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Does revenue affect a urologist’s management recommendations?

Posted Oct 06 2010 12:00am

A common topic of discussion among some members of the patient and patient advocacy community is whether recommended management of prostate cancer for individual patients is driven by the potential revenue available to physicians and hospitals from differing recommendations.

The “New” Prostate Cancer InfoLink does not have a specific answer to that question. However, what we do now have is some additional information from an analysis by Manoharan et al.

The authors set out to estimate the potential reimbursement to a urology practice from managing a patient with low-risk prostate cancer in one of three ways over a 10-year period: by immediate robot-assisted laparoscopic prostatectomy (RALP), by immediate open radical prostatectomy (RP), or by active surveillance (AS). All reimbursements in their estimate are based on Medicare reimbursement rates, so it is reasonable to assume that such estimates are at the low end of the potential reimbursement scale, and that urologists probably receive higher levels of reimbursement for commercially insured patients.

Here is a summary of what Manoharan et al. estimate as the total 10-year revenue stream for the urology practice from a low-risk prostate cancer patient who is covered by Medicare:

  • US$3,057 for a man treated with immediate RP (i.e., an average of $300 per year over 10 years, but “front-loaded” because of the fees for the surgery).
  • US$4,091 for a man treated with immediate RALP (i.e., an average of $400 per year over 10 years, again “front-loaded” because of the fees for the surgery).
  • US$7,964 for a man managed with AS, inclusive of a 15 percent probability of the need for surgery sometime after the start of AS (i.e., an average of $800 per year over 10 years).

These estimates are based on specific assumptions about the frequency and need for follow-up visits for PSA testing, DREs, and repeat TRUS-guided biopsies. They do not include costs associated with the initial diagnosis of prostate cancer, only the costs after initial diagnosis.

The “New” Prostate Cancer InfoLink has no way to validate the accuracy of these estimates. Arguably, they are encouraging for low-risk patients, because they give a urologist a good reason to see a long-term commercial value to active surveillance and therefore encourage patients to consider this management strategy.

At the other end of the scale, however, recent advertising for urologists to fill positions in community-based practices in some parts of the US have mentioned annual, pre-tax “take home” income  of $750,000 and higher. At least at face value, there would appear to be something of a disconnect between numbers like these and the numbers being suggested in the paper by Manoharan et al.

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