Welcome to the Inagural Issue- APRIL 2007


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Our Commitment is to Our Membership!

President's Message byDouglas Chinn, M.D.


The CUA is supporting our voices as urologists and fighting to maintain or gain ground on many issues. During this past year, we have had issues with Balance Billing, Radiology turf battle, CAP reimbursement rates, Medicare audits (CERT Process), and Medicare cuts.


The CUA has many representatives attending various meetings to support urology issues.
Dr.Joseph Kuntze was recently elected to President-Elect, he has been a contributing member on the COL and we look forward to his succession as an officer. READ MORE...



HEALTH CARE REFORM IS IN THE AIR

By Jeffrey Kaufman MD, FACS
California Medicare Carrier Advisory Committee

WSAUA Health Policy Chair

AACU President

It seems that not a day passes without at least one of the major news services focusing on some aspect of our current health care crisis.  Employers are increasingly vocal about the impact health care costs are having on their bottom line and their ability to compete with foreign companies.  Blue Ribbon commissions are wondering whether patients are getting value for their money... READ MORE... 



CUA Young Urologists Report

By Daniel J. Cosgrove, M.D.

CUA Representative to the Young Physician's Section of the CMA

The CMA met in Sacramento for the Annual Meeting on October 28-30 and just prior, the CMA Young Physicians Section (YPS) held our Annual Assembly.  I was honored to represent the CUA at the YPS Assembly and am taking the position over from my esteemed colleague Dr Lamia Gabal-Shehab who has moved on to become the president of the Orange County Urologic Society. READ MORE...




10th Annual California Health Care - Leadership Academy
Friday-Sunday, April 13-15, 2007
Monterey Conference Center, Monterey, California
MORE INFO...

CMA's 33rd annual Legislative Leadership Conference
Tuesday, April 24, 2007 (11:30am - 1:30pm)
Sheraton Grand Hotel, Sacramento, CA
MORE INFO...

American Urological Associtation Annual Meeting
Saturday - Thursday, May 19-24, 2007
Anaheim Marriott, Anaheim, CA
MORE INFO...

CUA Interim Board Meeting
Sunday, May 20, 2007 - 11:30am - 1:30pm
Anaheim Marriott during AUA Annual Meeting
Marquis Ballroom, Northwest Salon

CUA Annual Meeting and Lunch
Tuesday, October 30, 2007 (12:00pm - 1:30pm)
During the Western Section AUA 83rd Annual Meeting
MORE INFO...


BALANCE BILLING ARTICLES
balance billing: the practice of billing the patient for the difference between a health care plan's payment and the physician's full charge.



California Urological Association
1950 Old Tustin Ave.
Santa Ana, CA 92705
TEL: 714-550-9155
FAX: 714-550-9234
EM:
info@cuanet.org
WEB: www.cuanet.org

 



Our Commitment is to Our Membership!
President's Message by Douglas Chinn, M.D.

The CUA is supporting our voices as urologists and fighting to maintain or gain ground on many issues. During this past year, we have had issues with Balance Billing, Radiology turf battle, CAP reimbursement rates, Medicare audits (CERT Process), and Medicare cuts.

The CUA has many representatives attending various meetings to support urology issues. Dr. Joseph Kuntze was recently elected to President-Elect, he has been a contributing member on the COL and we look forward to his succession as an officer.

Dr. Jeffrey Kaufman will be attending the Joint Advocacy Conference meeting in Washington D.C., along with other representatives from the Western Section AUA, where he will be able to meet with leaders on the Hill lobbying our concerns this month. He will also learn about current legislative issues. I will also be attending the CMA Leadership Academy with Dr. Kaufman in April.

Dr. Phil Weintraub will be representing the CUA at the CMA's Commission on Legislation meeting in Sacramento this month as well.

Dr. Marty Prah has accepted the newly elected position of CMA Alternate Representative, and we look forward to his participation and insights. He will be working with Dr. Thomas Hildreth who is currently the CMA Representative.

Dr. Robert Eisenberg is our representative to the California Technology Assessment Forum (CTAF) where he attends the meetings and is requested to submit assessment statements from the CUA on various technology issues.

