Practice Competition and Treatment of Newly Diagnosed Patients with Prostate Cancer - Avinash Maganty

June 26, 2023

Ruchika Talwar converses with Avinash Maganty about his study on Practice Competition and Treatment of Newly Diagnosed Prostate Cancer. They delve into the healthcare industry's shift from independent to employed physicians, especially in urology. This trend towards larger, consolidated practices could influence care decisions in areas with discretionary care, such as prostate cancer. The study uses the Herfindahl-Hirschman Index (HHI) to measure the impact of this shift on prostate cancer treatment. Dr. Maganty's findings indicate a slight reduction in treatment for men managed by monopolistic practices, particularly for those at high risk of non-cancer mortality. He further discusses the potential implications of consolidation, including access to care and potential financial toxicity for patients due to higher costs. Future studies are suggested to further explore the impact of consolidation on patient outcomes and care delivery.


Avinash Maganty, MD, MSCR, Urologist and Urologic Oncology Fellow, University of Michigan, Ann Arbor, MI

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hi everyone, and welcome to UroToday's Center of Excellence in Health Policy. We have Dr. Maganty from the University of Michigan discussing his area of research and recently published study, Practice Competition and Treatment of Newly Diagnosed Prostate Cancer. Thanks for being here with us today, Dr. Maganty.

Avinash Maganty: Yeah, my pleasure. Thanks for having me.

Ruchika Talwar: So let's talk a little bit about the background of this study. We've seen a recent shift over the past, I'd say 10 or so years, there have been trends in practicing physicians where we're seeing a shift from the independent physician to an employed physician. Tell me a bit about how that change has also been seen in urology.

Avinash Maganty: Yeah, I think as you said, particularly over the last 10 years, but even over a shorter time span within the last five years, we're noticing that there are fewer urologists practicing in a small practice setting, meaning a setting in which there are one or two urologists and there is increased movement towards larger groups, primarily multi-specialty groups or those that may be affiliated with a larger hospital system. And this is pretty consistent with other similar specialties, or subspecialties rather in this growing era in which there's an emphasis on a lot of administrative labor to comply with value-based care.

Ruchika Talwar: Exactly. And I think the latest number that I read recently was over 70% of practicing physicians are now employed, which is a stark difference from how the practice of medicine was a decade ago that we had mostly sole practitioners. And how did that lead you to ask the question that you're looking at in this study?

Avinash Maganty: Yeah, it's an interesting question and what our overall framework for this was that there are things in the healthcare delivery system, whether that be how it's structured, policy payment reform or incentives that could influence care. And I think particularly with prostate cancer in which there is potentially discretionary care or areas of uncertainty that in which patient preferences and physician preferences may be guided more by these nonclinical factors can take effect. And so as consolidation being a large nonclinical factor, at least in the present era, we were interested in understanding whether or not this had any influence on prostate cancer care.

Ruchika Talwar: And what was your hypothesis specifically?

Avinash Maganty: So it largely centered around this idea of incentives, which prior literature and work has shown that financial incentives can influence decision making in prostate cancer, particularly in circumstances in which there tends to be clinical uncertainty or in other words discretionary care use of treatment. And so consolidation has widely been regarded as this framework in which prices, particularly commercial prices can increase for physicians or professional services. And we've seen that in hospital mergers and consolidation. And so as a form of incentive, this could in theory or we could hypothesize that this may also influence management of men with prostate cancer.

Ruchika Talwar: And what were the methods of your study?

Avinash Maganty: Sure. So we used Medicare administrative claims from a 20% sample. And using that data, we basically measured competition or this economic surrogate of consolidation by the, what's termed Herfindahl-Hirschman Index or what we refer to as HHI for short. And essentially it's basically a measure of flow of patients to individual urology practices as a measure of competition. And we used basic mixed effects models as a statistical method to determine the association between the practice's level of competition and use of treatment for individual beneficiary with prostate cancer.

Ruchika Talwar: And what did you find?

Avinash Maganty: So we found a very modest decline in treatment associated with men managed by practices with low competition. In other words, these are practices that tend to be more monopolistic or in other words they dominate a given market. This reduction in treatment was primarily observed among men who had a very high risk of non-cancer mortality. So we separately stratified our analysis by risk of death from non-cancer causes, which was determined or measured from a predictive model. And the largest decline in use of treatment by men managed by practices with low competition was largely seen in that group, almost 12%. So going back to what we were previously discussing earlier, the idea that nonclinical factors, potentially incentives, work at these levels of on the margin or rather where care maybe considered more discretionary, such as in these men for whom the decision to treat may be less straightforward than perhaps a younger healthier man, for instance.

Ruchika Talwar: Interesting. Now I know you didn't find any large difference, but I think this is a really intriguing question. There have been studies in the past showing that the quality of care declines when you see practices that are consolidated. Similarly, recent trends looking at an increase in private equity ownership has shown to change the cost of care, specifically cost of care actually goes up in certain instances after a practice has been purchased by a private equity firm. Has there been any similar analysis to yours outside of urology? And if so, what do they find?

Avinash Maganty: Yeah, there has been a few that have been performed in primary care and some in general surgery, looking at the use of TAVR or other minimally invasive surgical approaches and consolidated markets. These studies have largely focused on utilization, as you mentioned, spending and cost and uptake of these more minimally invasive services. Finding that increased consolidation leads to higher use of these services, but specifically in urology and then more specifically trying to get at the idea of quality has, I think, not been examined to a great extent yet.

Ruchika Talwar: Yeah, it's an interesting question as I've stated. There's a lot of policy coming out of organized medicine. For example, recently at the annual American Medical Association meeting, there was policy passed calling for further study to explore the impact of consolidation of these practices and looking at how it affects both quality as you study, but also outcomes. And I think your work here is really forward-thinking in that there hasn't been a lot done in outcomes. So just getting your thoughts here, what other scenarios do you think we should be studying in this situation? How else can patient outcomes or care delivery be affected by consolidation?

Avinash Maganty: Yeah, it's a great point and I think one that we need to work harder at getting at, and it's certainly a challenge, but I think a few things that we can think about are one is potentially access to care. I think consolidation people may view as a way to centralize care, which may have its benefits in certain circumstances, but it also could have unintended consequences in other circumstances. So I think that could be potentially a big one. And another issue as we discussed initially is this idea of higher prices and then as you alluded to spending, which that's from a potentially health system level. But at the same time there is some evidence to suggest that these higher prices that these consolidated practices may negotiate, could be transferred to patients through higher premiums, higher deductibles, for instance and that could maybe perpetuate financial toxicity experienced by these patients. So I think there are definitely multiple unintended consequences of consolidation that we have really just touched the surface of, and I think certainly could be a area of interesting work.

Ruchika Talwar: Yeah, absolutely. I think it'd be an interesting way to justify decreasing these regulatory burdens that have made it so difficult for solo practitioners to survive out there. So I commend you for tackling this important topic in this way. And thank you again for spending time with us here at UroToday.

Avinash Maganty: Oh, absolutely. My pleasure. Thanks for your interest.

Ruchika Talwar: And to our audience, thanks for tuning in. We hope to see you back soon.