To Succeed Under ACA, Community Urologists Must Build Relationships with Patients and Organizations

David F. Penson, MD

Much discussion was sparked in the urologic community by an October 2013 article in the journal Urologic Oncology about how the Affordable Care Act (ACA) will affect practicing urologists.

Written by Kirk A. Keegan, MD, and David F. Penson, MD, MPH, both of the Department of Urologic Surgery at Vanderbilt University, in Nashville, Tennessee, The Patient Protection and Affordable Care Act: the impact on urologic cancer care¹ looked at the ACA’s anticipated effects in three areas: cost containment, quality improvements, and social/legal justice.

According to Penson, the doctors tackled the topic because it had not previously been addressed in peer-reviewed literature. Yet it’s a key area for evaluation, the authors maintain, because the ACA will have a significant effect on cancer care in the United States.

“Because genitourinary malignancies represent an impressive 25% of all cancer diagnoses per year, this legislation could have a profound impact on urologic oncology,” the authors wrote.

Penson spoke with Urologists in Cancer Care to discuss key points presented in the article, developments since he and his colleague wrote the piece in early 2012, and tips for urologists as they move forward in an ever-changing regulatory environment.

“We’ve learned a lot in the last year with regard to the ACA,” Penson said. “We’re going to have to start talking about how urologists interface with other providers and how they deal with quality measures, and thinking of ways to provide comprehensive care.”

UCC: What will the expansion of the insured pool of American patients mean to urologists?

Penson: More patients will be diagnosed with genitourinary cancers and will need good urologic oncologists, but we don’t know if there will be enough well-trained, qualified urologists to meet the demand, and the ACA has nothing in it to provide more.

We do want to address this issue of the workforce shortage, but it takes a long time to train a urologist. If tomorrow you said, ‘We’ll open up 50 more slots per year,’ we wouldn’t see a benefit for 5 to 7 years. And who pays for that? That’s a key issue, because there’s no money for it coming from the federal government.

As a result, the ACA will force urologists and other providers to think about using allied health care professionals—nurse practitioners and physician assistants—in ways we hadn’t thought about previously. The American Urological Association has been trying to educate allied health professionals to help urologists, but this effort has proceeded with a key guiding principle: that these professionals must always practice under the direct supervision of a qualified urologist.

At the same time, our colleagues in other specialties, like primary care, ob/gyn, and medical oncology, may start to treat more patients with urologic conditions, in part because it will be harder for patients to get in to see a urologist if the number of patients with diagnosed GU problems increases, as expected under the AUA. That’s not necessarily a bad thing. Perhaps more primary-care doctors can treat simple BPH or stress incontinence before sending a patient to a urologist. That being said, I believe it would be preferable for urologists to find a way to meet this increased demand, as opposed to having other specialties start to treat conditions traditionally in the urologist’s domain.

Q: What reimbursement concerns are associated with the ACA’s rollout?

A:While you are going to see a lot more patients added to the rolls, some are not going to have the most favorable insurance, at least in terms of provider reimbursement and/or patient co-payments and deductibles. In general, Medicaid tends to pay less than private insurers, yet a lot more of our patients will be Medicaid patients. Urologists will have to come to grips with whether they want to open their doors to Medicaid patients, because there will be more of them. Many of these patients previously would have shown up with no insurance, so doctors will get something where they used to get nothing, but that still may not be enough for providers to want to take on that role.

Even if we don’t take those patients, we can expect reimbursements for our services to be cut after an Independent Payment Advisory Board (IPAB) takes over for MedPac in advising the government on Medicare reimbursement rates. IPAB will consist of 15 people (none of whom may hold other employed positions), including up to three doctors, and it will make recommendations every year about reimbursement with an eye toward cost reduction. Those recommendations will not be like Med- Pac’s, which are suggestions, but will be considered regulation, to be overturned only by Congress, which currently can’t agree on anything. Essentially, this will be an unchecked panel of economists and lawyers (with no currently practicing doctors) that will make decisions without any congressional oversight.

For 3 to 7 years, IPAB’s recommendations will have no impact on hospitals or pharmaceutical companies, so, initially, they can only affect doctors. The end result will be that our Medicare reimbursements will drop. We won’t see increases in what we get paid, and if we get paid at a steady rate, we won’t keep up with the cost of living.

Q: Will the ACA contribute to the trend toward urologists joining hospitals or healthcare systems, or merging to increase the size of their practices?

