Payment slide, regs, ACA: Urologists' least-favorite things

National Report-In health care’s modern era, change is constant. Yet the more some things change, the more they stay the same.

Both axioms are true for urologists who responded to this year’s Urology Times State of the Specialty survey.

More than 80% of urologists now use an electronic health record, compared to 27% in 2006, when the first State of the Specialty survey was conducted. Robotic procedures comprise 7% of the surgical procedures urologists perform, up from less than 2% in 2006. More than one-third (37%) of urologists were solo practitioners in 2006 versus less than one-fourth (23%) today. The expected age of retirement has inched up from 65 to 67.5 years, as has the mean age of urologists overall (51 vs. 56).

Nevertheless, the following have held true over the survey’s 8-year history: Declining reimbursement remains the number one concern of practicing urologists. Professional satisfaction far outpaces financial satisfaction. About 60% of urologists expect their use of non-physician providers to increase. And only half of urologists would still choose medicine as a career if they had to do it over again.

The State of the Specialty survey is designed to capture the current state of your profession. It examines key concerns and controversies facing U.S. urologists, business and employment trends, clinical practice shifts, demographics, and future plans, including plans for retirement.

The survey now divides responses by practice size, setting, and tenure. This uncovered significant differences in financial satisfaction (those in larger groups and with shorter tenures are more satisfied), whether intensity-modulated radiation therapy (IMRT) ownership represents a conflict of interest (twice as many academic vs. private practice urologists believe it does), and EHR usage (reported by nearly twice as many urologists in large groups as those in solo practice).

The survey questionnaire was developed by Urology Times and administered by Readex Research in September 2013. The survey was closed for tabulation with 391 usable responses: a 9% response rate based on a net effective mailout of 4,301. The margin of error was ±4.7 percentage points at the 95% confidence level. (Also see, “How the survey was conducted")

Concerns, career satisfaction

For the eighth consecutive year, declining reimbursement was the issue that concerned urologists the most. Nearly all survey respondents (88%) reported being extremely or very concerned about falling reimbursement, which was followed by increasing government regulations (86%), the Affordable Care Act (73%), increasing overhead (71%), and restrictions on ancillary services/self-referral (53%).

Lesser concerns included the transition to ICD-10 (34%), hiring a urologist (24%), hiring/retaining staff (20%), and selecting or implementing an EHR (19%).

“I was impressed that the conversion to ICD-10 and the implementation of EHR are near the bottom of the list,” Rick Rutherford, the AUA’s director of practice management, told Urology Times. “These certainly are higher on the list of concerns for practice managers that I communicate with every day. Perhaps the focus on reimbursement is because of the impending Medicare cuts and the congressional logjams recently.”

Indeed, all physicians face a 24% cut in Medicare payment effective Jan. 1 that is mandated by the sustainable growth rate (SGR) formula. At press time, there was still hope for a permanent SGR fix in the form of a bipartisan proposal from the Senate Finance and House Ways and Means committees that would freeze current payment levels through 2023 and then provide annual 2% increases to physicians who participate in certain payment models. (Also see, “SGR fix may also help preserve Stark exception")

The history of flat Medicare reimbursement rates stretches over the past decade amid climbing physician overhead. Thus, it comes as little surprise that, in its 8-year run, the State of the Specialty survey has consistently shown slumping reimbursement and increasing overhead at or near the top of urologists’ concerns.

In a related survey question, only 13% of urologists overall say they’re extremely or very satisfied financially. While that number is essentially unchanged in those practicing in groups of 10 or more urologists, it drops to 9% among solo practitioners. Extremely/very high financial satisfaction is also reported by only half as many urologists in private practice (9%) as those in academic, hospital employment, or other practice settings (17%-18%). (The “other” category includes those in multispecialty groups, government-employed urologists, residents, and urologists practicing locum tenens.)

“I suspect the financial satisfaction among larger groups is a function of better economies of scale, the ability to invest in technology that contributes to practice efficiency, etc.,” Rutherford said.

Just under half (46%) of urologists say their compensation is fair compared to that of other surgical specialties, while a similar number (45%) consider it not fair or not at all fair and only 10% give it an extremely/very fair rating.

