What Lies Ahead in Urology

Raoul S. Concepcion, MD, FACS

Medicine is becoming increasingly complex. The data and information that need to be processed by a provider in order to care for patients continue to increase daily. When this pressure is combined with the growing demands placed on our time to satisfy all the regulations that have been thrust upon us by the government and payers, it is no wonder physician burnout is becoming more common and driving many into premature retirement. This early exodus compounds the preexisting shortage that many specialties anticipate will worsen over the next decade. As the general population continues to live longer due to advances in care and nutrition, an increasing number of patients require medical care, so much so that providers who remain will be inundated with more and more patients. With diminishing payment and concomitant mounting overhead, this vicious cycle of early retreat will continue as providers are no longer able to effectively manage all of these patients and still provide the quality of care that we all strive to deliver, our patients deserve, and payers mandate. It is the patient who ultimately loses in this scenario.

There is an old joke that goes something like this: If you ask a urologist who are the best 3 best urologists in the area, you will be told, “Me, firstly, but I cannot think of the other 2!” Most would agree that physicians, especially surgeons, take pride in their training and skills. We steadfastly believe, almost to a fault, that no one besides ourselves can operate as well or manage patients as efficiently. As we know, the beauty of urology as a specialty is the diversity of patients that we encounter every day. But along with that diversity, there has to be ongoing mastery of the data and literature in order to optimize outcomes. For prostate cancer alone, we have discussed, ad nauseam, the influx of therapies, molecular testing, advanced imaging, guidelines, etc, that challenge us as we outline a treatment plan for a single patient. It is fair to say that even the most talented provider has neither the capacity nor the time to keep up-to-date on the current literature across the spectrum of diseases, malignant or benign.

The consolidation and creation of large practicing groups in the field of community urology started in the mid- 1990s and formed the nidus for the Large Urology Group Practice Association. As many of you are keenly aware, the initial aim was to create practices that could leverage their geographic footprint within a particular market or service area to improve contracting rates with commercial payers. The next iteration was designed to take advantage of size, in light of government regulations already in place, to vertically integrate and create service lines that allowed ease and convenience for both the patient and provider and enhanced revenue for the group. As we transition from volume- to value-based care, a premium is now being placed on outcomes and quality of care, as well as cost constraints in this budget-neutral plan.

From my vantage point, there are a few things that urologists need to consider in order to be successful in this new model, especially those in larger groups that can facilitate this paradigm shift:

1. Encourage subspecialization within your practice. Driving patients toward providers that have clinical interest and a passion for a particular disease state should enhance care, promote better outcomes, and improve patient satisfaction.
2. Develop standardization/pathways of care, based on current guidelines, and, more importantly, monitor compliance with the guidelines. For those who are noncompliant, be willing to enforce penalties to maintain the group culture.
3. Begin to develop true outcome metrics to support your pathway design. As we know, many of the metrics that are currently deployed are process measures. For a starting point, we should define limited metrics that can be measured easily.
4. Encourage data aggregation. We all falsely believe that our individual group’s data are worth the barrel price of oil charged by the Organization of Petroleum Exporting Countries during the oil embargo crisis of the early 1970s. Respectfully, groups need to rethink this. The value of data is dependent on who is buying, what questions are being asked, and whether there is sufficient volume and geographic representation.

With large urology practices currently managing thousands of patients across many disease states, the more we can agree to pathway adherence, outcomes tracking, and compliance and develop a comprehensive plan for data sharing, the more successful we can be as a specialty moving forward.