mount Carmel was not only leasing space, but they were allowing physicians who were leasing to purchase shares in the building.  Urological Associates leased a large area on the top floor with a beautiful view of downtown Columbus.  Again, I designed the floor plan.  Each physician had a large office with a view of the city.  We had a dedicated section for ultrasound, 2 dedicated cystoscopy rooms, a large area for the secretarial staff and records, a nursing office, a staff lounge, 3 banks of 3 exam rooms each, a manager’s office, a library/conference room, and a large reception area.

 

As we added physicians and expanded our staff, we added to our office space twice.  We added more physician offices, a large operating room, and a dedicated research suite with offices and exam rooms.  The total space was 12,000 sq ft.  As large as this seems, it was always busy.  I purchased as many shares of the building as I was able.  Because some physicians chose not to invest, I was able to acquire a disproportionate share.  This was a very profitable investment.

 

Eventually, Urological Associates began to work at the Mount Carmel East Hospital located on the far East side of Columbus.  We added a small secondary office in an office building on that campus.  I never used that office, and I rarely went to Mount Carmel East Hospital except to assist my partners with complicated surgeries.

 

 

Physician compensation

Physician groups have different formulas to divide profits.  Each has merits and disadvantages.  Mark and JP always divided profit equally without consideration to variation or productivity.  We continued that practice throughout my time at Urological Associates.

 

The system of equal compensation eliminates any dispute over who did what.  It also eliminates any advantage of seeing insured rather than non-paying patients.  Everybody simply did whatever work was needed.  Everyone was given the same amount of vacation, and everyone had the same amount of office hours.  Whoever was available saw the hospital consultations until all the day’s work was finished.  The system isn’t too bad if everyone has a good work ethic.

 

An equal compensation system disadvantages the most efficient and most productive.  During most of my career, this was me.  But I was satisfied anyway.  I cared more about high-quality partners and harmony within the group.  We were making more money that I ever anticipated, and I loved the practice.  As we hired more partners, things became more complicated, but we did not change the system.  One of the partners cheated and generated income independently during time that he was theoretically working for the practice.  He even forged documents to cover up his fraudulent breach of contract.  We reported him to the Board of Medicine and successfully encouraged him to leave Urological Associates.

 

 

Office staff

When I began in 1980, JP’s nurse/secretary, Ruth, ran the office.  Ruth and JP had worked together for many years, and both were old.  We had 2 other nurses, Sally, and Brenda.  The small office accommodated only a small staff, and the office was equipped to do little beyond simple patient visits and very minor procedures.  My secretary, Barb, also functioned as a receptionist.  She mostly worked out of a closet.  Nurses came to the office on Saturday morning along with all weekdays.

 

Once we enlarged the office space, we were able to grow our staff and the services that could be offered in the office.  In many ways, our office staff was more important to patient satisfaction than our physicians.  We hired the best staff that we could find, and we treated them well.  Although kind, JP had an authoritarian and somewhat condescending and abusive side.  His retirement was helpful to staff development.

 

As partners were added, the number of employees grew.  We had a dedicated receptionist, we had a shared group of nurses, and we each had a personal secretary.  Our staff became an extended family, so nobody wanted to leave.  This resulted in employees who stayed with us for many years.  Capabilities learned from years of experience are invaluable.  Returning patients got to know our staff.  Patients could sense the harmony within the office.

 

For years, our personal secretaries did the patient checkout, scheduling, and transcription for their individual physician.  Initially, Barb took care of my patients.  When Barb was promoted to Office Manager, Shirley assumed this position.  Both provided a sense of welcoming and competence for my patients, even though my personal time with the patient may have been brief.

 

Later, some of my partners determined that the office would be more efficient if the secretarial staff were divided by job description.  Some secretaries did transcription or pre-certifications while a different secretary, Kitty, did the surgical scheduling.  This was an efficient structure, but there was some compromise in the personal touch from individual secretaries.  Thankfully, our scheduler, Kitty, and our receptionist, Jackie, were amazing in their abilities to remember and relate to our patients.

