ICD-10, quality initiatives present hurdles, solutions

William F. Gee, MDUrologists praised the demise of the sustainable growth rate formula earlier this year, but a number of hurdles remain. In this interview, William F. Gee, MD, who began his term as AUA president in May, discusses current challenges facing the AUA and its members, possible solutions, and novel new AUA initiatives. Dr. Gee is clinical professor of surgery (urology), voluntary faculty, at the University of Kentucky College of Medicine and emeritus urologist at Commonwealth Urology, Lexington, KY. Dr. Gee was interviewed by Urology Times Editorial Consultant J. Brantley Thrasher, MD, professor and chair of urology at the University of Kansas Medical Center, Kansas City.

What are the challenges facing AUA members that you see as most important this year? 

We have different layers of challenges, and I think one of the biggest challenges facing all urologists is the same one facing all physicians in United States: the change in our coding system to ICD-10. For over 20 years, we have been using ICD-9, but on Oct. 1, the change-over to ICD-10 will happen, and that will affect all practices, large and small. Physicians who are in large practices and academic practices may be more equipped to deal with this. Regardless, we have been told that if you don’t use the proper code, whether it’s for an office visit or a procedure, you may not get paid. This is of concern not only to urologists, but to all physicians.

The AUA has worked to help our members adapt to the new system by offering helpful tips and training courses. Many specialties including the AUA are opposed to switching to ICD-10, but it is going to happen, so we need to be realistic and prepare for it.

Another challenge that urologists face is the increasing demand for our services without an increasing number of urologists. The number of urologists entering the field annually has been relatively stable for the last 18 to 20 years (about 245 to 260 per year). At the same time, 10,000 Americans turn age 65 every day, and many of these individuals will be needing services from urologists in the coming years.

NEXT: The AQUA Registry

Another challenge that a lot of urologists talk about relates to quality initiatives. Please discuss the new registry the AUA has started that hopefully will help members address these initiatives.

The AUA recognized several years ago that in the era of “big data,” it would be useful to establish a database to house information about how we treat various diseases. One of the first specialties to do this many years ago was cardiac surgery, which collected a lot of data about how heart surgery was done. As a result, they were able to improve outcomes for patients and also help physicians who did not have such good outcomes become better. Other specialties have done this as well.

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The program the AUA started last year is called the AUA Quality Registry, or AQUA Registry. This is a national urologic disease registry designed to measure and report health care quality and patient outcomes. Initially, the registry will provide data to help identify patterns and trends in the diagnosis and treatment of prostate cancer. It will gradually expand to include other urologic conditions.

The AQUA Registry will be implemented in three well-structured phases that comply with HIPAA regulations and privacy standards, seek input from patients, and develop observations and outcomes based on the patient- and physician-reported data. This will provide the urologic community with definitive resources for informing and advancing the care of our patients.

As I understand it, the registry software will de-identify patient-specific data, come back to the practice, and re-identify it after some of the information has been extracted.

Correct, and the outcomes data will be available first to the physician whose patient it belonged to. The individual doctor will be able to compare his or her outcomes to those of other physicians in the practice, whether it’s a large urology group, a smaller group, or university system. It will then allow comparisons to physicians all over the United States. The data will look at factors that influence prognosis and quality of life, assess the effectiveness of treatments and their safety, measure the quality and cost of care, and as I mentioned, allow urologists to compare themselves with their peers.  As of June 30, over 50 practices have enrolled in AQUA.  Every urologist should go to the AUA website and read about how to enroll their practice with AQUA.

NEXT: Goals in the coming year

What do you consider some of the major goals you hope to accomplish in the coming year?

The president of the AUA is just one individual who works with a large, very strong team comprised of AUA staff led by Executive Director Michael Sheppard, and a wonderful group of physicians who volunteer their time to the AUA Board of Directors and to the AUA’s many different committees. My goal is to help facilitate the work of these individuals and groups and do what I can to ultimately serve the needs of the members. The AUA is here to help our members deal with their challenges and advance the specialty of urology; I hope to be able to facilitate that.

We know that research, and taking it from bench to bedside, is a very important part of the AUA mission. I hear there has been a huge expansion of the AUA Research Scholars Program this past year.

That’s correct. Research is really the lifeblood of urology.  Advances such as shock wave lithotripsy, which we take for granted, and new treatments for advanced prostate cancer are the result of research. We want to continue to encourage young investigators in their work, which is why the research pillar of the AUA has evolved so much in the past decade. The most recent major change was the rebranding of the AUA Foundation as a philanthropic organization now called the Urology Care Foundation. A primary focus of this organization is to generate funding to support and ignite the careers of our young scientists through the AUA Research Scholars Program. These awards are designed to encourage young urologists and some PhDs to become interested in either basic science or clinical research.

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This has been expanded greatly through a program that the AUA developed in partnership with the AUA sections a couple years ago. The AUA decided that, if an AUA section would donate $250,000 in funding, the AUA would do a 5:1 match of $1.25 million, which would mean an endowment total of $1.5 million per scholar.

