It all started with a phone call from urologist Todd Cohen to his former colleague, Michael Cram. That, in turn, led them to host a meeting with several other urologists having practices in the Carolinas. Gathered around a platter of sandwiches and a batch of fresh ideas, the group spent three to four hours discussing the feasibility of creating a new, combined practice group.
Then, the serious work began. It took a year of research, legal strategy and requirements, vetting background and compliance records, contract negotiations, asset acquisition, real estate assessment, licensure and privilege applications, human resources development and a new Medicare identification number, to combine 31 physicians and 200+ employees under one group name with 13 urology centers—Carolina Urology Partners, PLLC. The newly formed entity was official as of March 1, 2011.
The ambitious merger of seven independent practices, now called divisions, extends Carolina Urology Partners’ footprint across seven counties in the Charlotte region and makes it the eighth largest urology group in the country.
“We cover a very large swath of the region,” says Cram, co-CEO for the group. “Between the seven divisions, we take care of about a quarter of a million patients.”
“One of the things we want to communicate to our patients is that the long-standing relationships they’ve had with their physicians and their community won’t be changing,” says Cohen, sharing CEO responsibilities with Cram. “We have different scrubs on and a different sign on the door, but none of the doctors from the practices are changing as a result of this merger.”
The compelling reason for a merger of this kind is the rapidly changing medical environment towards protocol care; that is, standardization. Protocol care requires a certain level of sophistication that is difficult to provide in a smaller environment.
“Protocol care provides the best quality and makes sure nothing falls through the cracks,” says Cohen. Most of the established protocols for urology are designed by the American Urological Association.
Carolina Urology Partners (CUP) offers the full gamut of services and treatment within urology. “People don’t realize how many different things we do,” says Cram. “All of the group’s doctors are both urologists and surgeons.” Then he ticks off a broad array of issues they regularly address: incontinence, vasectomy, infertility, prostate disorders, kidney stones, urinary tract infection, sexual dysfunction, erectile dysfunction, cancer (kidney, bladder, testicular, adrenal, prostate), testicular disorders, voiding dysfunction, pelvic prolapse and urinary frequency.
Many of the CUP doctors have undertaken fellowship training in sub-specialties such as stone disease, cancer, infertility, robotics and urogynecology. “Patients can be guided towards the most expert care possible,” says Cram.
Several of the CUP doctors have been involved in research, mostly concentrating on clinical, drug and device studies. Now, because of their larger size post merger, there is an additional opportunity to pursue research into detection, diagnosis and prognosis of cancers treated within urology; specifically to study new biomarkers. Cram describes the opportunity as “an enormous benefit.”
The merged practices will provide a huge patient population with a diverse demographic whose conditions and disease can be studied over a long period of time using protocol-coordinated efforts. Volume and protocol are key to valid information. To meet these goals, CUP has established a research quality, anatomic and clinical pathology laboratory.
“We are involved in state-of-the-art research which will allow our doctors to get cancer patients to diagnosis and appropriate treatment earlier—right here in our office building,” says Cram with evident excitement. The laboratory also houses two uropathologists and renders diagnostic and biopsy test results in-house.
These are exciting times for urology. “We’re looking for something better than the current PSA tests,” says Cohen. New bio-markers are being tested and introduced; there are exciting new markers in bladder cancer. “We’re definitely getting a lot of interest in our lab from bio-marker companies that see it as a place to put their newest diagnostic tools to the test,” says Cram.
The formation of a large group with a research laboratory and a diverse demographic will also allow the doctors at CUP to better determine the extent of treatment in difficult cases.
“One hundred percent of men get prostate cancer if they live long enough,” says Cohen. “There’s no way to tell whose cancer may be fatal.”
Most prostate cancers grow so slowly that they may not cause any problems. Cram explains that there are two big questions: how do you find men before they develop prostate cancer, and how do you prevent over-evaluation of men who will never develop a clinically-significant cancer. Prostate cancer can be a dangerous disease because it is asymptomatic until late stage.
“My grandfather was diagnosed at age 99; treatment was not an issue,” says Cohen.
A Well-Humored Practice
“Most people see us as a guy’s doctor, but 40 percent of our patients are women,” says Cram. Carolina Urology Partners consists of several physicians who treat primarily women for such problems as pelvic prolapse, incontinence, and complex voiding dysfunction. The group has several specialists who have extensive experience treating the complexities associated with quality of life for female patients of all ages.
“These doctors are not only urologists and surgeons, they are specialists in reconstructive female pelvic health,” adds Cram. Additionally, the group’s only operative female urologist in Charlotte sees many patients, both male and female.
Approximately five percent of the group’s patient care is centered around erectile dysfunction (ED). “Fifteen years ago, nobody talked about ED,” says Cohen. “Men still don’t talk to each other about it.”