 

We employed several registered nurses.  Four of our nurses became certified urology nurses.  All had long-term employment with us, and they became very skilled and knowledgeable.  The nurses worked with whichever physicians were in the office on that day rather than for a specific physician.  A nurse brought each patient back to the office or exam area before my visit and showed the patient out to the secretarial area following my visit.  This system assured that patients had all concerns addressed while maximizing my efficiency.  One nurse was assigned to phones, and that nurse spent all her time responding to patient questions or answering calls from patients.  I insisted on nurse triage for any clinical phone concerns.  A urologist was always in the office if needed, and patients were consistently given urgent appointments when appropriate.  We were an uncompromising service organization.  Our office opened at 7:00 a.m. and phones were answered until about 6:00 p.m.  This was accomplished by scheduling overlapping shifts for the staff.

 

We hired Becky as a head nurse.  Becky developed a comprehensive book of clinical policies and procedures.  These policies formalized our nursing education and nursing competencies.

 

Staff diversity changed with the times.  During my first 20 years, our staff was entirely white and female.  During the last third of my time with Urological Associates, we hired a part-time male ultrasound technician, a gay male nurse, a lesbian nurse, and an Afro-American secretary.

 

We provided a generous uniform allowance for the office staff.  They would coordinate their purchases, and the staff planned identical scrub outfits on many days.  This resulted in a sense of camaraderie, and it gave the office a professional appearance.

 

Office lunches were provided by pharmaceutical representatives on most days.  We even had a sign-up sheet so the reps could reserve their days.  If a rep wished to talk with the physicians, this could be assured only by bringing lunch for the entire office staff, usually over 20 people.  Reps competed for bringing the best meals.  They usually had the opportunity to discuss their products with 3-4 urologists in a single visit.  The reps considered this to be invaluable, and the cost was irrelevant for them.  Today this might be illegal and considered to be corrupt, but the staff loved it.

 

Office management

After Ruth retired and as we grew the practice, a formal office manager was needed.  This position was given to my personal secretary, Barb.  Barb became familiar with the complexities of personnel management and insurance contracting.  This was a complicated job and Barb excelled.  We used an attorney and an accountant as consultants.

 

Retirement benefits and pension

In 1980, Urological Associates had a 25% profit sharing and pension program, fully funded by the corporation.  This was extraordinary by prevailing standards.  Over time, we made modifications as required by law, but we maintained a generous retirement program.  Vesting was as slow as legally allowed to encourage long-term employment.  Our long-term employees were able to amass huge retirement accounts that have served them well.

 

Ultrasound

Our office had a dedicated 2-room ultrasound area, and we employed 2 full-time and one part-time ultrasound technicians.  We performed up to 30 studies daily.  These studies were read by the ordering urologist, and that urologist was consistently in the office to directly view the study when needed.  Many of our ultrasound studies were invasive ultrasound-guided prostate biopsies.

 

Urodynamics

I began a urodynamic capability when I joined Urological Associates in 1980.  Electronic urodynamic testing was a new technology, and I had some research experience as a resident in Cincinnati.  When we moved to a larger office, we included a dedicated urodynamics room.  Our nurses were trained to perform these studies.  Dr. Carey, our pelvic floor specialist, eventually assumed leadership of this capability.

 

Cystoscopy

The final office had 2 dedicated cystoscopy rooms, and these were generally busy.  We had multiple cystoscopes and an area for cystoscope preparation.

 

Lab

Our centrally located lab was always busy.  Urinalysis was the main test, but we also did semen analysis.  Our physicians always examined their own urine specimens.  Blood tests were ordered but blood was drawn elsewhere in the building.

 

For a time, we did our own urine culture and sensitivity tests.  These tests were inexpensive and accurate, and we usually had all results that we needed by the next morning.  We even came to the office on Saturday morning to evaluate specimens that had been processed on Friday.  Eventually, government regulation compliance became too difficult and expensive to continue these in-house tests.  We were forced to send the tests to a formal lab, tripling the cost to the patients and delaying the result for a few days.  If our government agencies didn’t have dysfunction, they would have no function at all.