Since the program was completed in December 2014, the number of scholars has increased from 14 to 27. In addition to section scholars, some research scholars are sponsored by industry partners, such as Astellas, and several scholarships are named after individuals who made substantial contributions.  The Urology Care Foundation now has an endowment of over $40 million and, in 2015, will use approximately $1.3 million to support scholars.

Also, the AUA also has a new research chair, Dr. Aria Olumi from Harvard, who has presented a lot of good ideas. He succeeds Dr. Johannes Vieweg.

NEXT: "We had a number of big [personnel] changes in the past year."

You mentioned one personnel change in the Office of Research. Can you talk about other leadership changes that have occurred at the AUA recently?

Yes, we had a number of big changes in the past year. We have a new chair of education, Dr. Victor Nitti, of the New York University Langone Medical Center. Dr. Nitti, as many people know, has been very active in work with urinary incontinence and female urology. He succeeds Dr. Elspeth McDougall in this position.

The Board of Directors also named a new editor of TheJournal of Urology, Dr. Jay Smith of Vanderbilt University Medical Center. Dr. Smith will be working to make some changes in terms of how the Journal is presented online and taking into consideration the different ways of communicating with urologists.

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The AUA also has a new secretary, Dr. Manoj Monga, who succeeds Dr. Gopal Badlani. Dr. Monga practices at Cleveland Clinic, where he is director of the Stevan B. Streem Center for Endourology & Stone Disease. He is working hard on making the 2016 AUA annual meeting in San Diego better than ever.

There was also a change on the international education side, correct?

Yes. There is an increasing demand for our educational courses and products around the world. In fact, urologists from over 100 countries attended the 2015 AUA annual meeting. The AUA has formed relationships with a number of countries-in particular, China, Japan, India, and Brazil-and some other less-developed countries that are very hungry for our education.

For the last few years, the AUA secretary has been the point person for forming relationships with representatives from these countries, but this has become a unique portion of what the AUA does. So the AUA created a new position called the chair of Global Initiatives, and filling that position is Dr. Inderbir (“Indy”) Gill of the Keck School of Medicine of the University of Southern California. Dr. Gill is not only well known to U.S. urologists for his important contributions to endourology, but in many other countries around the world.

NEXT: "I would not be surprised to see repeal of the IPAB in the next year or two."

You are known for your strong background in advocacy. This year, many AUA members will consider the elimination of SGR a big win for us. What are some of the other advocacy challenges on the horizon for AUA members?

Another issue that has become front and fore, not just with the AUA but with other physician organizations, is the Independent Payment Advisory Board or IPAB, which the AUA opposes. We have heard this referred to as a “death panel,” which I think is probably too strong of a phrase.

The IPAB, part of the Affordable Care Act that was passed 6 years ago, would be a board of about 15 physicians and other individuals tasked with achieving savings in the Medicare program; if Medicare spending exceeds targets, the IPAB would be triggered and would have the authority to make changes to payment rates and program rules to rein in spending. Congress has the power to overrule the IPAB, but only by a supermajority vote.

The physician community has objected to this since it was first announced. Now, a new bill, H.R. 1190, the Protecting Seniors’ Access to Medicare Act, has been introduced that would effectively block the IPAB. And the momentum seems to be moving in the right direction among our legislators. On June 23, the House approved H.R. 1190 by a vote of 244-154, with both Republicans and Democrats supporting it. I would not be surprised to see repeal of the IPAB in the next year or two.

What other advocacy issues is the AUA currently working on?

Another important issue is reform of the U.S. Preventive Services Task Force (USPSTF). Urologists are all familiar with their decision to give the PSA test a “D” grade for prostate cancer screening, which means insurance companies have the option not to pay for it. They have made a number of other unpopular decisions.

The AUA has tried unsuccessfully to have the USPSTF at least consult with the appropriate specialty before issuing a recommendation. The task force consists basically of statisticians, people with expertise in public health, and some primary care physicians. They choose their own members. The AUA has tried to nominate people to the USPSTF, but to date, no urologist has been selected for the panel. Other specialties have had similar experiences.

There is a bill in Congress, the USPSTF Transparency and Accountability Act of 2015, which would create more transparency of the USPSTF and ensure that key stakeholders are involved in developing and reviewing USPSTF recommendations.

The AUA also continues to oppose any changes to the in-office ancillary services exception, which allows physicians to provide certain services, such as advanced imaging, in their offices.

NEXT: "Maintenance of certification is a real concern to many urologists."

I understand the AUA and American Board of Urology (ABU) leadership are working together to make maintenance of certification as user-friendly as possible. Would you care to comment?

This past year, I had the opportunity to travel and speak to a number of AUA sections and state urology organizations. The three things I heard over and over from urologists in all practice settings are: 1) that they are overwhelmed by government rules and regulations, 2) they are very frustrated with the EMR and the time it has added to their day, and 3) they are very concerned about changes in how they are recertified by the ABU. We are all committed to lifelong learning; that’s what makes medicine exciting and interesting to many of us. But maintenance of certification (MOC) is a real concern to many urologists, and I understand that the ABU is working to possibly make some changes in MOC. We will have to wait and see what they have to say.

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