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The bill, H.R. 2474, would tie the Medicare physician fee schedule to the Medicare Economic Index (MEI), something the AACU and the AMA have long supported

What is H.R. 2472?

"This year's Summit was one of the biggest and most exciting so far," says Kevin Koo, MD, MPH.

2023 AUA Summit focuses on 4 main legislative priorities

Telemedicine risks can be managed by staying informed and educated.

What are the potential legal risks of telehealth?

Based on 5- and 10-year study periods, physicians with single or multiple paid medical malpractice claims “were shown to have a greatly elevated risk of having additional paid claims during a future period,” the authors wrote. 

Prior paid malpractice claims linked to increased risk of future claims

While AI is promising, there are potential legal and ethical challenges that must be addressed, according to the experts. 

Policy experts stress the need to regulate artificial intelligence in health care

 provides take-home messages from the study, “Estimating the impact of the Inflation Reduction Act on the out-of-pocket costs for Medicare beneficiaries with advanced prostate cancer,” for which he served as the lead author. Cortese is a medical student and business student at the Perelman School of Medicine and the Wharton School of Business at the University of Pennsylvania in Philadelphia.

I want to preface this with the fact that I'm still a student entering the match this year for urology residency, so I have a lot to learn myself. But if I had to boil it down to a couple of take-home messages it's that there are real, tangible consequences when we prescribe medications to our patients, not just the [adverse] effects studied in clinical trials. For example, that financial toxicity I mentioned before. Additionally, we have to work closely with our patients to understand what do those finances look like for medication regimens, and we need to be equipped with the tools in order to counsel them effectively. So, trying to explore, like we're doing with this practical guide that's coming up, but also other tools that we're able to use in order to counsel our patients more effectively without adding a lot more paperwork and administrative burden to our days. So, just making sure that we're equipped with the right tools.

And then I think, lastly, on a policy level, it's important to push for the right balance of both protecting patients with cost sharing, but without encouraging wasteful or indiscriminate spending. There is data out there to suggest that when patients experience no cost sharing that there is higher utilization of low value care and services. But when there's too high, you're indiscriminately cutting back on both high value and low value care. It's striking the right balance of making sure that people are invested, but not breaking the bank. These measures in this Inflation Reduction Act paper that we wrote, demonstrated that it could affect 10s of 1000s of patients with advanced prostate cancer. Just imagining how many patients across the country that are not specifically in urology that could benefit from this new provision, the Inflation Reduction Act, is pretty exciting. I think those are couple of the main takeaways.

And I think, one last point that I have to add, I think that providers and their associated practices are increasingly becoming financial counselors for their patients. And I think this role should be embraced, whether it be the individual clinician, their practice at large, or a dedicated group if they have a bigger infrastructure. But I think it's important that as we continue to counsel our patients on the best medications, the most evidence-based regimens, it's also important to know that we are driving the decision making for a lot of what patients decide to pursue, and becoming more versed in this space can only help the clinicians.

This transcription has been edited for clarity.

Videos

“There are real, tangible consequences when we prescribe medications to our patients, not just the [adverse] effects studied in clinical trials,” says Brian Cortese. 

Study highlights the importance of financial considerations for treatment decisions in urology 

In this installment of “Begin Your Journey,” urologist Amanda C. North, MD, talks with host Scott A. MacDiarmid, MD, FRCPSC, about burnout among women urologists as well as advocacy work regarding telemedicine reimbursement. North is an associate professor of urology at Montefiore Medical Center in Bronx, New York. MacDiarmid is a urologist with Alliance Urology Specialists in Greensboro, North Carolina.

MacDiarmid: Are there a few takeaways of why burnout appears to be higher for women in urology?

North: We know work-life integration is harder for women. I think the younger generation of men are more committed to work-life integration than maybe the older generation. I think, when we look at older urologists, many of them had a more historic model of a woman at home or a woman working part time with a man working full time plus in the office. And now families are more dual-income, both trying to contribute at home. But we do know that women carry a disproportionate burden at home, with raising children, obviously child birth and all of that. The 2021 census took place during the pandemic, so child care issues, homeschooling during the worst of the pandemic, again, disproportionately impacted women. But I think something that we need to understand further is we know that women urologists are far more likely to be employees than men in urology. Men in urology are more likely to be practice owners and partners, where they have more of a say in the day-to-day operations of their practices. We know physician autonomy relates to burnout. The more say you have in your practice, the more autonomy you have in your practice, the less burnout you feel. And with women disproportionately going into academics and disproportionately being employees, it may also be that they have a lack of autonomy in their work life in addition to having the home burden, and that may well play a big factor in the increased burnout we see.