 

 

Research

Shortly after I started at Urological Associates, I read about preliminary encouraging findings treating bladder cancer with BCG.  BCG was neither approved nor easily available.  I became aware that Community Clinical Oncology Program (CCOP) was conducting research with BCG, so I joined CCOP and enrolled in their study.  Mostly, I wanted to use the agent for my own patients.  This research was unfunded, and there was little administrative requirement.  I treated several patients and sent data to Dr. Donald Lamm, the national principal investigator (PI).  In 1987, Dr. Lamm published the first of several papers showing the successful results.  My name was included on the first 3 landmark papers, and BCG is still the preferred treatment for superficial bladder cancer.

 

When Dr. Ho joined the practice, he convinced the other partners that we would benefit from a more comprehensive research program.  We had the case volume, and we developed the infrastructure.  These research projects were funded by the medical industry.  Protocols and consents were complicated, so management of these projects was expensive.

 

With our final office expansion, we added a dedicated research area.  We hired a dedicated research staff.  At the peak, Urological Associates was involved in 9 separate research projects.  After our costs, there was no net profit from research, but it was enjoyable, and research kept us on the leading edge of our field.

 

Teaching

Teaching was not a focus at Urological Associates, but we were involved.  At Mount Carmel Hospital, we taught surgery, ob/gyn, and family practice residents.  Surgery and family practice residents rotated on our service and came to the office. 

 

Ohio State University had a urology residency, but they had a very small and limited urology staff during my 28 years at Urological Associates.  OSU had only 1-2 urologists at a time for their large hospital, and they were unable to effectively recruit good urologists because of their restrictive structure.  Urology residents rotated to Riverside Methodist Hospital, but Urological Associates clearly had the best academic urologists in Columbus.  Since my departure, OSU has developed a strong urology department with a good faculty.

 

OSU offered to give our urologists academic appointments and to include us in the urology resident training, but their terms were too restrictive.  We declined.  We would have been required to attend many meetings at OSU to qualify.  Resident training can be rewarding, but the inconvenience would have detracted from our focus on patient care.

 

The medical school in Dayton, Ohio, wanted a urology rotation, so they gave us faculty appointments at their institution with no strings attached.

 

My primary teaching interest was assisting/instructing my partners with complicated surgical procedures.  I was never comfortable allowing residents to act as the primary surgeon on my private patients.  I had no doubt that there was a quality compromise if I did not do this surgery myself.

 

Phones

I hate to get an answering machine response when I make a telephone call with an important concern, and I suspect this attitude is universal.  When I was making decisions for Urological Associates, all telephone calls during office hours were answered by real people.  If the receptionist was unable to answer before the first 2 rings, any available person was required to answer.  I never wanted to hear the fourth ring.  We had several lines, so they were almost never all occupied.

 

All clinical issues were referred directly to our experienced nursing staff for triage.  Patients with urgent problems that could be managed in the office were given an appointment, generally on the same day.  The nurse could immediately consult one of the physicians in the office when needed.  Patient needs were always prioritized.  We took direct and serious responsibility for all patients who contacted our office for help.

 

Pagers and call

JP and Mark never carried a pager, and “call” was informal.  Outside of regular office hours, an answering service received the office phone messages, and they tried to contact the physician.  Mark and JP could check with the answering service when convenient.  The hospital used overhead paging to reach physicians when they were in the hospital.

 

In 1980, Steve and I carried pagers.  When the pager beeped, we needed to find a phone to call the answering service. Then we needed to call whoever wanted us.  This was inconvenient, but there were no cell phones.  Later, pagers showed a phone number that should be called.  Later yet, a digital message could be displayed.  Until JP and Mark retired, Steve and I received their urgent messages because we were the ones that could be contacted.  In the early years of cellular service, I had a 12-pound shoebox-sized cellular phone in my car.

 

When small portable cellular phones became available, most physicians carried both a cell phone and a pager.  I decided that a cell phone alone was preferable.  With a cell phone, messages could be left directly, and most calls could be answered without additional inconvenience.