Dr. Danny Cosgrove will now represent our younger urologists as the Representative to the CMA's Young Urologist Representative.

As you can see we have many members within the State that are our reaching arms for information and representation.

We have received many hotline issues which we are in the process of working out. Please continue to let us know of arising problems in your area.

Be sure to join us at two of the upcoming CUA meetings:
1) During the AUA meeting in Anaheim on Sunday, May 20, 2007 - Anaheim Marriott Hotel, 11:30-1:30 pm – lunch will be served.
2) During the WSAUA Annual Meeting in Scottsdale on Tuesday, Oct. 30, 2007 - Hyatt Regency Gainey Ranch, Scottsdale, Arizona at 12:00 noon, lunch will be served.

I would like to thank Envisioneering Medical Technologies and representative Myrick Tantiado for supporting the CUA's Annual Members meeting in Maui last year. We certainly appreciate the help from contributing companies to assist in our goals.

This year we have made all California non-members a member at no charge for the year. We hope you will see that the CUA does make a difference. We are an organization that really works behind the scenes without any fluff. We work and lobby against issues that negatively impact your practice. The CUA is one of the strongest state societies in the USA.

The CUA is on the move for California urologists. It takes all of us, not just a few of the leaders to make our voices heard. Please support the organization that supports urology practices.

The CUA is a very amicable organization. I invite any of you who wish to become involved in the work of the CUA to contact myself or Jeannie DeSantis at the office. We need new energy, ideas and initiatives and welcome your thoughts, suggestions and input.


HEALTH CARE REFORM IS IN THE AIR
By Jeffrey Kaufman MD, FACS
California Medicare Carrier Advisory Committee, WSAUA Health Policy Chair, AACU President

It seems that not a day passes without at least one of the major news services focusing on some aspect of our current health care crisis. Employers are increasingly vocal about the impact health care costs are having on their bottom line and their ability to compete with foreign companies. Blue Ribbon commissions are wondering whether patients are getting value for their money and decrying what is perceived as a lack of quality in the system. Consumers are in an uproar over increases in their health insurance premiums even while coverage is diminished, deductibles and co-pays are increasing and many can't get coverage at any price. Of course, that's assuming you can even get into the system. The media have seized on the fact that 47 million Americans are without any type of coverage which has significant impact not only on their resources but on the rest of us providing their care or paying into the system. Throughout all this, the government is scrambling to address the problem of who to cover, how much to cover and how to pay for it. While there is no consensus in sight on how to resolve these problems, no one seems to have difficulty identifying and characterizing the challenges-and agreeing that we are already at the crisis level.

Recognizing that states are the "laboratories of innovation for health care reform", the AMA recently hosted an excellent meeting addressing these and other issues entitled the State Legislative Strategy Conference. I was one of only two urologists among over 200 physicians and medical group executives who met to discuss those challenges to delivering affordable, quality health care common among the various states. Of course, any meaningful long term solution will ultimately have to come from Washington but at the moment, a number of states have made a beginning. Massachusetts, Maine, Vermont and Maryland have all passed legislation aimed at who pays for health care (even while they are short on ideas on how to lessen overall health care costs). New York, California and many others are currently considering similar plans. In common, many of these proposals are moving toward universal mandatory coverage, pay or play funding, and mandated or model benefit packages (such as ob coverage, midwifery, chiropractic and/or naturopathic services, emphasis on prevention and healthy lifestyle, gym membership, and direct reimbursement for non-physician providers such as nurse clinicians or physician assistants). Many also address information technology, pay for performance measures and limited coverage bare-bones packages in an effort to address cost control (the real problem). Others are more focused on shifting the cost burden by considering mandatory coverage for only the largest employers (Maryland's unsuccessful attempt to legislatively single out Wal-Mart) or selectively taxing hospitals, physicians and other health care providers. Interestingly, however, not a single proposal has yet come forth that would tax the insurance industry's healthy profits.

