P r o t e c t in g t h e P o l i t i c a l a n d P r o f e s s i o n a l I n t e re s t s o f U r o l o g y S i n c e 1 9 6 8 Winter 2016
WHAT’S INSIDE Advocate Spotlight
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Urologists Take Action
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States Focus on Residences
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AACU Board of Directors OFFICERS
PRESIDENT Martin K. Dineen, MD PRESIDENT-ELECT Charles A. McWilliams, MD IMMEDIATE PAST PRESIDENT Mark D. Stovsky, MD, MBA, FACS SECRETARY/TREASURER Mark T. Edney, MD HEALTH POLICY CHAIR Jeffrey M. Frankel, MD STATE SOCIETY NETWORK CHAIR Patrick H. McKenna, MD, FAAP, FACS
SECTION REPRESENTATIVES MID-ATLANTIC Mark L. Fallick, MD NEW ENGLAND Kevin R. Loughlin, MD NEW YORK Elliott R. Lieberman, MD NORTH CENTRAL Peter M. Knapp Jr., MD NORTHEASTERN Kevin J. Barlog, MD SOUTH CENTRAL Damara L. Kaplan, PhD, MD SOUTHEASTERN Jonathan Henderson, MD WESTERN Eugene Y. Rhee, MD, MBA
AACU SENTINEL STAFF EDITOR: Charles A. McWilliams, MD MANAGING EDITOR: Tristan Powell EXECUTIVE DIRECTOR: Wendy J. Weiser WJWeiser & Associates, Inc. 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 (847) 517-7225 Fax: (847) 517-7229
Learn more about the AACU and its many initiatives at: www.aacuweb.org
President’s Message
JAC2016 Mobilizes Urologists, UROPAC Connects BY: MARTIN K. DINEEN, MD Article originally appeared online at
As president of the American Association of Clinical Urologists, I am proud to lead a vital organization of dedicated physicians during a period of profound change. Government regulations and payer policies increasingly alter, if not compromise, the provision of urologic care. Pushing back individually, while valiant, cannot accomplish the kind of systemic change that our patients and practices require. Urologists are uniquely represented within organized medicine and the halls of power. National groups including the AACU, AUA and LUGPA regularly educate lawmakers, regulators and medical directors on how proposals would impact the urologic community. UROPAC - Urology’s Advocate on Capitol Hill is yet another organization that facilitates relationship-building and advocacy. The AACU recently resumed sole ownership of the political action committee that supports candidates who believe in preserving the doctor patient relationship and the
independent practice of urology. The restructuring of UROPAC and renewed vitality of its leadership comes at a perfect time. Not only will control of the Senate be influenced by the PAC’s strategic donations to select candidates, but we have the opportunity to elect one of our own to the U.S. House of Representatives. Retired Florida urologist, Dr. Neal Dunn, is seeking the Republican nomination in the Sunshine state’s second district. Whoever wins the GOP contest is likely to defeat incumbent Democrat Rep. Gwen Graham (D), according to the Cook Political Report. Dr. Dunn attended George Washington University Medical School and completed his residency training at Walter Reed Army Medical Center. He went on to serve in the U.S. Army for over 10 years. His entrepreneurial spirit drew Dr. Dunn and his young family to Florida, where he ultimately founded Panama City Urology Center, Bay Regional Cancer Center and the Advanced Urology Institute.
