Creating a Niche

The Hubbard Clinic uses in-office procedures to maintain profitability as an independent urology practice

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LOUISVILLE These days, small, independent practices seem harder and harder to come by. The trend towards hospitals employing physicians in large group practices is undeniable. Certainly, physicians are turning to employment models to combat skyrocketing costs and ensure longevity in a changing healthcare landscape.

However, John Hubbard, MD, urologist and the sole physician at The Hubbard Clinic, says there are profitable ways to maintain your independence. A self-described “country doctor,” Hubbard has capitalized on experience, personal circumstances, and bargaining power to establish a niche practice. “I’ve been in practice a long time. I know what I like. A great staff is a must. I know what I want my patients to have, and I like for my nurse extenders to do the same thing … Because of that I opened my own practice in 2000,” says Hubbard.

The key, according to Hubbard, is choosing in-office procedures that have low risk for infection and performing those only on healthy patients. He uses a nurse anesthetist and performs all procedures under conscious sedation. Patients who are ill or on a lot of medications get referred to someone else, so they can be done in a hospital setting.

Limited from doing big surgeries because of his own back surgery but desiring to grow his practice, Hubbard found his perfect formula in a niche urology practice built around voiding problems in women and men. Wanting to remain a solo practitioner, he uses nurse extenders to help cover his patient load. One ARNP and one PA-C see female patients for routine and follow-up visits, while Hubbard focuses on male patient visits and procedures for all patients.

Six years ago Hubbard brought most procedures in-office after receiving accreditation for office-based surgery, and he says the benefits are staggering. Insurance companies benefit because it costs them less than the same procedure done in a hospital. Physicians receive a slightly higher reimbursement for in-office procedures than hospital ones. Patients benefit by paying reduced copays instead of hospital copays, and they have the comfort of seeing familiar faces and not worrying about hospital infections.

Office-Based TVT Sling

For Hubbard’s female patients, incontinence is a common problem. The muscle cradle that supports the bladder can become relaxed with pregnancy and childbirth, causing leakage when the bladder is under pressure. In 1998, Hubbard began doing tension-free transvaginal tape (TVT) sling surgery, which provides a backboard for the urethra and bladder to prevent leakage. Hubbard prefers the TVT to other tape procedures because it uses one vaginal and two pubic incisions, allowing for a longer tape. “There are no sutures that hold it, so the more tape you have for the body tissue to grab, the longer it’s going to last,” he says. “I have done right at 1800 [TVTs] since 1998, and I have yet to take one out for pain, infection, or body rejection.”

For patients who have the procedure, Hubbard recommends a six-week muscle training course that uses a vaginal probe to measure patients’ squeezing and muscle strength and provides much better results than simply prescribing at-home Kegels. With the TVT and some muscle strengthening, patients can avoid future pelvic prolapse surgery, something Hubbard does not do.

Hubbard also does not treat pelvic floor pain without bladder symptoms. For muscle or nerve problems he refers to a physical therapist who specializes in the pelvic floor. “We see more that have pelvic floor pain that have bladder symptoms along with it, and we’ve found the great majority turn out to be interstitial cystitis,” says Hubbard.

Interstitial Cystitis

Not many treatable conditions start with negative test results, but when the patient reports frequent urination and urgency, pelvic pain, and pain with sexual activity but has negative urine cultures and negative local cystoscopy, the diagnosis is often interstitial cystitis (IC).

Often misdiagnosed as recurrent urinary tract infections, IC does not have a known cause. It is characterized by a lack of tightness in the lining of the bladder, resulting in microscopic leakage of urine through the bladder wall, which irritates surrounding muscles and nerves. It affects both men and women but is much more common in women.

According to Hubbard, “70% of the treatment is telling patients, ‘We know what it is. It is not dangerous, and you are not crazy. You have to watch your diet, and we will look at allergies.”

When Hubbard suspects IC, he suggests patients undergo cystoscopy. “We go on how much the bladder will hold, when you’re feeling the pain as we’re filling the bladder, and do you break blood vessels after we fill the bladder?” says Hubbard.

Dietary factors and allergies greatly influence the condition. The first step is educating patients that it is a chronic condition, and avoiding certain foods and beverages can improve symptoms. The second step is to check for allergies. “Part of our workup when we do biopsies [during cystoscopy] is to check for mast cells to give us an idea if there’s a strong allergic component. If so, we have an allergist that’s very familiar with interstitial cystitis that we work with to help that aspect,” says Hubbard.

Treatment also includes medication. Elmiron is the only medication FDA approved for the treatment of IC, although it has some drawbacks: it takes a long time to work, does not work in every patient, and can be expensive. However, The Hubbard Clinic also employs the use of natural products and other medications to treat the symptoms. The newest treatment in Hubbard’s toolbox is Botox. Approved three years ago for use in neurogenic bladders, physicians have begun using Botox in IC patients to help the bladder retain more and hopefully reduce pain. When all else fails in particularly difficult cases, Hubbard refers for a urinary diversion technique called an ileal conduit.

Other In-Office Procedures

In addition to the TVT sling, Botox, cystoscopies, and biopsies, Hubbard can also do bladder distensions, correct bladder neck contractures and urethral strictures, and remove small bladder tumors in office. For male patients, Hubbard offers the transurethral needle ablation (TUNA) and transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia (BPH).

Hubbard still does some procedures in the hospital when insurance will not cover office procedures or when the overhead is prohibitive for him, such as the case with Medicare patients. But he is banking on the in-office procedures to help him maintain his independence and the small office feel his patients appreciate.