Professional satisfaction is a different, more positive story. Overall, nearly half (45%) of urologists report being extremely or very satisfied professionally. That number is generally consistent regardless of practice setting, tenure, and practice size, although it’s slightly lower, at 38%, among those who are hospital employed.

Only half (52%) of urologists would choose medicine as a career if they were starting out today, but a full 89% would still choose urology. As with the professional/financial satisfaction data, this finding suggests that urologists enjoy patient care but are weighed down by the administrative and regulatory hassles of practicing medicine.

Business practices

Over the past 5 to 10 years, one of the primary changes in how physicians manage their practices has been the incorporation of electronic systems, namely EHRs and electronic prescribing. Eighty-one percent of urologists now use an EHR, according to the survey, up slightly from 75% last year. E-prescribing usage is also high at 87% (vs. 83% in 2012). Among groups of 10 or more urologists, EHRs and e-prescribing are used almost universally (97% and 98%, respectively). The adoption rate among solo practitioners, by comparison, is 53%.

Adoption of EHRs and e-prescribing “may be close to the peak for larger groups,” Rutherford said. “However, I expect the 2015 meaningful use payment adjustment will incite solos and small groups to adopt in 2014, so there may be a surge in that cohort.”

Change has also resulted from a declining urologist work force. More than one-fourth (28%) of survey respondents say they’ll retire within 5 years. Based on 10,000 urologists in patient care in the U.S., Rutherford pointed out that the data project a loss to retirement of 560 per year, with only half that many new urologists completing training annually.

With funding for additional residency slots unlikely to increase any time soon, advanced practice practitioners (APPs)-primarily certified registered nurse practitioners (NPs) and physician assistants (PAs)-are being called upon more and more to shoulder the workload. PAs are now used by 39% of urology practices and NPs by 30%-similar to 2012 figures but markedly higher than numbers reported in 2006 (15% and 20%, respectively).

Across practice settings, academic practices most often use PAs and NPs (57% and 53%, respectively), while private practices use them the least (33% and 23%, respectively).

Overall, 58% of urologists expect their use of APPs to increase in the next 5 years, only 2% expect it to decrease, and the balance say it will stay the same.

Rutherford noted that preliminary data from an AUA work force survey show slightly fewer respondents indicating use of PAs and/or NPs compared with the Urology Times survey, possibly due to a variation in the number of academic respondents between the two surveys.

“Your survey respondents, like many industry analysts, see the shrinking supply of urologists facing a growing demand for care as baby boomers age and see the use of NPs and PAs as one of several strategies to meet this challenge,” he said.

Another trend that is shaping the urology work force is the shift to hospital employment by some urologists. The State of the Specialty survey shows 13% of urologists are hospital employed and another 36% have considered hospital employment. Rutherford says the AUA data suggest the number who are currently hospital employed is higher.

“Preliminary AUA data seems to indicate that urologists have considered the option of hospital employment, but the saturation point may have been reached, at least in the short term. Other reports show this trend is plateauing,” Rutherford said. “In my view, it is a business model that will succeed in some areas and fail in others, but it is probably here to stay.”

By far the biggest reason for considering hospital employment is less administrative hassle (cited by 78% of respondents). Other reasons were more free time (39%) and better reimbursement (38%).

Clinical practice

Not unlike the move to hospital employment and the growth of EHRs, the use of robotic surgery appears to be leveling off. Overall, urologists report that 7% of their surgical procedures are performed robotically-a figure that has remained unchanged during the past four installments of the survey. But the figure is twice as high-15%-among those in academic practice. The majority of urologic surgeries (66% of the total) are performed endoscopically or percutaneously, 23% are open, and just 4% are laparoscopic.

During a typical week, urologists spend about 7 hours each on office-based procedures and outpatient surgery, 6 hours on inpatient surgery, and 3 hours doing procedures in ambulatory surgery centers. However, academic urologists spend considerably more time on inpatient surgery (over 11 hours per week) than do those in private practice (4.5 hours). The variance is similarly wide for urologists in large groups, who spend nearly 8 hours performing inpatient surgery, compared with only 3.5 hours for solo practitioners.

