Giving ground to urology groups on key IR procedure is undermining the specialty, radiologist warns
Interventional radiologists are concerned that giving ground to urologists on a key interventional procedure is undermining the IR specialty.
Urology of Virginia announced in January that it had hired an in-house IR specialist to perform minimally invasive treatments on patients with enlarged prostates. The private practice joins a growing number of urology outfits offering prostate artery embolization at their own outpatient centers rather than in hospitals or IR practices.
Urologists have touted these “partnerships” between the two specialties as a value-added benefit for patients. But some radiologists are worried such arrangements are trouble for their specialty.
“There is no ‘partnering’ going on with this model,” Adam Lustig, MD—an IR with the 65-year-old Medical Center Radiologists private practice in Norfolk, Virginia—wrote on social media March 7. “This model is taking clinical decision-making and control of patients out of the hands of independent interventional radiologists, undermining the specialty, and reducing interventional radiologists to nothing more than employed technicians, employed by non-radiology and non-interventional radiology practices.”
A tech, rather than a doc
In an interview Tuesday, Lustig said Urology of Virginia was previously one of his largest referrers for prostate artery embolization procedures, which involve inserting a thin catheter into the groin or wrist using imaging guidance. The tube is directed to the arteries that supply blood to the prostate, with an IR injecting particles to reduce blood flow, shrink the gland and relieve symptoms.
Lustig said his practice approached Urology of Virginia about a possible partnership to open an outpatient PAE center together. However, the two couldn’t reach terms favorable to Medical Center Radiologists and the talks ended. In January, the urology group announced the hiring of interventional radiologist Yi Yang, MD, MPH, and the opening of its own “state of the art” new IR department.
“By combining the expertise of both specialties, we aim to provide our patients with the highest level of treatment tailored to their specific conditions,” the practice said at the time.
Lustig is troubled by the offering and what it portends for interventional radiology.
“The model is to hire an interventional radiologist for a flat fee and that's it,” he told Radiology Business. “They have no say in the strategic direction of the group. They don't share in any profits. They have no equity. It's really: You're just an employed technician, and it's sort of commoditized labor at that point. That's not really the direction [Medical Center Radiologists] wanted to go.”
Urology of Virginia did not immediately respond to requests for comment sent Tuesday.
Debate on Twitter
Shashidhara Murthy, MD—an IR specialist and Lustig’s colleague at Medical Center Radiologists—posted the original Radiology Business story on social media Feb. 28, adding an expression of his concern.
“Selling out to urology is not something to be proud of. IRs in this region had built a successful PAE practice with great patient satisfaction and results,” wrote Murthy, whose post drew more than 9,500 views as of late Tuesday.
Others also have weighed in since then. Kavi Devulapalli, MD, MPH—a blogger and image-guided surgeon—said he believes there are merits to IR physicians teaming with urologists and other specialists. However, the success of these collaborations depends on how the partnership is structured.
“I agree with everything Adam [Lustig] says. Our field has been sold out. Cat is out of the bag. Unfortunately, this is the new operating standard for urologists who like anyone else face cost and reimbursement pressure. I don’t blame individual physicians for working in this structure,” Devulapalli wrote March 7. “This behavior absolutely needs to be called out, but at the same time we need to take action and work hard to (re)build our own practices,” he added later. “We need to offer the IR community a better alternative. Will more IRs take risks and fight for what they believe in? I sure hope so.”
Urology of Virginia launched its IR department in partnership with Prostate Centers USA, an interventional radiology group headquartered in McLean, Va. Numerous others have done the same, including the Michigan Institute of Urology, Central Ohio Urology, and Urology of Indiana—with the latter two backed by private equity investors. Under terms of the agreement with MIU, Prostate Centers USA manages the center and handles the billing, Radiology Business reported in December 2023. Leaders labeled the arrangement as a managed services agreement, with MIU paying the IR group a management fee.
Sandeep Bagla, MD—a radiologist, founder and CEO of Prostate Centers USA, and noted expert on prostate artery embolization—also commented. He disputed notions that anyone is “selling out” to urology and said he believes these partnerships strengthen the profession.
“‘Undermining IR’ as a specialty implies it diminishes their value when it actually increases it—to the overall population that IR can impact, increasing their opportunity to do advanced cases rather than the average IR job (which is made up for the most part by minor nonvascular procedures), to demonstrating their value to the stakeholders, unlike a hospital system or radiology group, which may not see the value of IR,” Bagla wrote March 8.
“You guys ... we need to be on the same side. We have too many forces working against us as a specialty to work against each other. We can all have different careers and keep moving the needle in our own ways. We are stronger together,” Mary Costantino, MD, an IR based in Portland, Oregon, added March 11.
A slippery slope?
Lustig said he’s concerned about where these arrangements lead IR as a specialty. Radiologists working in urology groups may lose their other trained skills if they regularly concentrate on prostate artery embolization.
He also worries other specialties will get the same idea and begin taking away additional services from IR practices, such as gastroenterology groups offering hemorrhoidal artery embolization.
“Now you're talking about taking more than just PAE, but really all the big embolization procedures—which generate a lot of RVUs and revenue—out of training programs and into these private equity-owned other groups like urology and GI and ortho,” Lustig said in an interview. “The training is going to degrade for these up-and-coming IR residents.”
Lustig believes this could lead down a path where other specialists own these interventional procedures, and what’s left for IRs is hospital-based work and acute trauma cases, with far less daily variety in their practice. Other physicians competing with IRs for these procedures is one thing. But Lustig believes urology groups are creating a monopoly, where they can simply self-refer all PAEs to themselves.
He hopes the Society of Interventional Radiology and IR community will have a larger discussion about these arrangements in a forum outside of social media. SIR declined to comment for this story on Tuesday.
“Over the last 10 years, SIR has fought hard to create a pathway for IR to be an independent, primary specialty, separate from diagnostic radiology,” Lustig said. “I think this work is being undermined, again, by this new model where you're owned by another specialty. You're paid a flat fee for your services. Really, you’re a commodity and you're not an independent physician or consultant. We own you. We're telling you to do it, and we expect you to do it. I think in a lot of ways that's the undercurrent, and this is going in the opposite direction of what SIR and our specialty has been fighting for, for a very long time.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.