 

From 1980 through 1987, Steve and I took all our own calls unless someone was on vacation.  In 1987, after adding Dr. Stewart, we decided to take turns covering weekends, but we all continued to take calls on our own patients during the week.  Even on weekends when I was not on call, I preferred to get calls about my own postoperative patients, and I continued to see my own hospital patients on weekends.  This pattern continued until I left in 2008.

 

Policies

JP and Mark had few formal policies.  When Urological Associates incorporated, they distributed stock shares.  This required formal officer titles and a stock buy-sell agreement.  Departing partners would receive continuing income for 1 year to compensate them for accounts receivable.

 

As we added partners, more specific policies were needed.  Although I generally formulated the policies and developed consensus among the partners, all policies were ultimately decided democratically.  We added policies to manage situations such as disabled partners and impaired partners.  These eventually became important.  Toward the end of my time with Urological Associates, we developed policies that would adjust income for partners wishing to work less and take more vacation.

 

 

Advertising

Urological Associated did not advertise at all, ever.  I consider advertising medical specialist services to be inappropriate and adverse to patient interests.  We attracted referrals from primary care physicians by providing good quality care to their patients, by providing patient satisfaction, and by communicating with the referring physician. 

 

Experience tells me that the biggest ads come from the worst physicians.  Advertising is about physician profit and not at all about patient benefit.  I’m embarrassed and disgusted by the medical ads that I see for treatments that I know to be inferior and by physicians whose competence is in question.  Good urologists do not need to do this.

 

 

Bills and Collection

Urological Associates essentially had a monopoly for urology in the Mount Camel Medical Center market.  This was our territory, and we felt an obligation to take care of all patients regardless of their ability to pay.  Nobody was turned away.  We did not collect money at the reception desk for patients who had not yet been seen.  Physicians almost never discussed bills with patients.  Following the visit, the secretaries politely asked patients if they wanted to pay their co-pays, but there was no adversity if they declined.  Bills were sent for account balances after insurance paid, and bills were sent to uninsured patients.

 

Patients who failed to pay were rarely sent to collection, and they were not turned away from future visits if they had an outstanding balance.  Patients might be sent to collection if we knew that they had personally received reimbursement from their insurance company without passing the reimbursement to us.  We might enforce collection for patients who we knew could easily afford to pay.  Certain services such as vasectomy were considered discretionary, so we required payment.  We assumed that other non-paying patients simply were unable to afford their care, so we ignored the outstanding balance.  After all, we were making plenty of money, while they were having trouble getting by.  This generosity reversed itself when Urological Associates merged to become Central Ohio Urology Group.  Generosity was no longer affordable.

 

 

Parties

In 1980, Urological Associates held a yearly Christmas party for the small staff.  Sometimes this was held at JP’s German dinner club, the Manechor.  Spouses were not invited.  Bonus checks were distributed. After we moved, we held our Christmas parties at our office.  Only many years later did we decide that spouses should be included at our Christmas parties.

 

After several years, we began to also have summer parties that included spouses and children.  Some of these took place at Steve’s house with his swimming pool.

 

For several years, Steve and I had yearly Halloween parties for our referring physicians.  Most of these were held at my house.  Eventually, they became so big that we needed to have the parties in an outside tent.  These were loud and wild events.  We had a live band.  Police often showed up due to complaints from distant neighbors.  One complaint was from the opposite side of the Scioto River.  Our final party had 800 attendees.  We decided to stop having these events.

​

Urological Associates was audited by the IRS one year.  After a full week examining our records, the agent’s only concern was the expense of our Halloween party.  He required us to show him photos of the party and we complied.  Ultimately, he decided that the party should be considered a personal expense, and we were required to pay about $1000 additional taxes.  I doubt if these additional taxes came close to covering the cost of his audit, but he probably felt compelled to find something wrong with our books.  On the positive side, he did acknowledge that it looked like a great party. 

