Why treating CP/CPPS is not popular with uros
Many men complain that they face hostility and lack of interest from their urologists. But there are good reasons why this is so. CPPS patients tend to be anxious, demanding and hypervigilant, and are difficult to cure with the tools at the urologist’s disposal. And then there’s the issue of money. Urologists are surgeons and make their money that way. Below is the view of one urologist, circa 2001. Incomes and prices have increased since then, but the same attitudes prevail:
First off, in the US, a physician may charge the equivalent of about $150 for an initial visit, but follow-up visits are probably more like $75. Insurance will likely pay about 1/2 of that, or less. HMO patients may be such that the doctor gets one payment per year regardless of how many visits (capitation.) As we all know, multiple visits are the norm for CPPS, so let’s say that out of your 20 patients/day, 5 of them are “new” at the $150 rate. So with the “discount” that insurances will pay for “negotiated rates” (about half) that’s about $375. The other 15 at $40 equals $600. So let’s say with just office visits, a urologist could expect to pull in $975/day revenue. That’s seeing 20 difficult patients and would likely take 8+ hours. Does this make sense so far?
Now, out of the roughly $1000 revenue, about 60% will go to expenses. Employees, nurses, pension plans, capital equipment, office equipment, insurance (malpractice is HUGELY expensive in the US), leaving about $400 on the “bottom line”. If the doc works 5 days a week, for 50 weeks (and I like to have more than 2 weeks vacation personally) then that’s about $100K/year profit. Then taxes …
NOW, let’s look at a surgical practice. A urologist can see 3 patients with kidney stones, and then set them up for lithotripsy, and the litho gets recompensated at a rate of about $800 per procedure for an hour’s work. A non-Medicare radical prostatectomy nets about $2000.
Basically it is difficult for a urologist to make ends meet seeing only non-surgical patients. You might say, “$100K is great money”, but if you trained 14 years, you’d expect a bit more.
In addition, many of us got into urology because we enjoy surgery. The office is often drudgery, and you get patients who clearly aren’t surgical who need to be seen, but are a drain. If your office schedule is so full of non-surgical patients that high-margin surgical business is shuttled to your competition, then it will be detrimental to your financial solvency. I experienced this first-hand, and know it to be true. I personally would choose another specialty if I had to see more than 1-2 CP/CPPS patients/day. It would drive me bonkers. Not that I don’t like many of the guys, but it’s just saying the same old thing, and often getting nowhere. Patients look at you like you’re their enemy, have a disdain because you cannot cure something that no one in medicine can, and are remorseless about calling asking questions without answers, and then getting upset when you say, “I don’t know.” It’s a no-win scenario. Sorry to say. I empathize with CPPS sufferers, but as Dr. Shoskes has said, the practice of CPPS isn’t profitable, and the academician is the only one who can ever be considered to have a good shot at being a CPPS expert. The “prostatitis clinics” (e.g. Tucson and Manila) are lucrative due to package deals, and fees that aren’t negotiated through insurance contracts, but I also feel that what is provided in those “centers” is not really good medicine, though perhaps some folks notice some benefit (though perhaps they were destined to get better despite treatment!)
Perhaps I’m just pipe-dreaming and perhaps my points will never be taken seriously, and I’m not telling you all to try and encourage your own family docs to be your CPPS-treating docs, but my point is that most urologists are never going to be very interested in the non-surgical aspects of CPPS treatment. Period. I simply would rather have empty slots in my schedule than fill it with a CPPS patient. I find it repetitive, unfulfilling, and fruitless most of the time (not to mention frustrating as many are psychologically disturbed, and I work poorly with this population). I’m a hands-on guy, and am trying to cultivative a practice that is as purely surgery driven as it can be. One way to do that is to subtly or not-so-subtly discourage patients one knows will be non-surgical so that the schedule is open for that stone or cancer that will require your surgical expertise.
Thanks for the time to expound on the financial implications of CPPS treatment. These are the realities, and the insurance companies pay us less and less per unit “work” each year despite inflation. I am working hard to save and scrimp because I believe someday there will be come a time when diminishing returns will force me into another profession, unless I can maintain a high percentage of high-margin surgical patients, and as I refuse to lower myself into hiring physician extenders (PA’s or NP’s to see my patients while I supervise), and since I intend on giving patients who do come their money’s worth in terms of time and effort, I may be fighting a losing battle.