As the 2008 elections approach, it's certain that this topic will be debated more on the national scale. Among polled Americans, health care is considered the number one domestic issue at present. Unfortunately, costs are increasing, Medicare funds are running out, President Bush has indicated his desire to cut billions from health care programs as he seeks to balance the budget over the next 5 years, and despite arguing the issue for years, we still are no closer to replacing the flawed and unfair Sustained Growth Formula used to update Medicare fees.

Locally, you would have to be living under a rock not to know that governor Schwarzenegger recently put forth his own proposals to deal with California's situation. One item included a prohibition on balance billing for patients seen in the emergency room. The CUA worked with CMA to challenge this administrative rule and it was withdrawn. Otherwise, you would have lost all leverage in contract negotiations with payers who would offer take-it-or-leave-it contracts knowing that you would be obligated to accept whatever they chose to allow as payment in full for any patient seen in an emergency situation. Other aspects of his plan include a tax of 4% on hospitals and 2% on physician gross receipts. Obviously, for specialties like ours with very high overhead and certain very expensive items (such as LHRH agonists and bladder cancer drugs) which have little or no profit margin, such a tax is unacceptable But what you may not realize is that there are currently at least 15 competing pieces of legislation seeking to reform the health care system before legislators in Sacramento and the Governor's is not only dead on arrival, it has not even been formally introduced (nor is it likely to be). Although Arnold has national stature and his proposals received a great deal of attention, they are only discussion points. In fact, his agenda has something to displease everyone among the major stakeholders (Democrats, Republicans, unions, employers, MDs and hospitals) even while it would be a dream for insurance companies who would reap windfall profits. Nonetheless, with so many proposals under discussion, there's a good chance that some type of compromise bill will emerge. Recall however that this is the same legislature that passed a version of Sen. Sheila Kuehl's (D-Santa Monica) single payer system last session only to have it vetoed by the governor. Naturally, it is again under consideration and while the legislature is in session, one never knows what may happen.

Another concern regarding insurance payments is the proliferation of silent PPO's. This market allows the secondary sale of contracts you have signed to other groups not bound by the original document to deal with you fairly. The market is so huge (and so many physicians are unaware of the implications) that millions of dollars that should be reimbursed for care are instead siphoned off to middle men. Most of us have signed contracts with mixed rates that pay appropriately for many of the procedures we do but significantly underpay for others. If the contract is good on balance, we usually accept the bad with the good concluding that, overall, the contract will pay sufficiently. As managed care has proliferated and various contracts include different groups of poorly reimbursed procedures, it has become possible to cobble together a list that includes nothing but the poorest paying codes. With the silent PPO market in full play now, an agent acting as a clearing house can compare all the contracts you have signed over the years and choose that which will pay the least for any given patient, for any given service, on any given day and pay you the lowest amount possible. Since many of the contracts you have signed have not actually been with insurance companies (the middlemen in these schemes are nothing more than re-packaging contracted groups that re-sell further down the line), your computer would not likely identify the underpayment as such. Even when you make an effort to drop a poorly performing contract, these middlemen may not acknowledge your decision and continue to pay at the lower rate until your system catches the error. Bottom line, most practices are losing a great deal of income due to this process. The CMA, AMA and other groups have introduced model legislation that would halt this abuse by demanding clarity in contracting and prohibiting the resale of any contract without your specific agreement. Without control over your contracts and fee schedule, you have no ability to steer the economic health of your practice.

The final state issue to address concerns the ongoing pressure from the American College of Radiology to prohibit reimbursement for imaging procedures to anyone other than a board certified radiologist. In the past year, many bills were introduced (unsuccessfully) into a number of different state legislatures that would ban anyone other than a radiologist from performing or billing for CT, MRI or PET scans. While there are few urologists who presently own these units without the cooperation of a radiologist, some larger groups have realized the benefit of performing their own studies recognizing their ability to provide quality care to their patients based on what is taught in our residency programs and tested for on our boards. Additionally, the treating urologist's intimate knowledge of his patients' medical condition often makes him the best equipped party to interpret those studies. Even if we ignore that issue, the move to prohibit any doctor other than a radiologist from doing imaging is now being extended to include ultrasound. While many of your radiology associates would claim that such is not their goal, the private payers have seized on this turf battle within the house of medicine to cut back on reimbursements. Highmark, the Blue Shield Blue Cross carrier for western Pennsylvania and Oxford Health Plan, the northeast payer are both now denying payment to urologists who perform in-office studies including bladder ultrasound and ultrasound imaging to direct prostate biopsies. The AUA has established an ad hoc committee to deal with these issues but it remains our responsibility to aggressively insist that these procedures are an integral part of any urology practice, that we are trained to perform and interpret them to the highest quality standards and that our patients would be severely injured by referring them elsewhere. It is deeply unfortunate that the radiology community does not see the folly of fighting over turf lest we all suffer (I was always taught that when circling the wagons, the idea was to shoot outward!). But, until this attack on the integrity of our specialty is resolved, we must remain vigilant against any threats of prohibition on any aspect of the skills we have been so thoroughly trained for.