MacDiarmid: Share with us the advocacy work that you folks are doing with the government.

North: It's amazing. There are 2 urology PACs, or political action committees. One is through the AUA—the AUAPAC—and the other is UROPAC, through the AACU. Both have done incredible advocacy work. I think one of the hottest topics for advocacy right now relates to reimbursement for telemedicine. During the pandemic, there was a waiver where we were able to do audio and video telemedicine and get reimbursed. Also, physicians were allowed to practice telemedicine across state lines during the emergency waiver. That's obviously all coming to an end. And so the future of telemedicine is going to be highly dependent on whether we get reimbursed for our work. Every year on the census, we've asked telemedicine questions. This year, in particular, [we included questions] relating to video and audio telemedicine to help demonstrate to our representatives in Congress the need to continue to pay for telemedicine because it provides such a value to both urologists and more importantly to our patients. Allowing elderly patients who may not understand how to use video telemedicine, to be able to have a phone call visit with their urologist can be very helpful. I take care of children; if we're talking about something like bedwetting, it's very easy to do that over the telephone. I work in the Bronx; many of our patients lack broadband access. So again, being able to do that as a phone call rather than requiring video can be very valuable to our patients. These are the types of issues where we try to marry what we do in the census to what the legislative affairs component of the AUA is doing so that we provide the data they need to advocate for us and for our patients. That's been something I'm very proud of working on the data committee.

“I think one of the hottest topics for advocacy right now relates to reimbursement for telemedicine,” says Amanda C. North, MD. 

Expert discusses advocacy for maintaining telemedicine reimbursement 

 highlights implications of findings from the study, “Estimating the impact of the Inflation Reduction Act on the out-of-pocket costs for Medicare beneficiaries with advanced prostate cancer,” for which he served as the lead author. Cortese is a medical student and business student at the Perelman School of Medicine and the Wharton School of Business at the University of Pennsylvania in Philadelphia.

They can be placed into 2 buckets. One is policy and then one is clinical practice. In the policy bucket, it highlights that the Inflation Reduction Act could impact the livelihoods of a lot of patients by reducing their annual out-of-pocket costs. And, yes, [they] are implementing this maximum and the cost is going to be distributed; that money doesn't disappear, that cost is taken up by other players, such as Medicare Part D plan sponsors, Medicare itself, as well as some of the pharmaceutical companies that are creating those drugs. So, there is a cost-sharing that's happening, but we have to make sure that we're able to provide these medications to our beneficiaries without totally breaking the bank. If they're unable to afford them anyways, then they're no good.

Second, I think in the practice bucket, it gives clinicians and especially urologists, in this case, something to think about when it comes to treating patients with advanced prostate cancer. Financial toxicity is something I'm very passionate about exploring and seeing how we can reduce it. It's this side effect of certain high priced, maybe specialty medications. Providers need to be acutely aware of how prices of these medications affect their patient's well-being. We tried to be a little bit provocative in this article talking about how certain medication regimens for example, abiraterone with prednisone as well as androgen deprivation therapy, that's 1 of the regimens accepted by the American Urological Association. We tried to say that based off of the out-of-pocket costs, as well as their clinical outcomes, that this medication regimen might honestly be the most cost-effective across all of them. Of course, there's caveats to that. We go into a greater discussion about exactly what are the ups and downs to that statement that we made. But I think it's important that we hypothesize and discuss the implications of what does this look like practically for urologists in the community as well as academic medical centers to prescribe to their patients.

"The Inflation Reduction Act could impact the livelihoods of a lot of patients by reducing their annual out-of-pocket costs," says Brian Cortese. 

Policy and practice implications of the Inflation Reduction Act for urology

 discusses the advocacy surrounding PSA screening recommendations at the 2023 AUA Summit, where he was part of the discussion "Breaking Down Barriers to PSA Screening". Murphy represented R. Frank Jones Urological Society at the Summit, and he is currently an assitant professor of urology at Northwestern University's Feinberg School of Medicine in Chicago, Illinois.