JAC 2016 Mobilizes Urologists, UROPAC Connects CONTINUED FROM PAGE 1
Dr. Dunn has secured notable local and national endorsements and recently joined fellow urologists at the Joint Advocacy Conference (JAC), where urologist appreciation was on full display. Likewise, urologists expressed support for UROPAC by committing more than $70,000 during the two-and-a-half day event. In addition to political sessions such as those led by Dr. Dunn and political analyst Stuart Rothenberg, the JAC 2016 agenda included informative and engaging presentations on urology’s joint legislative priorities. The most urgent campaign calls for reform of the U.S. Preventive Services Task Force, which is in the beginning stages of reconsidering its recommendation against all men being screened for prostate cancer with the PSA test. Dr. David Penson pointed out numerous flaws in the USPSTF process and the 2012 recommendation, while representatives of the patient community, including the Men’s Health Network and Susan G. Komen, explained how the urologic community might be mobilized in support of this effort. What’s more, on visits to Capitol Hill on the last day of the conference, urologists called on elected representatives to cosponsor legislation that would improve future USPSTF recommendations. The “USPSTF Transparency and Accountability Act” (H.R. 1151) would also decouple the un-elected panel’s recommendations from having any impact on Medicare payment policy. Another high profile priority of the urologic community is increased federal funding for graduate medical education. The number of residency slots funded by Medicare has
remained unchanged since 1997. While other federal and state government programs, as well as academic medical centers, have slowly stepped in to accommodate an increasing number of domestic and international graduates, more and more newly minted doctors are being caught up in the bottle neck between medical school and residency. Armed with fresh statistics showing the shortage of surgical specialists outpaces family medicine, urologists urged members of Congress to support the “Creating Access to Residency Education Act of 2015” (H.R. 1117). While high-intensity meetings on Capitol Hill concluded JAC 2016, congressional advocacy expert Brad Fitch shared important information about the influence of district meetings and facility visits. According to the Congressional Management Foundation’s “Perceptions of Citizen Advocacy on Capitol Hill,” 94% of staffers say district/state office constituent visits have “’some’ or ‘a lot’ of influence…, more than any other influence group or strategy.” The results of this survey bear out the relevance of the AACU’s JAC365 online guide to scheduling in-district meetings and facility visits. Urologists should never feel as though they do not or cannot influence decisions that impact our patients and profession. UROPAC – Urology’s Advocate on Capitol Hill, and initiatives such as JAC365 and the AACU State Society Network ensure that policy makers and urologists understand and pay attention to the urology community’s concerns.
Washington shouldn’t decide whether or not a man has access to prostate cancer testing. The decision to test for prostate cancer is one best made between a man and his doctor. How can you answer his questions about prostate cancer if Washington tells him not to ask them?
UROPAC shares this message with lawmakers.
www.UROPAC.com 2
www.UROPAC.org
Contributions to UROPAC cannot be deducted as a charitable contribution for federal tax purposes. UROPAC is a bipartisan political action committee (“PAC”) for members of the American Association of Clinical Urologists and the American Urological Association. Contributions are voluntary and you have a right to refuse to contribute without reprisal. PAC funds will be used in connection with federal elections and are subject to the prohibitions and limitations of the Federal Election Campaign Act. UROPAC uses contributions from individual members to help elect candidates to federal office that are supportive of UROPAC’s legislative agenda. Federal law requires UROPAC to use its best efforts to collect and report the name, mailing address, occupation and the name of employer of individuals whose contributions exceed $200 per calendar year.
State Society Network
SPOTLIGHT AACU Mobilizes Urologists to Oppose Prostate Cancer Screening Penalty The AACU State Society Network secured support from 22 state, section, and subspecialty groups on a letter (PDF) that disputes a proposed payment penalty for physicians who order a PSA test for prostate cancer screening. The leaders of organized urology question the limited exceptions to the wide-ranging recommendation and warn, “CMS must not implement quality measures and screening recommendations derived without input from specialists in the related health condition.” Connecticut Physician Advocacy Holds Payers Accountable Thanks to the tireless efforts of prostate cancer survivor and orthopedic surgeon, Dr. Scott Gray (Danbury, Conn.), and at the urging of the Connecticut State Urology and Medical Societies, the state’s official patient advocate is speaking out for men suffering with post prostatectomy erectile dysfunction. Healthcare Advocate Vicki Veltri recently called on ConnectiCare and other payers to comply with a law requiring the coverage of 5-PDI’s for post-prostatectomy potency rehabilitation.