Finally, a few comments about Medicare. As you realize from my past columns, the last minute reprieve that prevented a 5% cut in payments January 1st was a loan, not a gift. Without a substantial change in the Sustained Growth Rate formula, fees will fall 10% next year, and more thereafter. Despite all of our lobbying efforts in the past, the new Democratic Congress must be convinced yet again that updating the payment formula is the right thing to do. As tiring as this perennial effort has become, we cannot afford to back off from insisting that updates should be based on the cost of delivering medical care with appropriate adjustments upward every year. Needless to say, with the federal deficit growing and funds diverted to Iraq and the war on terror, there is growing resistance in Washington to spending more on health care. Some have also seized on reports that they are not getting value for the dollars already spent and have focused on performance criteria to justify new levels of reimbursement.

Indeed, part of the legislation that froze Medicare fees this year was a pay for performance plan scheduled to begin July 1st. Using criteria borrowed from the previous voluntary plan, those participating will receive additional payments up to 1.5% of their total fees. Over time, these criteria will hopefully be adjusted with input from the AUA to allow a more meaningful and user friendly system. I hope to report more on the nuts and bolts of this in future articles. Other CMS issues specific to California include a new NHIC policy that will reimburse for the use of Botox injections for neurogenic bladder dysfunction. I believe this is the first such policy in the country and should expand access to this therapy for appropriate patients. At the same time, after extensive discussion, Trelstar is finally now considered when computing the least costly alternative medication among the LHRH injectables for prostate cancer. Please review the published quarterly updates for current reimbursement levels based on Average Sales Price +6%. A presentation will also be made this month to CMS regarding proposed rule changes governing independent pathology laboratories (so called "pod labs"). The AUA has discussed this at length since certain pathologists have criticized the practice of urologists partnering with pathologists to focus on urologic specimens. While many believe the emphasis improves quality by concentrating experience, some pathologists feel threatened and some have raised concerns about potential abusive billing practices. A great deal of discussion has gone into constructing our response to CMS hoping that they recognize our concerns and rule accordingly. The issue may have far reaching effects beyond payment for pathology processing since the principle also impacts other shared investments between specialists focusing on the same medical problem. I will have more on this in a future article but please write or contact me if you have an interest in this issue.

Last, I have previously written on California's experience with the Recovery Audit Contractor program, a bounty hunter scheme designed by Congress, administered by CMS, created to review processed charges and demand reimbursement for incorrect overpayments. At the next Medicare meeting as well as at our annual Joint Advocacy Conference in Washington at the end of March, more on this program (which has now been made permanent and expanded to all 50 states) will be presented. I will update you on these developments in a future article but please notify the CUA if you feel you have been unfairly targeted by the RAC.