PSA screening as a whole went down after the US Preventive Services Task Force gave PSA screening a D grade. That was because they thought that the risks of the tests actually outweighed its benefits. There was some data behind that for them that made that recommendation possible. They really focused on level 1 evidence and clinical trials. We didn't really have a lot of great data in that space, because the trials had been contaminated in the control arm. Those trials showed that up to 83% of the people in the control arm had screening. We had to go with data that the US Preventive Services Task Force doesn't usually use, which is retrospective data that they don't consider.

The other thing that happened in the time that that decision happened was we were not using active surveillance and monitoring approaches for prostate cancer. We can surveil people and avoid overtreating them with surgery and radiation by a lot. Now, 43% of people are getting active surveillance instead of active treatment, so that risk/benefit ratio should be skewed towards much more benefit towards screening now. We're in a different day, different era. I think has been reevaluated with urologists involved. That grade that is provided by the US Preventive Services Task Force, it's now a C. That's C still means that insurances can either cover that test or not.

One thing that I highlighted in my presentation was that I go out to the community and do screening in the community on Chicago's south and west side. Even with me showing up with my team with a free PSA test, it's hard for me to reach people to get them to do this test. We bring out giveaways, and other health materials are provided, food is provided sometimes, and still men won't get it because it's not ranking high on their priorities of things to do. We often serve people who are uninsured, underinsured, or even if they're insured, only about 38% of them will get a PSA screening in a given year.

So given all that, we wanted to make sure that it was highlighted that men really need to be screened, and it should be covered by insurance. The C grade makes it hard for folks. It's pretty much covered in men 55 to 69, based off The US Preventive Services Task Force recommendation. But it is not covered for aged 40 to 54 routinely, and that's a time when men with family history and Black men with African ancestry are at increased risk of cancer compared to whites for having prostate cancer. Our purpose was really to tell Congress that we need men with high risk for prostate cancer to be treated as if they had an A or B grade on their PSA screening so that insurances will be forced to cover the tests without a copay going to the patients, which will discourage many men from actually participating in PSA screening, even high risk men, who just are not aware of the benefits of it.

"We wanted to make sure that it was highlighted that men really need to be screened, and it should be covered by insurance," says Adam Murphy, MD, MBA, MSCI.

Dr. Murphy highlights advocacy for PSA screening at the 2023 AUA Summit

 discusses advancements that she hopes to see come from the 2023 AUA Summit. Asafu-Adjei is a urologist at Loyola University Medical Center in Chicago, Illinois, as well as the 2023 AUA Gallagher Scholar and a member of Urology Times’ Editorial Board.

I hope in the next couple of years, especially with some of our asks, I hope that more people have on their mind the goals of practicing in some rural and underserved areas around the United States. There just are not enough urologists. As we continue to gain support for the SPARC Act, and really get that through, I think this will allow us to place more urologists where the need is, and continue to close that gap.

Telehealth, I think that's here to stay. As we continue to advocate for that, along with some of the other specialties, I think, we want to continue to show the world that when you perform telehealth, it's just as much work as if you're seeing someone in the office. It also is a great approach to dealing with the access to care issue that we face in medicine constantly. I really hope to see continued support and expansion of how we deliver medicine and help with access to care.

I think that there's also a ton of exciting work and research and support around fine tuning and being more specific in how we target our high-risk prostate cancer patients. African American men are at a higher baseline risk for prostate cancer. How this plays into policy and how some African American and other high-risk men, how they're able to get the care they need early on is important. I hope that as we continue to gain more support for that policy area, I hope that we do see more men that can get to a urologist, get screened appropriately, and hopefully get treated in a timely fashion, as appropriate.

Continued conversations and work with Medicare and our representatives to preserve physician payments and reforms. I think there's a lot of great doctors doing great work. We have to continue to also make those reimbursements and that compensation equitable. I hope that we continue to see hopefully a stable system when it comes to physician reimbursements. But I think the future's bright, and I think we have a lot more people engaged, and we are using different avenues, social media, different platforms, to get more people informed. I think in the next few years, we're going to see a lot more voices out there, and I think that's going to move the needle on some of these issues.

This transcription has been edited for clarity. 

"The future's bright, and I think we have a lot more people engaged," says Denise Asafu- Adjei, MD, MPH. 