A: Accountable care organizations, which are encouraged under the ACA, will reward efficient high-quality, low-cost care by developing novel capitated payment models to replace fee-for-service reimbursement. More and more patients with prostate or bladder cancer will probably be treated through ACOs under the ACA. So, how will urologic oncologists interact with ACOs? Will they contract with them, or be employed by them? We believe the majority of entities that will have the capacity to form ACOs will be hospitals or multi-specialty clinics, and this will result in more urologic oncologists being employed by these kinds of organizations. In fact, there will be many incentives in the next 5 years for urologists to consider employment opportunities in hospitals or healthcare systems.

Acknowledging this, large group urology practices will be in a good position to negotiate contracts with ACOs, which could counteract this trend of absorption by hospitals. Large groups out there definitely will be able to provide more efficient care, given their economies of scale. Their ability to provide comprehensive care will be an advantage for them in negotiating with ACOs. When a patient is diagnosed with prostate cancer, the government or payer might offer a single capitated payment for care—for example, Medicare may pay $10,000 for the year ahead to take care of this low-risk patient. If the practice keeps the cost under that, it will make money, and if it goes over that, it will lose money. Large groups will be well-positioned to play that game.

Q: In the urologic community, what has been the experience with ACOs so far?

A: Some of the larger groups across the United States have started participating in ACOs, and the results have been informative and educational. The nice thing about getting in on the ground floor is that they are able to set the rules in their areas. Urologists can build relationships between themselves and ambulatory surgery centers, radiation centers, and hospitals and, leveraging those connections, a savvy specialist can say to a payer: ‘I’ll provide evidence-based care. We have alliances with facilities that are willing to adhere to quality measures, and here’s how I’ll document for you that I’m doing a good job. In return, here’s what I want you to pay me.’

Q: What should community urologists know about the quality measures they will be subject to under the ACA?

A: The US Department of Health and Human Services is planning to publicly report physician and hospital performance, especially how well providers comply with quality measures, and even to give financial incentives to patients who use selected doctors. The information will be shared via two websites.

A concern with that system is that we will end up incentivizing hospitals, doctors, and nursing homes to comply with measures that may or may not be related to good care. It could also mean that healthcare providers will spend an inordinate amount of time documenting compliance, potentially at the expense of patient care.

Another problem will crop up if the administration experiences glitches in rolling out these websites, as it has with the site for the health insurance exchanges. Our reimbursement will be tied to the results of these databases, and we may end up being penalized erroneously. How do we then say, ‘You made a mistake?’ We just don’t have that option.

Q: What are some of the social justice and legal implications associated with the ACA?

A: An aim of the ACA is to redress the racial, gender, fiscal, and regional disparities in healthcare coverage. But will just expanding Medicaid coverage help? A study out of Oregon² demonstrated that having Medicaid doesn’t improve patient outcomes any more than having no insurance at all. That tells me that it’s not enough just to have an insurance plan; you need to have good care associated with it. The bill tries to get everyone access to the best health care possible, but I think it fails in that respect. As far as legal implications, the ACA is lacking in that it doesn’t call for tort reform. However, it is focused on reducing Medicare fraud. There’s a general perception that there’s a lot of Medicare fraud out there, but I don’t know if that’s true. If your practice gets audited by Medicare, you’re at high risk for a penalty if only because the regulations and rules around Medicare reporting and documentation are so burdensome and complicated that you often make mistakes when you don’t mean to.

There’s no doubt that the government will use this as a way to recoup some money. But if you put in a mechanism for tort reform, it would save money, as well, by reducing the number of frivolous lawsuits and costs related to the defense of medicine. If we’re worried about the rising costs of health care, and if that’s a way to control costs, why aren’t we pursuing it?

Q: What can community urologists do to prepare for success in this new environment?

A: Community urologists have to be very patient-focused. It’s going to be very important that their patients are their advocates. Payers will be looking at patient satisfaction, and legislators, too, will be less interested in doctor than in patient opinions. So when patients show up and say, ‘My doctor can’t keep his doors open—help him out,’ they’ll listen. Urologists also will have to explore new relationships with hospitals, other urologists, and other providers, and start to think about different business models. The one we have now for community urologists includes a lot of ancillary ownership, and these practices are going to need a backup plan in case that model is not as viable under the ACA.

References

1. Keegan KA, Penson DF. The Patient Protection and Affordable Care Act: the impact on urologic cancer care. Urol Oncol. 2013;31(7):980-984. Published online ahead of print, July 12, 2012.
2. Baicker K, Taubman SL, Allen HL, et al. The Oregon experiment — effects of Medicaid on clinical outcomes. NEJM. 2013;368:1713-1722.