Safety, communication, quality: Resolve to improve your practice in 2022

Robert A. Dowling, MD

The new year is a time to reflect on the past and prepare for the future. Looking back at topics covered in 2021, I am going to suggest some resolutions for your practice in 2022.

In the March 2021 edition of Urology Times®, I looked at the most recent data (2019) on Medicare Part B drug spending, which revealed increased usage of denosumab and mitomycin.¹ I concluded that urology practices continue to derive substantial revenue from administering “buy and bill” drugs. Leading the list were denosumab (Xgeva), onabotulinumtoxinA (Botox), leuprolide acetate, and sipuleucel-T (Provenge). Of the 17 Part B drugs most commonly used by urologists, total spending in 2019 increased for 10 drugs and decreased for 7 drugs over the previous year. Price was the factor driving the change in spending in 7 drugs, whereas it was utilization in 10 drugs. Resolution #1: Understand the fraction of your revenue from Part B drugs, your net profit by drug, your purchasing power (vendor options), and how policy changes in this area could affect your practice—before they happen.

Then in April, I noted that Tamsulosin tops the list of Part D drugs prescribed by urologists,² the most recent data (2018) showing that drug costs to the Medicare Part D program also continue to increase each year. However, urology accounts for less than 1% of the spending in this program. Expensive oral drugs are under close scrutiny—especially if there are generic equivalents—and urologists prescribe and, in some cases, dispense some of these drugs. Resolution #2: Be sure you are prescribing and dispensing the most clinically and cost-effective alternatives for your patients, and check that your information systems (electronic health records) are configured to display formulary information as you prescribe.

The opioid epidemic continued to be a hot news topic in 2021 in the United States, with landmark court cases holding large manufacturers and distributors accountable. Many states require continuing medical education on controlled substances as part of the license renewal process. In May, I reviewed prescribing habits in the specialty as reflected in Medicare Part D data (2018) and learned that urologists collectively prescribe opioids in numbers and rates lower than the national average of all specialties and unevenly across the US.³ Hydrocodone/acetaminophen was the most common opioid prescribed by urologists, and very few urologists were linked to claims for long-acting opioids. Resolution #3: Follow clinical guidelines and best practices (auanet.org//guidelines/guidelines/opioid-use) for prescribing opioids, including only prescribing opioids when nonopioid alternatives are inappropriate.

Payments from industry to physicians continue to receive scrutiny, as I outlined in April.⁴ General payments from manufacturers to urologists in 2020 reported to and by Centers for Medicare & Medicaid Services (CMS) under the Sunshine Act are sharply down from the previous year, represent a small fraction of general payments to all physicians, and average $211 per urologist. Most of these payments are from device manufacturers, and payments are concentrated in just a handful of individual companies, drugs, devices, physician recipients, and disease states. Resolution #4: Log on to the Open Payments site (openpaymentsdata.cms.gov/) and review your data.

As year 5 of the Quality Payment Program (QPP) draws to a close, and its impact was again muted by last-minute changes and flexibilities invoked by extreme and unusual circumstances (COVID-19 pandemic), urologists may be lulled into a sense of complacency. I reviewed the most recent data for the Merit-based Incentive Payments System (MIPS) in August.⁵ In general, urologists participating in QPP group reporting used the same generic quality category measures as clinicians in most other specialties. But with a few exceptions, they scored worse on average. In the “Promoting Interoperability” category, urologists outperformed their peers on e-prescribing and providing patients electronic access to their health information. They underperformed relative to peers on supporting electronic referral loops. The data begin to form specialty-specific benchmarks not readily available from other sources, which could guide improvement efforts. For example, in 2019, a performance rate of 95% on the measure “Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High-Risk Prostate Cancer” was significantly above average for all clinicians, but significantly below the mean score for urologists. One of the most valuable benchmarks—cost category measures—was not reported by CMS in 2019. Resolution #5: Focus on 1 improvement area where your score is below the urology average.

My September column looked at the QPP data used as a source of information about the specialty itself.⁶ The Medicare data suggest that approximately 35% of urologists are in organizations they dominate (what might have once been called single-specialty groups). This compares favorably with general surgery (17%), cardiology (28%), and orthopedic surgery (31%). Many providers are probably familiar with factors that have caused specialists to consolidate, and these data help quantify that consolidation—at least among Medicare providers. Urology-dominated groups appear to have a foothold, which is good news for those who prefer this model of practice.

In December, I reviewed the overlap and impact of 2 important rules governing patient access to their health information—the HIPAA Privacy Rule and the Information Blocking Rule.⁷ These rules empower patient access to their health information and impose significant penalties for violations. Compliance with these rules is straightforward but requires a shift from the traditional concept of medical record ownership and a physician audience to the contemporary concept of shared access with the patient and others they designate. I provide some specific scenarios and recommendations for compliance. Resolution #6: Review your patient access policies for compliance with these 2 rules.

Finally, I wrote about my experience on the patient side of care.⁸ My turn as a patient reminded me that providers may not always treat patients the way they would want to be treated. There are many opportunities for positive change that require no significant investment of money or time—only for the provider to walk in the patient’s shoes. As 2022 kicks off, take a fresh look at how you communicate, maintain a safe environment, and ensure optimum quality in your practice—you could be the next patient.

References

1. Dowling RA. Part B data reveal increased usage of denosumab and mitomycin. Urology Times®. March 25, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/part-b-data-reveal-increased-usage-of-denosumab-and-mitomycin

2. Dowling RA. Tamsulosin tops list of Part D drugs prescribed by urologists. Urology Times®. April 13, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/tamsulosin-tops-list-of-part-d-drugs-prescribed-by-urologists

3. Dowling RA. The urologist’s role as a responsible opioid prescriber. Urology Times®. May 31, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/the-urologist-s-role-as-a-responsible-opioid-prescriber

4. Dowling RA. Industry payments to urologists see sharp decline in 2020. Urology Times®. August 6, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/industry-payments-to-urologists-see-sharp-decline-in-2020

5. Dowling RA. How does urology’s 2019 MIPS performance stack up? Urology Times®. August 26, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/how-does-urology-s-2019-mips-performance-stack-up-

6. Dowling RA. What CMS data reveal about urology practice composition. Urology Times®. September 22, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/what-cms-data-reveal-about-urology-practice-composition

7. Dowling RA. Is your practice compliant with patient record access rules? Urology Times®. December 8, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/is-your-practice-compliant-with-patient-record-access-rules-

8. Dowling RA. A urologist's experience on the patient side of care. Urology Times®. October 12, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/a-urologist-s-experience-on-the-patient-side-of-care