Pediatric urologists face a challenging future

In an address at the American Academy of Pediatrics Section on Urology annual meeting, Dr. Cromie said that the practice of pediatric urology is changing, as is the talent the specialty hopes to attract. Mounting difficulties with Medicare reimbursement and stricter post-9/11 immigration laws are among the external forces threatening the supply of pediatric urologists in the United States. Internal forces, including increasing educational debt and the salary discrepancy between pediatric urologists and colleagues in adult urology, are also hindering the ability to attract talent.

In addition, while the number of surgical cases in pediatric urology has increased over the past 5 years, case complexity has significantly decreased, making pediatric urology potentially less fulfilling than other surgical subspecialties. However, Dr. Cromie also foresees new opportunities for pediatric urologists in the next decade.

Dramatic changes in patient demographics will occur, Dr. Cromie said. By 2013, nearly 10,000 Americans will turn 65 years old every day; by 2030, 20% of the population will be over 65 years of age. These individuals will account for three to five times the health care costs of those of a person under age 65.

Medicare spending is expected to reach $504 billion by 2012, a 100% increase from the agency's 2002 budget. The burden of increasing costs will be shouldered by a diminishing work force.

The United States is also experiencing a progressively falling birth rate that will significantly diminish the patient "pipeline" for pediatric urologists. Since 1990, the total number of pregnancies in the United States has declined steadily, by an average of more than 1% per year. As a result, medical schools increasingly emphasize geriatrics as a career choice. Federal and state funding will be directed toward this population, as will medical job opportunities.

"People are always going to have children, and there will always be a medical career for people who care for children," Dr. Cromie said. "While it appears that there's a diminution in the birth rate in America, this is only in a decade, and a decade is a very short period of time."

A new order of business

Dr. Cromie also discussed the economic implications of consolidating for-profit health plans. He explained that medical coverage in the United States is largely controlled by seven companies, two of which-United Healthcare and WellPoint, Inc.-dominate the landscape and are rapidly gaining control of the marketplace. Such consolidation, he said, limits consumer choices and may adversely affect the quality and affordability of health care.

With diminishing employer-provided health benefits and the growth of health plans based on high deductibles, Dr. Cromie described a health care environment in which the patient becomes a consumer, concerned with the costs and benefits of procedures and medications. He added that market competition, retail products, and transparency of provider performance and pricing are here to stay and will be driving forces in market change. Consumer-driven health care represents a fundamental market reform.

Changes in government policies will also have a financial impact on the medical community. The shift of Medicaid costs to states will likely reduce health care coverage. In addition, changes in Medicare reimbursement will have a domino effect on commercial rates, creating a precedent for what insurance companies are willing to cover.

Another big change on the horizon for practicing urologists is replacement of the ICD-9 coding system with the international standard, ICD-10, a multi-year project that will create ten times the number of possible diagnostic and procedure codes. Computer systems, software and electronic databases will have to be reconfigured, and office staff will need to be trained to facilitate the transition, which may cost between $1.1 and $14 billion, an investment that will be shared by payers and providers.

Ultimately, Dr. Cromie maintained an optimistic outlook on the future of pediatric urology.

"Young urologists are prepared for these changes," he told Urology Times. "They are computer-fluent, they are global in their thinking, and they are knowledgeable and talented."

Dr. Cromie advises pediatric urologists to "be prepared, be knowledgeable, be alert, be current, and be flexible; that's what it's going to take to change the face of medicine."