THIS IS HOW ADVOCACY WORKS! 1. A constituent/patient has a compelling story to tell. 2. Physician and patient advocacy groups provide support and leverage their networks to secure meetings with the legislature’s leadership and influential members. 3. Legislation is passed and laws are enforced after capitalizing on years of relationship building in the halls of power. Your support of state urology societies and the AACU through annual membership makes these efforts possible. To ensure the urologic community is heard at every level of government, physicians must frequently take action on their patients’ behalf. After all, very few men will march on their state capitol with a banner announcing, I Have Erectile Dysfunction. There’s no getting around the fact that this takes physicians away from their families, jobs and practices for hours at a time. The AACU and your state urology societies exist to facilitate this kind of advocacy, however, with valuable tools and information. Visit the AACU online and contact the Executive Office to learn more.
Urologists Take Aim at Prior Auth., Work Force at AACU Conference BY: ROSS E. WEBER Article originally appeared online at
Leaders of more than 30 organizations representing urologists and scores more attendees came away from the 2015 AACU State Advocacy Conference with a better understanding of the complicated socioeconomic issues facing the profession and a resolve to not stand idly by as public policies impacting their patients and practice are developed in Washington and state houses across the country.
The event, now in its eighth year, brought together representatives of state, regional and subspecialty groups, many of which do not traditionally engage in political advocacy. After nearly every session, conference goers turned to one another to explain how the subject specifically affected them, or that the newfound insight would be of great value to colleagues back home. CONTINUED ON PAGE 5 3
Urologists Take Action on Worrisome Definitions of ‘Quality’ BY: ROSS E. WEBER Article originally appeared online at
Health care reform requires the simultaneous pursuit of three goals, according to economists and government officials. As defined by these non-medical experts, the so-called “triple aim” seeks an improved experience of care, improved health of populations, and reducing per capita costs. To measure patients’ subjective experience on all three components, public and private payers, as well as clinically focused physician groups, are scurrying to define “quality.” There is some urgency to this effort because the law that repealed the Medicare sustainable growth rate (SGR) formula requires physician payments to be largely based on quality as of January 2019. If defining quality is left only to payers, there is cause for alarm. Two recent proposals from the Centers for Medicare & Medicaid Services (CMS) stray far from the Institute of Medicine’s definition of quality: “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” A public policy research firm working on CMS’s behalf turned a blind eye to current professional knowledge by proposing that providers be penalized for recommending PSA-based screening for prostate cancer. Using the flawed U.S. Preventive Services Task Force recommendation against PSA testing as its primary source, the CMS contractor concluded that the intent of its proposal “is to discourage the use of PSAbased screening in the general population of men,” and that less testing indicates better performance. Individual physicians and organizations representing urologists, including the AACU, mobilized in strong opposition to this recommendation (See State Society Spotlight). In official comments submitted by AACU Health Policy Chair Jeffrey Frankel, MD, the AACU points to “the
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importance of an individualized decision on PSA-based testing between the patient and the physician.” The letter continues: “Physicians should not be penalized for ordering a test that, while not perfect, has long been recognized as an important tool in the diagnosis of prostate cancer.” Likewise, urology caucus members and delegates to the AMA House of Delegates secured approval of a new policy for the influential national organization during its 2015 interim meeting. Resolution 225, authored by the AACU and AUA, calls on the AMA to, among other actions, “…continue to advocate for inclusion of relevant specialty societies and their members in guideline and performance measure development…” CMS requested comments on another proposed quality measure in recent weeks that opens the door to mandated physician participation in Medicare and Medicaid. A “Request for Information” solicited feedback on a proposal to collect information on a physician’s participation, or lack thereof, in Medicaid, health insurance exchange plans, and other activities. This data would be synthesized into a quality measure and factor into provider Medicare payments. In a letter to CMS, the AACU warned against such a measurement, asserting that the government’s collection of such information may “…prompt physicians to stop treating Medicare patients…” Non-clinical definitions of “quality” will play a huge role in post-SGR Medicare payment schemes. Physicians will find that they must check many more boxes to demonstrate the quality of their care. Urologists must continue to take action to ensure these quality measures do not harm patients and medical practices. Much more information on this subject was shared during the 2016 Urology Joint Advocacy Conference, held on Feb. 28 – March 1, in Washington, DC.
