Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large, 

Robert A. Dowling, MD

The new year is a time to reflect on the past and prepare for the future. Looking back at topics covered in 2021, I am going to suggest some resolutions for your practice in 2022.

®, I looked at the most recent data (2019) on Medicare Part B drug spending, which revealed increased usage of denosumab and mitomycin.

 I concluded that urology practices continue to derive substantial revenue from administering “buy and bill” drugs. Leading the list were denosumab (Xgeva), onabotulinumtoxinA (Botox), leuprolide acetate, and sipuleucel-T (Provenge). Of the 17 Part B drugs most commonly used by urologists, total spending in 2019 increased for 10 drugs and decreased for 7 drugs over the previous year. Price was the factor driving the change in spending in 7 drugs, whereas it was utilization in 10 drugs. 

: Understand the fraction of your revenue from Part B drugs, your net profit by drug, your purchasing power (vendor options), and how policy changes in this area could affect your practice—before they happen.

Then in April, I noted that Tamsulosin tops the list of Part D drugs prescribed by urologists,

 the most recent data (2018) showing that drug costs to the Medicare Part D program also continue to increase each year. However, urology accounts for less than 1% of the spending in this program. Expensive oral drugs are under close scrutiny—especially if there are generic equivalents—and urologists prescribe and, in some cases, dispense some of these drugs. 

 Be sure you are prescribing and dispensing the most clinically and cost-effective alternatives for your patients, and check that your information systems (electronic health records) are configured to display formulary information as you prescribe.

The opioid epidemic continued to be a hot news topic in 2021 in the United States, with landmark court cases holding large manufacturers and distributors accountable. Many states require continuing medical education on controlled substances as part of the license renewal process. In May, I reviewed prescribing habits in the specialty as reflected in Medicare Part D data (2018) and learned that urologists collectively prescribe opioids in numbers and rates lower than the national average of all specialties and unevenly across the US.

 Hydrocodone/acetaminophen was the most common opioid prescribed by urologists, and very few urologists were linked to claims for long-acting opioids. 

Follow clinical guidelines and best practices (auanet.org//guidelines/guidelines/opioid-use) for prescribing opioids, including only prescribing opioids when nonopioid alternatives are inappropriate.

Payments from industry to physicians continue to receive scrutiny, as I outlined in April.

 General payments from manufacturers to urologists in 2020 reported to and by Centers for Medicare & Medicaid Services (CMS) under the Sunshine Act are sharply down from the previous year, represent a small fraction of general payments to all physicians, and average $211 per urologist. Most of these payments are from device manufacturers, and payments are concentrated in just a handful of individual companies, drugs, devices, physician recipients, and disease states. 

Log on to the Open Payments site (openpaymentsdata.cms.gov/) and review your data.

As year 5 of the Quality Payment Program (QPP) draws to a close, and its impact was again muted by last-minute changes and flexibilities invoked by extreme and unusual circumstances (COVID-19 pandemic), urologists may be lulled into a sense of complacency. I reviewed the most recent data for the Merit-based Incentive Payments System (MIPS) in August.

 In general, urologists participating in QPP group reporting used the same generic quality category measures as clinicians in most other specialties. But with a few exceptions, they scored worse on average. In the “Promoting Interoperability” category, urologists outperformed their peers on e-prescribing and providing patients electronic access to their health information. They underperformed relative to peers on supporting electronic referral loops. The data begin to form specialty-specific benchmarks not readily available from other sources, which could guide improvement efforts. For example, in 2019, a performance rate of 95% on the measure “Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High-Risk Prostate Cancer” was significantly above average for all clinicians, but significantly below the mean score for urologists. One of the most valuable benchmarks—cost category measures—was not reported by CMS in 2019. 

 Focus on 1 improvement area where your score is below the urology average.

My September column looked at the QPP data used as a source of information about the specialty itself.

 The Medicare data suggest that approximately 35% of urologists are in organizations they dominate (what might have once been called single-specialty groups). This compares favorably with general surgery (17%), cardiology (28%), and orthopedic surgery (31%). Many providers are probably familiar with factors that have caused specialists to consolidate, and these data help quantify that consolidation—at least among Medicare providers. Urology-dominated groups appear to have a foothold, which is good news for those who prefer this model of practice.

