Ask the Experts – Jonathan Henderson, MD

Question 1. Much of the LUGPA annual meeting proceedings dealt with the organization’s advocacy efforts in Washington, DC. What do you see as the main takeaway points?

Answer
The winds are changing, and CMS [Centers for Medicare and Medicaid Services] and Congress are finally starting to recognize that a level playing field is in the best interest of all patients. Our main reason for our existence is our health policy work to further efforts to achieve site-of-service neutrality in CMS payments and all other aspects of continuing to boost the ability for independent urology to thrive.

There is no substantially good reason that the average consumer, through CMS, should pay a different price for the same service at 2 different locations. The ripple effect of different payments at different sites is profound. As we’ve seen for the past several years, there continues to be mounting pressure to provide site-of-service neutrality.

Question 2. Do you think the change in administration will impact advocacy efforts?

Answer
No, I don’t think so. We’ve seen administrations on both sides of the aisle as well as both houses on both sides of the aisle. We’ve worked well with everybody. We don’t consider our issues to really be partisan. They’re American issues. I do not see any change in our activities or our successes.

Question 3. One of the sessions at the LUGPA annual meeting discussed strategies for dealing with the BCG shortage. How big a problem has the BCG shortage been for LUGPA member practices? Has it impacted your practice?

Answer
Every practice in the country has been impacted by the BCG shortage. It is one of the most far-reaching and truly devastating healthcare emergencies our country has experienced. In my practice, we have resorted to a system whereby we dedicate a physician and nurse to maintain a list of patients who would, in normal times, receive BCG. They then triage the patients based on our allocation. Fully two-thirds of the patients who would have been given BCG are now deprived.

Question 4. You updated members on the findings from LUGPA’s benchmarking initiative. Why is benchmarking important?

Answer
Benchmarking is the proven method of measuring processes to determine effectiveness and need for improvement. Our data has been utilized in our member groups around the country for years. It has been used for decisions on physician reimbursement; utilization review; quality improvement; physician education. It helps individual doctors learn from others more efficient processes for treatment of various conditions in the OR, MIPS [Merit-based Incentive Payment System] measures, and so on.

Question 5. Have any noteworthy practice trends emerged?

Answer
The entrance of private equity (PE) into our LUGPA community. Virtually every practice has been approached and/or evaluated by PE. Over a dozen of our practices have entered into PE arrangements with about 5 different PE firms, and this represents somewhere around 300 urologists so far. This is exciting and interesting for anyone who understands free markets, anticipated organic movement.

As evidenced by the American Urological Association census, the trend of urologists to move to hospital-based employment is monumental. For the first time in history, this segment is the largest employment arrangement in our specialty. It has been facilitated, and actually made possible, by predatory hospital practices funded by old CMS policies of largesse from a bygone era when the hospital lobby influenced Congress and CMS to allow different payments for the exact same services based only on site of service. In fact, many times, more efficient [care and] better outcomes occur at nonhospital settings even though CMS reimburses far greater for those lesser outcomes.

Question 6. Are there downsides to the trend toward hospital-based employment?

Answer
The landscape changed 30 or 40 years ago. In past times, we had academic practices and private practices. Then we added a third player, which was private but hospital-owned practices. That third player has really been growing for the past 15 to 20 years, and it offers a lot of attractive benefits that some people are drawn to.

Independent medicine in the United States is the defense against the wholesale shift to single-payer socialized medicine. What people who are hospital employed have to realize is that those of us who maintain our independent practices are actually maintaining their ability to have a good-paying hospital job. Because if we do not have independent practices, they would just be slaves for the hospitals, indentured servants. We have to have those market forces to continue to provide them with reasonable salaries. The house of urology is big enough for everybody to have what fits them best, and while there are some attractive [aspects] to hospital employment, it’s not for everybody, and even for those people who are drawn to it, I would say, “Stop and think about it.” If everybody goes to hospital employment, the hospitals own everybody.