Urologists Take Aim at Prior Auth., Work Force at AACU Conference CONTINUED FROM PAGE 3
AACU State Society Network Chair Charles McWilliams, MD, of Oklahoma City, Okla., and President-elect Martin Dineen, MD, of Daytona Beach, Fla., designed a compact program that addressed urgent concerns, as well as emerging threats. Among these issues were the economic impact of the Affordable Care Act, physician employment and work force trends, the administrative burden of prior authorization requirements and telemedicine. Early in the meeting, health care attorney Mark Rust held the audience’s attention by detailing the practical impact of the ACA on the practice of medicine. Rust, counsel of record on behalf of the American Medical Association and 50 state medical societies on matters before the U.S. Supreme Court, described the pressures that are driving individual engagement, as well as industry consolidation, in the post-ACA environment. He also widened attendees’ understanding of narrow networks and retail medicine. Private Practice vs. Health System Employment In addition to changes in the insurance industry, the ACA precipitated a shift from independent private practice to health system employment. Two urologists with divergent experiences discussed the pros and cons of employment, as well as what to watch for before, during, and after a possible transition from one setting to another. Michael Fabrizio MD, CEO of Urology of Virginia in Virginia Beach, cited many reasons his practice joined a large regional health system in 2008, including: declining reimbursement, increasing administrative burdens, and cost concerns with electronic health records. Frustrated by a lack of autonomy and hospital administration, three years later Dr. Fabrizio and many of his colleagues re-established an independent practice. He generously explained the lessons he learned from this experience, including how to align and not be employed. Brian Jumper, MD, of Portland, Maine, past president of the Maine Medical Association, explained how he and his former partners remain satisfied in a state where 80% of urologists are employed. He believes hospital employment can be successful when physicians are respected by the administration and both parties share a common culture and goals. Prior Authorization Solutions Unlike these workforce developments, the administrative burden of prior authorization was well-established before the advent of the ACA, according to AACU Past President Richard Pelman, MD, of Seattle and Medical Society of Virginia President William Reha, MD, MBA, of Woodbridge, Va. They said urologists can take certain actions today to mitigate time spent on payer relations in the future. Dr. Pelman announced the reinvigoration of an initiative he began during his presidency. Successful advocacy depends
on data that back up the arguments made during visits with elected officials and their staffs, according to Dr. Pelman. To collect information on the impact of prior authorization in urology offices, he urged colleagues to track the amount of time medical assistants and other personnel spend on such requests using a worksheet derived from a resource previously distributed by his home state’s medical society. Dr. Reha, meanwhile, described a previously reported legislative victory achieved in the Virginia General Assembly earlier this year. In part, the new law requires a 24-hour turnaround on prior authorization requests for urgent medical needs, a deadline of two business days for health plans to act on a non-urgent prior authorization requests and insurers must provide a reason when denying a prior authorization request for a prescription, as well as post health plan formularies, medications subject to prior authorization, prior authorization procedures, and all prior authorization forms in a single place on the company’s website. Telemedicine and the Future Looking forward, AACU Western Section Representative Eugene Rhee, MD, MBA, and AUA Delegate to the AMA Aaron Spitz, MD, shared an eye-catching and media-rich presentation on the integration of telemedicine technology in the practice of urology. “Seeing” patients using a laptop or tablet is not science fiction. An important consideration, however, is whether those virtual visits can be reimbursed. Another prospective session addressed “Health Care in 2020.” Health care journalist and author Steve Jacob shared his vision based on more than 1,000 references and a year of in-depth research on the subject. He lamented a future in which a two-tiered health care system will be firmly entrenched and questioned how ill-defined “value” and “quality” measures will ultimately impact physician payment. He urged attendees to rebel against the notion that physicians have little ability to affect change. Despite physicians’ low opinion of their influence, Americans generally trust physicians the most when it comes to health care reform. Along these lines, the presidents of the AACU, AUA, and LUGPA addressed how each organization plays a role in state and federal health care policies. For his part, AACU President Mark Stovsky, MD, MBA, asserted that physicians can accomplish great things when they come together for a common purpose. Look no further than the repeal of Medicare’s sustainable growth rate formula earlier this year, which was approved just days after the 2015 Urology Joint Advocacy Conference. The 2016 event occurred Feb. 28 – March 1 in Washington, DC. As stressed countless times during AACU state advocacy conference presentations, there is strength in numbers. 5