Dr. Asafu-Adjei on advancements she hopes to see come from the 2023 AUA Summit

discusses the Specialty Physicians Advancing Rural Care (SPARC) Act, one of the key legislative priorities of the 2023 AUA Summit, which took place in Washington DC. Koo is a urologist at Mayo Clinic in Rochester, Minnesota and on the Board of Directors for the American Urological Association Political Action Committee (AUAPAC).

We know that our patients live in diverse geographic areas. Sometimes they're urban, sometimes they're suburban, and sometimes they're rural. Here at Mayo Clinic, our patients live across Minnesota and the surrounding states. Some of them are living in the cities and others are farming in some of our more rural areas. Regardless of where patients live, we want to be able to do the best we can for them as urologists and take care of their urological needs. But the urology work force is a bit maldistributed, which means that more urologists live in urban and suburban areas than rural areas and this creates some potential disparities in access to care, which is so important for us to address.

Telehealth is one option that can help us to bridge that divide, but we know that care is easiest for patients and most efficient and effective when that care is close to home. That's why helping urologists establish practices in rural areas and incentivizing those practices is so important. One of the pieces of legislation that has been supported by the AUA and by the urology community for many years, and it was first introduced in the last Congress, is the SPARC Act, which stands for the Specialty Physicians Advancing Rural Care Act. This is a bill that establishes a new loan forgiveness program for specialty physicians, including urologists who establish their practices in rural areas.

Specifically, it provides up to $250,000 of educational loan repayment for up to 6 years of service in those areas. Every year, about 1/6 of the total loan burden, up to $250,000, would be repaid every year for up to 6 years of service. This is really important because we're not going to solve the rural access to care issue with a single piece of legislation or a single policy intervention. We know that we need to address this issue from a number of fronts, including work force, including telehealth, including making rural communities a safe and affordable place to practice.

What we do know from the AUA census is that urology trainees, residents, and fellows have reported that one of the most effective strategies to helping new graduates from urology training establish practice in those much needed underserved rural areas is to include some form of loan repayment. That helps our new urologists to set down roots, to start practicing in those communities, and to make it affordable to set up practices when it can often be financially infeasible to do so.

This type of loan repayment program already exists for many primary care specialties. We know that primary care is important, but specialty care, just like urology, is also important. The SPARC Act, which is soon going to be reintroduced in the current Congress is a really important piece of legislation that we can all get behind—urologists, specialty physicians, and medicine at large—to help address rural access to care issues to help our new graduates and urologists who want to practice in rural areas do so and to make sure that this is one among several different policy interventions we can use to help our rural patients get the urological care they need and deserve.

"Helping urologists establish practices in rural areas and incentivizing those practices is so important," says Kevin Koo, MD, MPH. 

Dr. Koo discusses the SPARC Act

 gives a preview of what will be discussed during the 2021 American Association of Clinical Urologists Annual Meeting’s Telehealth Panel. Finkelstein is secretary/treasurer for the AACU.

“My opinion is that the practices that continue to utilize telemedicine moving forward after the pandemic are going to be the leaders in urology,” says Lisa J. Finkelstein, DO.

Panel to discuss telehealth at AACU annual meeting

In this video, American Association of Clinical Urologists (AACU) President 

 outlines what members can expect from the 2021 AACU Annual Meeting, including presentations on malpractice, telemedicine, and more.

Among the highlights will be a talk from Senator Bill Cassidy, MD (R-LA).

Dr. Lieberman previews the 2021 AACU annual meeting

 State Advocacy Network Chair for the American Association of Clinical Urologists, discusses recent developments related to scope of practice of advanced practice providers and how they affect the specialty of urology.

"A lot of ancillary providers want more privileges that the physician has, and we have  to be the guardians and the reason we're doing this is to protect our patients so that they get the best care available to them," says William C. Reha, MD, MBA.

Dr. William C. Reha discusses scope of practice issues in urology

discusses federal- and state-level efforts from the American Association of Clinical Urologists to address issues with prior authorization. Regan is a urologist with Advanced Urology Institute in Palm Coast, Florida and serves as chair of the AACU’s Health Policy Committee.

Terrence Regan, MD, also discusses appropriate use criteria for advanced imaging from the Centers for Medicare & Medicaid Services.

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