 

At that time, it was common for physicians to entertain referring physicians. Entertaining clients continues to be a standard practice in other industries.  Today, physicians are restricted from providing anything of value to referring physicians.  This could be considered a kickback subject to criminal penalties.

 

Interestingly, this same agent came to me as a patient about 2 years later with a prostate problem.  Of course, I took good care of him.  I asked if he was comfortable seeing me as a physician after he had penalized us.  He stated that, after spending a week in our office during the audit, he was favorably impressed with the quality of our practice.

 

 

End game

By about 2000, the economics of private medical practice were collapsing.  Government regulations had caused a decrease in productivity and a greatly increased overhead.  Reimbursement for the same services had been greatly reduced while inflation was increasing the cost of providing good patient care.  Our several younger partners needed an adequate income.  It appears that the federal government had decided to eliminate independent medical practices through economic starvation.  Most healthcare dollars were going to hospitals, pharmaceutical companies, insurance companies, and other members of the medical industrial complex.  This was bad public policy, but the large financial interests had the money to influence our legislators.  If this was considered to be a strategy to save money, it backfired.  The same service, when provided by a hospital rather than an independent physician, costs somebody 2-4 times as much.  And forget generosity.

 

Urological Associates first began to compensate by decreasing overhead.  This required that we decrease the quality of care that we provided to our patients.  Because the greatest expense was staff salaries, the partners decided to eliminate many of our most expensive and most capable staff.  Urological Associates substituted medical assistants for our experienced registered nurses.  Service and quality suffered.  Our next greatest expense was office lease, but that could not be rapidly decreased.

 

When the margin between overhead and revenue became too small, we had 2 alternatives.  The hospital offered to purchase our practice and pay generous initial salaries. Other urology groups had similar offers from their primary hospitals.  By employing physicians and controlling physician behavior, hospital systems could capture facility revenue and even increase this revenue by encouraging excess tests and procedures.  This had financial advantages for physicians in the short term, but it had many adverse long-term consequences for both physicians and patients.  Physicians and patients would become tools for predatory hospital administrations to use to generate revenue.  I understand how corporate institutions function.

 

The other alternative was to merge with several of the smaller practices into a “super-group”.  This strategy would allow the urologists to own their surgical center, lab, imaging center, and even radiation therapy center.  Government reimbursement was going dis-proportionately to these facilities rather than to physicians.  The “super-group” strategy had been successful elsewhere.  This was the chosen path forward.

 

The new entity was composed of several urology practices and was called Central Ohio Urology Group (COUG).  So that was the end of Urological Associates.  And that was the end of our benevolent patient centered practice philosophy.  No more generosity and humanity.  Future success was to be measured not by patients helped or lives saved, but by revenue, cash flow, and net income.  This was the inevitable consequence of bad government policy.  

 

COUG employed less expensive employees with less experience and capability.  Patients who were unable to pay their bills or co-pays were turned away before being seen.  COUG constructed facilities for surgery, imaging, and radiation therapy.  COUG was focused on revenue and profit with patient care a secondary consideration.  They advertised directly to patients and the public.  

 

I declined to become a partner at COUG.  I worked as a contracted employee for a couple of years to wind down my patient responsibilities, then I left in 2008 to continue practicing patient focused urology in a rural community and at mission hospitals in many resource-poor countries.  Of course, this was not profitable for me, but I had already saved more money than I would ever need.  I was fortunate.

 

COUG was initially successful, but the profit eventually declined.  COUG was acquired by US Urology Partners in December, 2018.  This began as a partnership with NMS Capital, a private equity company. Other urology groups have joined.   The hope is to maintain some physician autonomy and avoid hospital acquisition.  With a large number of associated urologists, it should be possible to leverage the urologist shortage and increase physician income. Ideally, this will allow the physicians to make decisions primarily in the interests of their patients while not compromising their incomes.  I understand that physician income has increased with this new arrangement. Will the patients benefit?   We’ll see.  Healthcare in the USA is troubled and uncertain.  I’m thankful that most of my career preceded the end of patient centered healthcare.