Entrepreneurial Activity among Independent Urology Groups

BACKGROUND:Independent physician groups may develop novel revenue streams through ownership of services (eg, radiology equipment, ambulatory surgery centers), supplementing fee-for-service income. This form of entrepreneurial activity and its implied incentives for utilization may influence physician behavior and patient management. We developed an index measuring entrepreneurial activity of independent urology groups and assessed its association with diagnostic testing in men with benign prostatic hyperplasia (BPH). METHODS:We identified Traditional Medicare beneficiaries with BPH presenting to an independent urology group between 2017 and 2019. Using factor analysis of 9 unique ownership characteristics, we developed an index measuring entrepreneurial activity of independent urology groups (0-100-point scale). We assessed the relationship between the entrepreneurial index and 3 types of testing within 90 days of the initial new patient visit. At the patient level, we measured completion of a urinalysis (guideline-recommended), optional BPH testing (eg, ultrasound, cystoscopy), and testing unrelated to a BPH workup (ie, prostate-specific antigen, testosterone). RESULTS:The urology group entrepreneurial index ranged from 0 to 97.2, with 20.6% (n=706/3430) of groups owning at least 1 ancillary service (ie, index >0). Among 49,285 men, an increasing entrepreneurial index (per 10-point increase) was associated with greater odds of undergoing a urinalysis (OR=1.13; 95% CI: 1.09-1.18; P<0.001), optional BPH tests (OR=1.05; 95% CI: 1.02-1.09; P=0.002), and testing unrelated to BPH (OR=1.21; 95% CI: 1.15-1.27; P<0.001). CONCLUSIONS:Entrepreneurial activity in urology, through ownership of ancillary services, is concentrated in a subset of groups. Among men presenting with BPH, the index was associated with increased guideline-recommended, optional, and unrelated testing.