Three-fourths of urologists (73%) still administer drugs such as luteinizing hormone-releasing agonists in their office, and 5% sell herbal/complementary therapies.

Income and expenses

Ancillary services, a significant source of income for many urologists, has been the subject of considerable controversy in recent months. In particular, a study by economist Jean Mitchell, PhD, found that nearly all of the 146% percent increase in IMRT for prostate cancer among urologists with an ownership interest in the treatment was due to self-referral (N Engl J Med 2013; 369:1629-37).

The State of the Specialty survey finds urologists divided over whether urologist ownership of IMRT constitutes a conflict of interest: 49% believe it is, and 51% say it is not. (Of note, the survey was fielded prior to publication of the New England Journal study.) However, 81% of academics believe that IMRT ownership is a conflict of interest-twice the percentage of private practice urologists (41%) who believe it is.

“The AUA supports transparency in disclosing financial interests in all practice settings; in fact, many urology practices already have such policies in place,” Rutherford said. “Urologists nationwide are committed to the rights of all patients stricken with cancer and support disclosure obligations that apply equally to providers with ownership interests in single-specialty or multispecialty practices, free-standing radiation centers, and hospital-owned facilities.”

He noted that the AUA has developed a statement of guiding principles for in-office ancillary services, which can be found at www.auanet.org/about/policy-statements/ancillary-guiding-principles.cfm.

As a whole, urologists derive about 13% of their income from ancillary services and 87% from patient care, although the ancillary income percentage is higher, at 18%, among those in private practice than those in other practice settings. A lithotripter is still the type of ancillary service or equipment most commonly invested in or owned by urology practices (53% report owning one), followed by ultrasound (41%), an ambulatory surgery center (29%), in-house pathology (28%), clinical laboratory (27%), CT scanner (19%), and IMRT (17%).

About half of urologists (48%) reported that their professional income decreased between 2011 and 2012, while 36% said it stayed the same and 15% said it increased.

Increasing overhead remains a challenge for all physicians, and urologists are no exception. When asked how costs changed for various items between 2011 and 2012, two-thirds (65%) reported that their non-physician staff salaries and benefits increased in 2012, and the same percentage indicated that other (unspecified) physician expenses rose.

Demographics

The survey shows the continued growth of large urology practices. Twelve percent of respondents belong to a group of 20 or more urologists (vs. 8% in 2012). The biggest percentage of urologists belongs to groups of two to four (31%), followed by soloists (23%), groups of five to nine (19%), and groups of 10 to 19 (16%).

Other survey findings concerning urologist demographics showed:

• Solo practitioners tend to be older. The average tenure for a urologist in private practice is 28 years, compared to 22 years for those in practices of two to nine urologists and 20 years for those in groups of 10 or more.

• Most respondents (59%) are in private practice (employee or ownership position), 13% are employed by a hospital, 12% are academic urologists, and 11% practice in a multispecialty group.

• Most (83%) say their specialty is general urology. Other common specialties are stone disease/endourology, urologic oncology (32% each), and incontinence/female urology (25%).

• Ninety-six percent of respondents are male.

• During an average week, 29% of urologists work 50 to 59 hours, 22% work 60 to 69 hours, and 14% work 70 or more hours. The mean is 53 hours.UT

How the survey was conducted

Through the use of an electronic survey representing Urology Times’ e-mailable circulation classified as urologists, the purpose of this research project was to gain a better understanding of the state of the urology profession. The original survey sample of 4,627 consisted of all active e-mails within the publication’s e-mail list classified as urologists. Data were collected via an electronic survey from Sept. 6-23, 2013. The survey was closed for tabulation with 391 usable responses: a 9% response rate based on a net effective mailout of 4,301. The margin of error for percentages based on 391 urologist respondents is ±4.7 percentage points at the 95% confidence level.

As an incentive to participate, those who responded to the survey were entered into a drawing to win one of three $100 Visa gift cards.

As with any research, the results should be interpreted with the potential of non-response bias in mind.

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