In December, I reviewed the overlap and impact of 2 important rules governing patient access to their health information—the HIPAA Privacy Rule and the Information Blocking Rule.

 These rules empower patient access to their health information and impose significant penalties for violations. Compliance with these rules is straightforward but requires a shift from the traditional concept of medical record ownership and a physician audience to the contemporary concept of shared access with the patient and others they designate. I provide some specific scenarios and recommendations for compliance. 

 Review your patient access policies for compliance with these 2 rules.

Finally, I wrote about my experience on the patient side of care.

 My turn as a patient reminded me that providers may not always treat patients the way they would want to be treated. There are many opportunities for positive change that require no significant investment of money or time—only for the provider to walk in the patient’s shoes. As 2022 kicks off, take a fresh look at how you communicate, maintain a safe environment, and ensure optimum quality in your practice—you could be the next patient.

1. Dowling RA. Part B data reveal increased usage of denosumab and mitomycin. 

March 25, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/part-b-data-reveal-increased-usage-of-denosumab-and-mitomycin

2. Dowling RA. Tamsulosin tops list of Part D drugs prescribed by urologists. 

April 13, 2021. Accessed January 13, 2022. 

https://www.urologytimes.com/view/tamsulosin-tops-list-of-part-d-drugs-prescribed-by-urologists

3. Dowling RA. The urologist’s role as a responsible opioid prescriber. 

May 31, 2021. Accessed January 13, 2022. 

https://www.urologytimes.com/view/the-urologist-s-role-as-a-responsible-opioid-prescriber

4. Dowling RA. Industry payments to urologists see sharp decline in 2020. 

August 6, 2021. Accessed January 13, 2022. 

https://www.urologytimes.com/view/industry-payments-to-urologists-see-sharp-decline-in-2020

5. Dowling RA. How does urology’s 2019 MIPS performance stack up? 

August 26, 2021. Accessed January 13, 2022. 

https://www.urologytimes.com/view/how-does-urology-s-2019-mips-performance-stack-up-

6. Dowling RA. What CMS data reveal about urology practice composition. 

September 22, 2021. Accessed January 13, 2022. 

https://www.urologytimes.com/view/what-cms-data-reveal-about-urology-practice-composition

7. Dowling RA. Is your practice compliant with patient record access rules? 

December 8, 2021. Accessed January 13, 2022. 

https://www.urologytimes.com/view/is-your-practice-compliant-with-patient-record-access-rules-

8. Dowling RA. A urologist's experience on the patient side of care. 

October 12, 2021. Accessed January 13, 2022. https://www.urologytimes.com/view/a-urologist-s-experience-on-the-patient-side-of-care

Articles

"Be sure you are prescribing and dispensing the most clinically and cost-effective alternatives for your patients, and check that your information systems (electronic health records) are configured to display formulary information as you prescribe," advises Robert A. Dowling, MD.

Safety, communication, quality: Resolve to improve your practice in 2022

On November 30, 2021, the Office for Civil Rights (OCR) at the US Department of Health and Human Services (HHS) announced the resolution of its latest investigations in its Health Insurance Portability and Accountability Act (HIPAA) Right of Access Initiative.

 Under the HIPAA Privacy Rule (1996), individuals have the right to timely access to their medical records at a reasonable cost, and the OCR has settled over 20 such cases/complaints since September 2019.

Separately, in 2020, the Office of the National Coordinator for Health Information Technology (ONC) issued a final rule implementing Section 4004 of the 21st Century Cures Act. Among other things, this rule implements interoperability requirements, defines information blocking, and seeks to give patients “more power in their health care.” Health care providers are affected by both rules, and adherence to a few simple principles will keep the busy practitioner compliant. Here is what you need to know.

Most urologists are familiar with the basics of HIPAA. The Privacy Rule gives people the right to see and/or get copies of their health information from their health care providers and health plans. After receiving a request, an entity has 30 days to provide an individual or their representative with their records, which expressly include medical records, billing records, clinical case notes, medical image files, insurance and claims records, and clinical lab results. Specifically excluded from this designated record set are psychotherapy notes, records compiled for use in an administrative, civil, or criminal proceeding, and records not used to make health care decisions. Entities may require that the patient submit a written request and take reasonable steps to verify the identity of the requestor. Doctors may not impose unreasonable measures, such as requiring individuals come to the office to make the request or requiring the individual to mail the request.