To Address Doctor Shortages, States Focus on Residencies BY: REBECCA BEITSCH, STATELINE
Last year, 369 students graduated from Iowa medical schools, but at least 131 of them had to finish their training elsewhere because Iowa had only 238 residency positions available. This is the world of medical resident matching. When states don’t have enough residency positions for the medical students they’ve trained, they become resident exporters. When states have more residency positions than they have students to fill them, they become importers. Medical students have a strong interest in where they end up. But so do states. Many have a shortage of doctors, especially in primary care. And physicians who go to medical school and do their residency in a single state tend to stay. Sixty-eight percent of doctors who complete all their training in one state end up practicing there, according to the Association of American Medical Colleges (AAMC). So while some states spend tens or hundreds of millions of dollars to support medical schools and build new ones, a handful are recognizing that it’s just as important to invest in residency programs—to increase the number of doctors practicing within their borders. Geographic Disparities Across the U.S., the number of medical students in each state tends to correspond to population, but there is a disproportionately large number in the Northeast, where medical education got its start in the late 1700s. Since then, the rest of the country has been playing catchup. There are now 175 medical schools spread across the U.S., but the number is growing. In 2007, AAMC encouraged states to increase the number of medical graduates by 30 percent by 2015. But as many states have expanded the number of medical students they train, the growth in residency slots has proceeded at a slower pace, pushing many graduates to California and the Northeast, where there are extra slots. Shelley Nuss, associate dean for graduate medical education (GME) at the Medical College of Georgia, said her institution has answered AAMC’s call to graduate
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larger classes. But that has created a bottleneck for instate residencies. For a state looking to increase its doctor ranks, that’s a problem: About half of the aspiring doctors who graduate from public Georgia medical schools end up practicing there, while 70 percent of Georgia medical school graduates who do their residencies in the state remain. Creating more residency slots—which are funded largely by Medicare, the state, medical schools and hospitals—isn’t easy. Medicare, the federal health insurance program for the elderly, is the largest public source of revenue, helping to cover the roughly $150,000 a year AAMC estimates that it costs to train each resident. However, the Balanced Budget Act of 1997 caps the number of residencies Medicare can fund. That leaves hospitals and states to pick up the slack. Most hospitals do not have residency programs. And many that want them often find they cannot get Medicare funding for them because they have inadvertently triggered the funding cap by having students come through for short training stints. In Georgia, the state tried to get hospitals to start residency programs by helping with startup costs, allocating over $14 million to match any funds set aside by hospitals. Medicare funding doesn’t come until the residents do, so those matching funds allowed hospitals to start developing their programs. The Medical College of Georgia is also responsible for establishing residency programs. In seeking to increase the number of slots in the state, Nuss, the GME dean, focused on 11 hospitals in rural areas that had enough patients and faced the variety and severity of illnesses and injuries to provide well-rounded training. Texas, which has increased its medical student population by 34 percent from fall 2002 to fall 2014, and where four new medical schools are expected to open within the next few years, has tried an approach similar to Georgia’s. To encourage hospitals without residency programs to start them, Texas offered $150,000 planning grants to launch new residency programs, followed by another $250,000 to develop them. Hospitals that already had programs could apply for $65,000 grants to add slots, said Stacey Silverman, with the Texas Higher Education Coordinating
Board. The state just allocated another $56 million to help continue expanding residency programs through 2018. Five new medical schools have opened in Florida since the Medicare caps were put in place in 1997, and many say the number of residency slots doesn’t accommodate the new schools and the state’s population growth. The state’s Medicaid program for low-income residents will help with startup costs for some slots, but the funds don’t arrive until later in the development process and are only available for certain types of specialties. Yolangel Hernandez Suarez, former associate dean for GME at Florida International University’s new medical school, said her quest for more residency slots took her to hospitals without any residents. She said she tried to convince hospital leaders that they should cover the startup costs because they would be training their own future doctors. “Physician recruitment isn’t easy, but residencies create a pipeline,” she said.