Given the current status of health care programs in America, it's clear that the status quo cannot last much longer. With so much at stake, each interest group has been lobbying for changes favorable to their interests at the expense of others. If we do not engage in the discussion as well, we will be forced to live with a system not of our making and very much not to our liking. Every urologist and every physician in California should speak up and let his legislator know what your day to day experiences are regarding the overbearing demeanor of the few, large insurance companies that now control the bulk of patients seen daily in our offices. Demand that the Department of Managed Health Care takes a more active role regulating the industry. Give them examples of how silent PPO's and the secondary market for physician contracts has robbed you of control of which patient you agree to see for what level of reimbursement (and ask for full contract disclosure legislation that prevents the secondary sale of your contract). Let them know how low paying Medicaid rates prevent you from providing care to the poor and needy without losing money. Give them examples of how many patients you have seen in the emergency room for free (and how disruptive that is to your practice) illustrating how important it is to retain the freedom to bill those who are able to pay, irrespective of who their HMO is when you're not under contract. Emphasize your willingness to adjust fees for hardship cases seen as an emergency but refuse to allow government to set fees arbitrarily that they unilaterally consider reasonable. Tell them how important imaging studies (and in-office ultrasound) are to your practice, how you were trained and tested throughout your residency in this area and how necessary it is for urologists to retain control of these tests to insure quality care to our patients (not to mention how your clinical knowledge of the patient's medical history makes you the most qualified physician to interpret those studies). Point out emphatically that you could not withstand an extra 2% tax across the board on gross receipts in this economic market and still retain a viable medical practice (nor should you be asymmetrically responsible for a service which benefits all the residents of the state equally). Remind them how important it is to retain MICRA without amendment or revision in order to restrain the threat of runaway malpractice costs-they only have to look to other states to see the unsupportable price associated with loosening those protections (and remind them yet again that economic damages have no limit under MICRA as fairness would demand).

I cannot emphasize enough how important it is that you engage in these discussions. Without your input, someone else will be advising those who make the laws and there can be no doubt as to who will benefit. This year and next may be the most crucial of your career with respect to determining the health of your future medical practice. Employ a bit of preventative medicine and get involved now. I hope to see many of you at the AACU-AUA Joint Advocacy Conference in Washington March 25-27, 2007 and at the CMA lobbying effort in Sacramento April 24, 2007. For those of you who can't find the time to attend these important events, please contribute to UROPAC, our specialty political action committee. Your dollars open doors allowing us access to make an argument on your behalf. Physicians absolutely must organize if we are to have a voice in any new system. And change is in the air.


CUA Young Urologists Report
By Daniel J. Cosgrove, M.D.
CUA Representative to the Young Physician's Section of the CMA

The CMA met in Sacramento for the Annual Meeting on October 28-30 and just prior, the CMA Young Physicians Section (YPS) held our Annual Assembly. I was honored to represent the CUA at the YPS Assembly and am taking the position over from my esteemed colleague Dr Lamia Gabal-Shehab who has moved on to become the president of the Orange County Urologic Society.

The YPS is comprised of CMA members under the age of 40 or those who are within the first five years of professional practice after completing training.

At the meeting I reconnected with old friends and met many new physicians. We all were there with similar goals; to support the CMA, to communicate to the CMA the perspective of its young physician members, and to encourage young physicians to get involved in organized medicine.

The YPS assembly began with a general discussion of political advocacy and getting physicians involved in the legislative process. We had a crash course in communicating with the press and learned about how the CMA media relations staff can assist with the sometimes frightening experience of talking with the media.

Dustin Corcoran, a lobbyist and VP of the CMA Center for Government Relations, gave a dynamic and fascinating presentation on lobbying, the political process and what is being done to get the CMA's interests before the Federal and California State Legislatures. Among other things, this year we can look forward to a lively debate on how to provide medical care to Californians who are uninsured, reimbursement issues, and the continuing defense of MICRA.

We had lunch with Dr. Jack Lewin, the outgoing CEO and Executive VP of the CMA as well as Dr. Anmol Mahal, now President of the CMA. They both stressed the importance of getting young physicians involved in the political process as legislative decisions made today will directly affect the way we practice medicine over the course of our careers.

We ended the session with a discussion on how to reach out to young physicians in every specialty and get people more aware and involved in the CMA. One way is through a much needed upgrade to the CMA website which will make it more user-friendly and accessible to our tech-savvy young physicians.

I think we all left the meeting energized and excited about the CMA. We could see how limited our lobbying resources are compared with those of the lawyers, the Insurance and Pharmaceutical industries and realize how important the CMA is (as is the CUA) in advocating and protecting our interests. If you are not yet a member of the CMA, please join. If you are a member, get more involved!!

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