Download Creating a Niche - The Hubbard Clinic

The Business Magazine of Kentucky Physicians
and Health Care Administrators
Special Section  Women’s Health
Creating a Niche
The Hubbard Clinic uses in-office procedures to maintain profitability as an
independent urology practice By Jennifer S. Newton
© 2013 Mentelle Media LLC
Left-right:
Patricia Hooker, PA-C; Sandy Nasief, medical assistant; Dr. John Hubbard;
Emmy Baker, APRN; Debbie Freeman, administrative assistant; Liz Fields, surgery coordinator;
Jill Watts, medical assistant
efit because it costs them less than the same
procedure done in a hospital. Physicians
receive a slightly higher reimbursement for
in-office procedures than hospital ones.
Patients benefit by paying reduced copays
instead of hospital copays, and they have the
comfort of seeing familiar faces and not worrying about hospital infections.
Office-Based TVT Sling
For Hubbard’s female patients, incontinence is a common problem. The muscle
cradle that supports the bladder can become
relaxed with pregnancy and childbirth,
causing leakage when the bladder is under
pressure. In 1998, Hubbard began doing
tension-free transvaginal tape (TVT) sling
surgery, which provides a backboard for
the urethra and bladder to prevent leakage.
Hubbard prefers the TVT to other tape
procedures because it uses one vaginal and
two pubic incisions, allowing for a longer
tape. “There are no sutures that hold it, so
the more tape you have for the body tissue
to grab, the longer it’s going to last,” he says.
“I have done right at 1800 [TVTs] since
1998, and I have yet to take one out for
pain, infection, or body rejection.”
For patients who have the procedure,
Hubbard recommends a six-week muscle
training course that uses a vaginal probe
to measure patients’ squeezing and muscle
strength and provides much better results
than simply prescribing at-home Kegels.
With the TVT and some muscle strengthening, patients can avoid future pelvic prolapse
surgery, something Hubbard does not do.
Hubbard also does not treat pelvic floor
pain without bladder symptoms. For muscle
or nerve problems he refers to a physical therapist who specializes in the pelvic floor. “We see
more that have pelvic floor pain that have blad-
Photography by Brian Bohannon
Louisville These days, small, independent
practices seem harder and harder to come
by. The trend towards hospitals employing
physicians in large group practices is undeniable. Certainly, physicians are turning to
employment models to combat skyrocketing costs and ensure longevity in a changing
healthcare landscape.
However, John Hubbard, MD, urologist and the sole physician at The Hubbard
Clinic, says there are profitable ways to
maintain your independence. A selfdescribed “country doctor,” Hubbard has
capitalized on experience, personal circumstances, and bargaining power to establish a
niche practice. “I’ve been in practice a long
time. I know what I like. A great staff is
a must. I know what I want my patients to
have, and I like for my nurse extenders to do
the same thing … Because of that I opened
my own practice in 2000,” says Hubbard.
The key, according to Hubbard, is choosing in-office procedures that have low risk
for infection and performing those only on
healthy patients. He uses a nurse anesthetist
and performs all procedures under conscious
sedation. Patients who are ill or on a lot of
medications get referred to someone else, so
they can be done in a hospital setting.
Limited from doing big surgeries
because of his own back surgery but desiring to grow his practice, Hubbard found his
perfect formula in a niche urology practice
built around voiding problems in women
and men. Wanting to remain a solo practitioner, he uses nurse extenders to help cover
his patient load. One ARNP and one PA-C
see female patients for routine and followup visits, while Hubbard focuses on male
patient visits and procedures for all patients.
Six years ago Hubbard brought most procedures in-office after receiving accreditation
for office-based surgery, and he says the benefits are staggering. Insurance companies ben-
Special Section  Women’s Health
Dr. John Hubbard says, ”Medicine is evolving
into a big industry assembly line." He prides
himself on his staff’s relationship with
patients and their dedication to dealing with
problems the same day.
der symptoms along with it, and we’ve found
the great majority turn out to be interstitial
cystitis,” says Hubbard.
Interstitial Cystitis
Photography by Brian Bohannon
Not many treatable conditions start
with negative test results, but when the
patient reports frequent urination and
urgency, pelvic pain, and pain with sexual
activity but has negative urine cultures and
negative local cystoscopy, the diagnosis is
often interstitial cystitis (IC).
Often misdiagnosed as recurrent urinary
tract infections, IC does not have a known
cause. It is characterized by a lack of tightness
in the lining of the bladder, resulting in microscopic leakage of urine through the bladder
wall, which irritates surrounding muscles and
nerves. It affects both men and women but is
much more common in women.
According to Hubbard, “70% of the
treatment is telling patients, ‘We know what
it is. It is not dangerous, and you are not
crazy. You have to watch your diet, and we
will look at allergies.”
When Hubbard suspects IC, he suggests patients undergo cystoscopy. “We go
on how much the bladder will hold, when
you’re feeling the pain as we’re filling the
bladder, and do you break blood vessels
after we fill the bladder?” says Hubbard.
Dietary factors and allergies greatly
influence the condition. The first step
is educating patients that it is a chronic
condition, and avoiding certain foods and
beverages can improve symptoms. The
second step is to check for allergies. “Part
of our workup when we do biopsies [dur-
Dr. Hubbard
performs office
based procedure
under monitored
anesthesia.
ing cystoscopy] is to check for mast cells
to give us an idea if there’s a strong allergic
component. If so, we have an allergist
that’s very familiar with interstitial cystitis
that we work with to help that aspect,” says
Hubbard.
Treatment also includes medication. Elmiron is the only medication FDA
approved for the treatment of IC, although
it has some drawbacks: it takes a long time to
work, does not work in every patient, and can
be expensive. However, The Hubbard Clinic
also employs the use of natural products and
other medications to treat the symptoms.
The newest treatment in Hubbard’s toolbox
is Botox. Approved three years ago for use in
neurogenic bladders, physicians have begun
using Botox in IC patients to help the bladder retain more and hopefully reduce pain.
When all else fails in particularly difficult
cases, Hubbard refers for a urinary diversion
technique called an ileal conduit.
Other In-Office Procedures
In addition to the TVT sling, Botox, cystoscopies, and biopsies, Hubbard can also do
bladder distensions, correct bladder neck con-
tractures and urethral strictures, and remove
small bladder tumors in office. For male
patients, Hubbard offers the transurethral
needle ablation (TUNA) and transurethral
resection of the prostate (TURP) for treatment of benign prostatic hyperplasia (BPH).
Hubbard still does some procedures in
the hospital when insurance will not cover
office procedures or when the overhead is
prohibitive for him, such as the case with
Medicare patients. But he is banking on the
in-office procedures to help him maintain
his independence and the small office feel
his patients appreciate. ◆
For patient referrals contact:
The Hubbard Clinic
3924 Dupont Square South,
Louisville, KY 40207
(502) 893-3510
www.hubbardclinic.com
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