More Than a Numbers Game For states with doctor shortages, it’s not enough to just boost the number of residency slots. They have to be in the right specialties, and in the right places. Rather than just look for hospitals to stash residents, Deborah Hall, president of the American Medical Student Association, said, states, schools and hospitals need to take a thoughtful approach to getting residents exposed to treating underserved patients and the illnesses and complexities they have—whether in rural or urban areas. Hall said doctors aren’t going to set up practices serving populations they haven’t gotten used to treating. “We need to give the training and experience that make them feel competent and confident to treat them.” Reprinted with permission from Stateline, an initiative of The Pew Charitable Trusts
AACU, Physician Coalition Recommend Stark Law Updates In a Feb. 5, 2016, letter to House and Senate committee chairs, the AACU and more than 20 organizations representing physicians expressed their views on how the Physician Self-Referral law can be modernized to reflect the evolution of health care delivery models. The signatories identified five fundamental updates to the Stark law that will be necessary to align it with post-SGR Medicare payment schemes: • Revise the definition of “group practice” by removing the current “volume” or “value” standard so that physicians who are part of a group practice may be paid on the basis of furnishing care without violating the Stark law. Virtually all the exceptions to the existing Stark law impose restrictions on compensation based on “volume or value” of referrals; however, inclusion of this language in the group practice definition creates enormous confusion and opportunities for technical noncompliance. • Provide the same protections from the Stark law for physicians operating in an alternative payment model for those provided waivers through Accountable Care Organizations (including the pre-participation period) eligible for the Medicare Shared Savings Program. This recognizes the variety of APMs that utilize various mechanisms and structures for encouraging efficient care. • Permit physician compensation for providing highquality and efficient care without violating the Stark
Law's “fair market value” standard even if the compensation is related to the volume or value of the referrals. The statutory definition of “fair market value” created by Congress simply reflects the clear rule that arrangements must reflect arm's length bargaining. The “volume or value” standard was a regulatory addition created by CMS. • Define Stark law “technical violations” as compensation arrangements that do not otherwise violate the Anti-Kickback statute. • Empower the Centers for Medicare and Medicaid Services (CMS) to create new regulatory exceptions to the Stark Law and in the future for purposes of promoting non fee-for-service payment structures. Just as Congress could not in 1993 foresee what exceptions might be necessary in 2016, this Congress cannot foresee how health care may be delivered years hence. It is essential that regulators have flexibility to refine the regulatory landscape as the health system continues to transform and as payment models continue to evolve.
Questions about any of the legislation referenced in this edition of the AACU Sentinel? Visit www.aacuweb.org or email: info@aacuweb.org.
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Two Woodfield Lake 1100 E Woodfield Road, Suite 350 Schaumburg, IL 60173-5116 ADDRESS SERVICE REQUESTED
9th Annual AACU State Society Network Advocacy Conference August 19 – 20, 2016 The Westin O’Hare Rosemont, Illinois
MORE INFORMATION AT AACUWEB.ORG