Cohen credits the intense marketing of the “blue pill” with the fact that men in large numbers are seeking out treatment for this common condition. Over six billion doses of oral agents for erectile dysfunction have been prescribed.
Cohen shares an interesting tidbit: The original oral agents were discovered, not developed. They were intended to be substitutes for nitroglycerin for angina. “What became clear is that the chest pains were not better but men still kept coming back for the pills—a solution to another age-old problem,” smiles Cohen.
Both Drs. Cram and Cohen are surprisingly fun in person, exhibiting a healthy amount of self-indulgent humor. Cohen jokes about the group’s acronym C-U-P both because of how it is pronounced letter-by-letter and the ubiquitous item it refers to—at least in urology offices.
Cram says doctors going into the field of urology “tend to be laid back, fun people.” Both Cram and Cohen stress humor as a way of relieving stress in a medical specialty that is scary, if not confusing, for many people.
Cohen believes humor to be part of the healing. “I’m very serious when I need to be,” he says in a statement that is fully supported each year on Halloween when he dresses up for his patients. I now have about 40 or 50 people who come on Halloween just to see my costume.”
But behind the expertise, healing and humor lies a strong “Patients First” culture. “Our patients are always our top priority,” affirms Cohen.
Cohen adds that he continues to be pleasantly surprised with how easy it has been to work with the dynamics of seven different cultures all at once. “When it comes to doctors, it’s really a merger of seven bosses,” says Cohen.
To ease any tensions of assimilating to the changes, all CUP board and finance meetings are open to all members. Currently eight board members represent the seven divisions. “It’s funny when you see your former competition in the same scrubs as yourself.”
“There were no layoffs in the merger; everybody was offered a job in the new group,” says Cohen. “We have realized that among the divisions, we share some very talented people that we are able to utilize in leadership positions to benefit the entire group.”
Undeniably, the employees are experiencing a turn towards the ‘corporate.’ A chief operating officer, chief financial officer and directors of human resources, billing, and marketing have been hired to fill out the management team. But most would agree that the merger has brought new excitement and energy to both doctors and staff, says Cohen.
A Well-Heeled Background
Cohen hails from Boston and attended medical school in Rochester, New York. His residency training was completed at the Cleveland Clinic in 1995 and was followed by a kidney stone fellowship at Duke University. He then made his first move to Charlotte and worked with a urology group here. The desire to teach took him to Ohio State in 1997, where he served as assistant chairman and associate professor of urology. Dr. Cram was his chief resident there.
Raised in Iowa City, Iowa, Cram is the grandson of a family doctor and the son of a plastic surgeon. He was attracted to urology because of its dual in-office and surgical nature. After graduating from medical school in Iowa, Cram completed his residency training at Ohio State where he met and worked with Dr. Cohen. He remained there after graduation for a year of teaching. Cram’s sister had settled in North Carolina about 20 years earlier. Having occasion to visit several times and enjoying the area, he decided to take advantage of an opportunity to create a practice in Lake Norman.
Both Cohen and Cram left Ohio State in 1999—Cohen to Gastonia to set up Piedmont Urology Associates; Cram to Lake Norman. It would be 10 years before they worked together again, even though for much of that time they lived only three miles apart. Cohen lives in Charlotte with his wife and daughter. He continues to teach within the group and as a consultant. Cram is married with two small children and lives in Mooresville.
The group’s physicians demonstrate their commitment to educate the population and provide services to underserved areas by going out into the community in a variety of ways including speaking engagements and community screenings. Currently, they are gearing up for the Great Prostate Cancer Challenge, a 5K Run, Walk and Stroller Jog scheduled for September 2011.
“This is the prostate cancer version of the Susan G. Komen Breast Cancer Run. We want to motivate Charlotte to come together and raise awareness for prostate cancer and its prevalence,” says Cohen. The Great Prostate Cancer Challenge began in Baltimore five years ago, founded by Dr. Sanford Siegel, a urologist and CEO at Baltimore’s Chesapeake Urology Associates.
The race began as a single venture in Baltimore and has now expanded to 27 cities across America. Cohen and Cram, colleagues of Dr. Siegel, have committed their time and efforts to bringing this race to the Queen City.
“The success of the ‘Challenge’ will bring prostate cancer awareness opportunities directly to our community year-round. Through this effort, we can bring in the screening bus—Drive Against Prostate Cancer—to do community health screenings bi-monthly throughout our area,” says Cohen.
By far one of the greatest ways the doctors give back is through the gift of time; seeing patients without insurance in hospital settings. “We don’t ask anything about the patient’s ability to pay or what insurance they have,” says Cohen. “That’s our mantra: take care of the patient.”