By Jeffrey Kaufman, MD – Past President CUA

As we go into Spring, 2016, the health care delivery landscape is evolving rapidly as the result of MACRA, passed one year ago to refine provisions of the Affordable Care Act (and once and for all, put an end to the SGR). We now have details on the post-SGR era: transitioning from stable reimbursement (0.5% annual increases) coupled with quality reporting (PQRS and Meaningful Use) into the next phase of Value Based Performance payments modified by MIPS scores (Merit Based Incentive Payment System). Beyond that we move to Alternative Payment Models (including ACOs, Bundled payments, Patient Centered Medical Homes and other novel experiments). Many of the details of potential APMs are not yet worked out but the government, nonetheless, is hurrying us in that direction. Much like the push to integrate electronic health records into our practices before they were capable of doing what is necessary (which has resulted in a firestorm of protests from physicians across the country), the government’s intent is to get us all into APMs and then work out the details later. Hopefully, the premature shift into APMs will not be like the premature use of EHRs which take a great deal more time, cost considerably more to participate with and dumb down records to accommodate the volume of irrelevant material needed to comply with audits and quality reporting but not necessary to delivering urologic care. Does this really sound like a logical approach? The carrots are getting smaller and the sticks larger as we move forward. There are many sources of information detailing the various bonuses and fines attached to performance but suffice it to say, failure to participate will become quite expensive, very soon. I can expand on detailed timelines, dollar amounts and criteria in a future article.

Practice pressures in California are reflecting the growing number of patients now enrolled in Medicare Advantage plans, Medi-Cal HMOs and narrow (or heavily tiered) networks. This movement of patients has impacted patient flow and interrupted historic doctor-patient relationships. But the trend is likely to increase since all of these plans are financially driven and very profitable to insurance companies. If you haven’t secured favorable contracts, you need to review your practice environment since these relationships are the foundation of upcoming APMs.

Medicare remains a bastion of fee-for-service medicine although quality performance and cost effective care are increasingly reviewed and used to modify fees (our transition to Value Based Performance Modifiers will be based on PQRS reporting and costs attributed to your care—you can control the former but the latter will be determined by CMS without your knowledge or input). We remain active at the California Carrier Advisory Committee consulting on many new tumor markers and you can look forward to a new Carrier Policy related to Testosterone Replacement Therapy coming soon. We have reviewed and commented on several drafts of this policy designed to cut down on the proliferating number of “Low T” clinics run by non-specialists but I think the final draft is one most urologists can live with. Please contact me if you have comments.

Travels: We are looking forward to the upcoming national AUA annual meeting held here in California in San Diego in May. I hope to see many of you there. I just got back from our annual meeting with legislators in Washington, D.C. at the Urology Joint Advocacy Conference with several other urologists from around the state including Eugene Rhee (former president CUA), Aaron Spitz (current CUA president) and Dean Hadley (president Western section, AUA). I think it was a successful effort talking with Congressional members and staffers about HR 1151 designed to revise the structure and function of the USPSTF who as you all know. made a grade D recommendation regarding PSA testing (does more harm than good in their opinion) without respect to individual patient risks. This has already resulted in many fewer patients tested with PSA, a substantial drop in prostate cancer diagnosis and a correspondingly increased number of patients presenting with more advanced disease, later in their course (and presumably less likely to cure their disease). This is very threatening to men’s health and takes us back to the 1970’s and the pre-PSA era. We impressed our legislators with the very great impact on diagnosing and curing prostate cancer likely to occur from this group who considers their recommendations without any input from experts in the field. HR 1151 will not reverse their PSA recommendations but will substantially change how the Task Force functions and de-couple their conclusions from Medicare criteria.

Across the country and especially here in California, we are suffering increasing problems with Urology manpower shortages. Forecasts predict we will be 130,000 physicians short of needs by 2025, ½ of whom will be primary care doctors and ½ specialists. Although primary care has received a great deal of attention and funding recently, there are only 9500 practicing urologists nationally of whom about 500 leave practice per year for various reasons. And we only have 302 funded residency slots. We are at the leading edge of the baby boomer generation (who will all need urologic care) and the ACA has expanded insurance coverage and access to care for millions of Californians. Although Nurse Clinicians and Physician Assistants can help with the load of patients with chronic disease in primary care offices, this is less helpful in urology where many patients need procedures or complex care not amenable to advanced practice nurses. Add to this the fact that urologists are the second oldest group of specialists with many planning retirement soon. Bottom line: our specialty is short-handed, getting shorter and at the leading edge of increased numbers of patients demanding/needing urologic care. I don’t have to tell you that every urologist I know is busy and having difficulty recruiting new partners. HR 2124 will provide new dollars to expand urologic training slots to help ease our future shortages. We forcefully made our points in Washington that patients with insurance coverage need to have available physicians to actually translate expanded coverage into increased access to care.

We also used our time in Washington to discuss the impact of EHR on our practices, costing us dearly in software and maintenance, slowing our patient flow and disrupting health care delivery emphasizing chart documentation over actual urologic care. We complained that physicians have become sophisticated data entry clerks, not doctors. Unfortunately, reliance on electronic records is only going to expand in the coming years.

Fortunately, we no longer need to waste our time lobbying against the SGR. And pressure to eliminate the IOASE (In Office Ancillary Services Exemption) of the Stark laws is no longer a major threat. The historic monopolizing specialties challenging us have given up for the most part after suffering defeat after defeat (due to our vigorous lobbying at many levels, national and local). Moreover, as we move away from fee for service where ancillary services might be a profit center to APMs where they become a cost center, the issue becomes moot. The Stark laws were written for a FFS environment and are no longer relevant to a VBP or capitated system like we’ll have with APMs. These changes leave us more time and political capital to focus on new or more challenging issues.

As you can imagine, lobbying Congress on Super Tuesday of the current election cycle was an interesting event. There is an enormous amount of rhetoric in Washington about healthcare. All Republicans promise to repeal Obamacare but none of them have a plan or clue about what they propose to replace it with. Handicapping the election, we are likely to have a Democratic President and the Democrats have a good change of taking back the Senate. The likelihood of major changes in our system is slim. We will see incremental modifications, revisions and refinement but the direction healthcare is changing is set. Fee for service is not dead—yet—but pressures are continuing to limit traditional models forcing evolutionary changes toward APMs including bundled and capitated care even though we don’t know the details of what those systems will entail. To remain successful, stay informed, stay alert and stay involved.


Jeffrey Kaufman MD, FACS

Past President CUA

Past President WSAUA

Member, Noridian, California Medicare Carrier Advisory Committee      

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