Changes in Urology

Raoul S. Concepcion, MD

Editor-in-Chief of

Urologists in Cancer Care

Director of Clinical Research Urologic Surgeon Urology Associates, PC Nashville, TN

The arrival of the vernal equinox could not have come fast enough. Many have endured a crippling winter, thanks to the polar vortex of 2014, or suffered significant personal loss and tragedy, including myself, in 2013. I was more than happy to put that year in the rear-view mirror. Spring to me has always been associated with new life and a welcome relief to the doldrums of winter. For those of us who have lost loved ones, this spring now represents a time of significant change as we learn to cope and live without those who were near and dear to us. We learn to live, or at least make an attempt, with a new normal. Change is hard. A golf instructor once told me: If you change your golf swing and it comes easy, you probably have not changed anything.

In urology, we are faced with very difficult and challenging times. Reimbursement continues to be slashed across all services while overhead increases—not a great formula for business success. There are more demands on our time in order to take care of our patients: electronic medical records, PQRI, peer reviews, audits, hospital committees, etc. Alternative payment reform models are being developed and rapidly approaching, much like a tornado in the plains of Oklahoma bearing down on the local trailer park. We may not like it, but make no mistake, it is coming. Obamacare has put new pressures on the already overburdened system. The individual and employer mandates put pressure on both sides of our business equation. ACOs continue to be promoted as the new model to manage patients. Of course, many of these are hospital- or system-based and do not clearly spell out the role of the specialist, and many of us are still skeptical about their long-term success. SGR, which we had hoped was going to get permanently repealed, has once again been kicked down the road, with what appeared to be a bicameral and bipartisan agreement getting torpedoed at the last minute. Once again, a temporary 12-month patch has been approved, only to be revisited, again, in 2015.

How has this affected our specialty? As we all know, there is a shortage of urologists, and we are also the second-oldest surgical subspecialty, outpaced only by the cardiothoracic surgeons. Many of the graduating residents and fellows are signing on with hospital/ integrated systems, which provide some element of “security” and freedom from having to run a business. Single-specialty groups are also selling to integrated systems. Concierge practices are sprouting up in certain markets, relieving themselves of the hassles of payers. Some are just walking away from this great field that has served us and our patients well.

But like the coming of spring and warmer weather, there is always renewed hope and opportunity to start over. Given the chance (and some time on the range), we hope our golf game and scores actually improve. A No. 16 seed in the NCAA basketball tournament may actually beat a No. 1 seed in the first round for the first time in history. The winner of the par 3 Contest at Augusta may actually win the Masters Tournament in the same year. There will be new opportunities as health care in the United States morphs. What those will look like has yet to be determined.

We, as providers, need to be willing to change and be openminded to take advantage of those opportunities when they do present: partnering with others in and out of our specialty; creating strategic alliances with groups and hospitals; sharing risk with insurance companies; looking at new service lines that may not traditionally be thought of as primarily urologic.

Business as usual, maintaining the status quo, will not be the way to position yourself or your group in the new world order of medicine if you want to survive as an independent entity. As a specialty, urologists have always been early adopters of technology and willing to look at new models of practice in order to provide optimal care to our patients. Churchill once said, “To improve is to change; to be perfect is to change often.” We are not seeking perfection, but survival may require the same mantra.

Change is hard. But all of us have worked very hard to be in the position we currently occupy. Now is the not the time for us to be complacent, sit back, and let others determine our destiny. We need to build new foundations, one brick at a time.