AACU supports legislation on prostate cancer screening, prior authorization, and more

In this interview, William C. Reha, MD, MBA, and Ian M. Thompson III, MD, highlight the legislative work that the American Association of Clinical Urologists (AACU) supports. Reha is the president of the AACU and Thompson is the chair of the membership committee for the AACU.

The AACU has shown a lot of support toward prostate cancer screening legislation. Could you highlight those efforts?

William C. Reha, MD, MBA

Reha: We've made a lot of headway with prostate cancer screening. Just to go back a little bit, when the United States Preventive Services Task Force came out in 2012 and gave prostate cancer screening a D recommendation, prostate cancer screening dropped off. Now, we're seeing more advanced disease, including metastatic prostate cancer. Recently, I believe it was a few years ago, the United States Preventive Services Task Force came back and gave it a C level, and we've started doing more prostate cancer screening with medical decision-making.

That being said, a lot of men still are reluctant to get PSA [prostate-specific antigen] screening, and a lot of the times it's because of the cost of the test. Maryland, New York, and Rhode Island are a few states that have enacted no-cost prostate cancer screening legislation. The AACU, working with the AUA and ZERO, have formed a collaborative task force to work in various states and introduce and get this legislation passed so that men can get appropriately screened for prostate cancer. Certainly, there's a lot of men at risk for this, especially those of lower socioeconomic class, and getting them screened and getting them treated if they have prostate cancer is important.

This year, we have introduced legislation in a number of states. Pennsylvania, California, New Jersey, and DC are some of the states we've introduced legislation. What we're finding is as we start getting more states with this legislation, it's becoming a little bit easier to get it introduced into other states. Again, the AACU is working with the other organizations in order to get this moving.

There has also been some advocacy surrounding prior authorization. Could you touch on that work?

Ian M. Thompson III, MD

Thompson: The economic burden to those that run practices for prior authorizations is [high]; it’s in the billions of dollars in its cost to the system as a whole. That's important, but I think what's most important is when you see that affecting the ability of our urologists and physicians as a whole to deliver the care that we need to. When you put that in the context of the work force shortages that we have, it exacerbates that. So, we're pushing for legislation that helps reduce the barriers of access to care that prior authorizations present.

Reha: We talked about billions; I think that the estimate is $23 to $31 billion a year of both direct and indirect costs to everyone for a prior authorization. Doctors suffer because we have to hire more staff in order to deal with the bureaucracy. Patients suffer because they may need a particular medication, and because of step therapy and other constraints by the insurance company, they're not getting the treatment that they deserve. It really is an issue. It's a large administrative burden.

For instance, just recently, I became aware and the AACU has signed on to a letter with the [American Medical Association], [that] Cigna, one of the health insurance companies, wants progress notes with any type of use of modifier 25. There's a list of societies and associations that signed on, but what a tremendous burden and what a tremendous cost for physicians, for health care, and [for] the patients. So, prior authorization is a real problem, and it needs to be strongly addressed. It needs to be much simplified because of the huge economic cost that we just talked about.

What other policy reforms do you think urologists should be especially interested in right now?

Thompson: Addressing the Medicare physician payment schedule. Nothing really changes except for reductions, for the most part. It was 2.2% as of January for the reduction of the conversion factor for Medicare payment. We know what the future holds right now if nothing else is done in the need for budget neutrality, and where that goes unless some real fundamental changes are made. That has drastic effects. We were just talking about the cost and burden with pre-authorizations, for instance. Now we're talking about the top-line revenue for practices. Whereas physician reimbursement from a professional side is getting reduced, we're seeing during that same period of time, over the past decade or so, increasing payments to hospitals. We see increased employment of physicians to help deal with those cost burdens and those reduction payments. A lot of that leads to additional burnout. My fear is if we don't address the payment schedule for physicians overall—because the private insurance just follows what Medicare does—then, over time, we'll see increasing numbers of docs leaving practice medicine, and it's ultimately going to adversely [affect] our ability to deliver care and reduce access.

Reha: Ian touched on a number of good points. From 2001 to 2020, as you would guess, practice expenses have increased about 39%. During this time frame, physician payment reimbursement by Medicare has basically been level. So, if you look at a graph, you have practice expenses going up, and physician reimbursement is level. Now we're the only provider—I hate to use the term “provider,” but using the term provider to describe us against skilled nursing facilities, hospitals, long-term care, durable medical suppliers—their reimbursement has gone up, just like the cost of doing business has gone up. So, when you look at what physicians are up against, and you look at real income from 2001 to 2022, we've taken a 22% reduction in real income, which is why we see that the majority of physicians who are under 40—I think it's 80%, or greater, and it's probably greater—are now employed. Because they just can't afford to be in private practice, either individually or a group. We're seeing that shift in more mature physicians and older physicians; they're selling to hospitals, for example. Private equity is another story.

