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.