The pressures on physicians are making it extremely difficult to run a medical practice, and something needs to be done. We need to work with our federal legislators [on the] Medicare Physician Fee Schedule, so that we have cost of living adjustments, we have an inflation update, and that the costs physicians are receiving are able to allow us to run a medical practice. It's a big issue for us at this point in time.

Thompson: I think it's worth putting this in context—food stamps got a 12% bump in October. Social Security got 8.7% bump in payment.

Reha: And physicians went down to 2.2%.

Thompson: Yes. We're taking care of the folks that need it. We're doing it for other groups within our country. We are dealing with the same inflationary pressures with every business, and we have no ability to pass along those costs to our end users. That affects what's going on in the labor market within the urology work force as well. Like you said, more employment, increased corporatization roll ups, which ultimately ends up in more expensive care and not as great access.

AACU recently held a discussion on the business of medicine. Could you provide a recap of that?

Reha: Let me let me introduce one of our speakers, Dr. Ian Thompson, who I'm going to let take this away. Him and Dr. Mark Edney gave a fantastic presentation. I think we had over 40 people in attendance that night.

Thompson: I appreciate that. It's driven a lot of additional conversations on- and offline with other urologists and some other forums as well, because it's a hot topic within urology. It goes back to the previous topics that we were discussing, the cost of doing business and decreasing payments, [and] what are you doing to hedge that. Dr. Edney gave a great presentation and an overview of the role of private equity and how it can come in and help some practices, what that looks like, and the mechanisms for that. I spoke a little bit about how I see it in some of the docs, in employment shifts, if you will, within the work force of urology right now. It was a great, robust discussion, and it's a topic that at the end, we all agreed that all urologists need to be aware of and educate themselves on, just like in any business, and make educated and informed decisions regarding private equity, if that was ever to come up in a conversation within their practice.

Reha: And we now have a platform called Doc Matters. I posted a question on Doc Matters concerning private equity, and we're starting to get some responses.

Thompson: I'm glad you mentioned that. Doc Matters is a great forum for us to be able to grow the engagement of our membership. It's a real value-add for our members to speak to and generate conversation regarding mostly policy, but a lot of things that affect urologists in all forms of practice. Since private equity is such a hot topic, that recorded webinar is posted within Doc Matters forum, so that our members can come and check it out, watch it, and keep the conversation going, as Dr. Reha mentioned.

Reha: [The recording is] also on the AACU website too. It's there if anybody wants to see the webinar again, just log in, and it's available.

What advancements in reform are you looking toward in the coming years?

Thompson: I think there's a great opportunity, in the context of everything that we've been discussing here, for all of our urology colleagues to be involved in organized medicine through the AACU. If you're not a member, become a member, donate to UROPAC or the AUAPAC. The more voices we have, the greater chance we have to influence policy at the federal level, but also at the state level. There's a lot of stuff that can get done at the state level. Being involved, and being involved in a way that you can tell your own story as a urologist not only as a physician, but the responsibility that you carry for telling the stories of your patients. That's really important. We owe it to them to communicate that to our policy leaders, so that things can change for the better.

Reha: I agree with everything Dr. Thompson has said. One other point I'd like to mention, I think collaboration is something important going forward. When we talked about prostate cancer screening, we talked about the AACU working with the AUA and ZERO, and I think when we start collaborating, we get more done. He already mentioned the UROPAC and the AUAPAC, and it's really great to have 2 PACs, because we go to Congress and now we have 2 voices. It's amplified as opposed to 1 PAC. What we're learning to do is we're learning to work together.

I'm an AMA delegate for the AACU also, and I think it's very important that we work with the AMA, we work with our state medical societies and our state specialty societies, and we work with other organizations, for instance, LUGPA, the Large Urology Group Practice Association, which again, represents urology. I think moving forward as far as innovation, if we can have an innovation in the sense that we're all more collaboratively working together for the house of urology, we're going to get more done on a state and national level.

Is there anything else you'd like to add?

Reha: Thank you, Urology Times for being a good partner with the AACU. We very much appreciate being asked to be here, and we appreciate the collaboration with Urology Times moving forward.