The Privacy Rule also describes how the access to records should be provided, when it should be provided, and at what cost it may be provided. In general, the records must be provided in a form and format requested by the individual if it is readily producible. It is expected that a physician office can readily produce an electronic or paper copy of an electronic health record (EHR) if requested. It is also expected that, if requested, a practice can produce an electronic copy of a paper record (for example, from a physician’s office that only has paper records). Covered entities may not require a patient come to their physical location to pick up the records, and both mail and email are acceptable delivery methods if agreed to by the patient. Some entities may be able to deliver electronic copies through a website or portal.

The rule provides that the access must be provided within 30 calendar days unless a reasonable exception applies (for example, records archived off-site). Finally, entities may charge only a reasonable fee that is based on the cost of labor, supplies, postage, and preparation of a summary if requested. The entity may charge an individual based on the actual costs to fulfill the request, an average calculated cost to fulfill similar requests, or a flat fee of $6.50 if they do not want to do the aforementioned calculations. If your practice is in the habit of charging a flat fee in excess of $6.50, it would be prudent to develop proof of the actual or average cost of fulfilling requests (labor, supplies, and postage).

Patient access to records is also part of the interoperability rule of the Cures Act. In that rule, information blocking is described as “a practice by a health information technology [IT] developer of certified health IT, health information network, health information exchange, or health care provider that, except as required by law or specified by the Secretary of HHS as a reasonable and necessary activity, is likely to interfere with access, exchange, or use of electronic health information (EHI).”

 The information that constitutes EHI aligns with the designated record set in the HIPAA Privacy Rule and has the same exclusions. The information blocking provisions and technicalities relating to which elements of an EHR must be made available for access, exchange, or use are most relevant to IT developers. Where physicians need to pay attention is how they have configured (or failed to configure) their particular system and/or policies to avoid invoking potential information blocking. For example, ONC clearly states, “It would likely be considered an interference for purposes of information blocking if a health care provider established an organizational policy that, for example, imposed delays on the release of lab results for any period of time in order to allow an ordering clinician to review the results or in order to personally inform the patient of the results before a patient can electronically access such results.”

 Progress notes in an EHR are clearly considered EHI that can be accessed, exchanged, and used by patients. It would likely be considered information blocking to systematically delay the availability of those notes to a patient through a portal, and it would almost certainly be considered information blocking to fail to respond to a patient request for that access in a timely fashion. Note that a claim of information blocking does not require a request for access. Information blocking is any practice that is likely to interfere with, prevent, or materially discourage the access, exchange, or use of EHI.

Let’s consider a few possible scenarios in a typical urology practice with a contemporary EHR/patient portal that might invoke 1 or both rules. Scenario 1: A patient undergoes an uncomplicated prostate biopsy and is scheduled for follow-up in 1 week. The final pathology report comes back a day later and shows high-grade prostate cancer. The patient calls the following day, requesting an electronic copy of their procedure note and biopsy results to share with their personal doctor and possibly get another opinion. A nurse calls the patient back and explains the doctor hasn’t yet signed their procedure note or reviewed the pathology results and encourages the patient to keep their scheduled appointment. Failure to make this EHI accessible to the patient would likely be considered information blocking. Indeed, this patient may well have seen their pathology results from a commercial lab vendor, who is subject to the same rules.

Scenario 2: A long-time complicated kidney stone patient is relocating to another city and wants their complete records in electronic format emailed to them, including some you have in paper format stored off-site. Your office policy is to require a written request and charge a flat rate of $30 plus $0.10/page (for paper records), which will amount to over $50 for this request. As defined in the Privacy Rule, the patient is well within their rights to a copy of their entire medical and billing records in the format they request if it can be reasonably produced. The practice is permitted to make a reasonable charge that is based on labor, supplies, and postage. In this case, it might be prudent to charge the patient the actual labor costs to scan the paper records or an average amount based on well-documented costs to the practice. The practice must inform the patient about requirements for written requests and fees ahead of time. The Privacy Rule also allows the covered entity to reasonably extend the time to respond to the request if the records are not readily accessible, as in this case.

Scenario 3 (Nightmare Scenario): You are the leader of a 10-physician single-specialty practice, and one of the partners is chronically delinquent with signing notes, returning patient calls, and reviewing labs. Although widely considered to be a good clinician with good patient rapport, this physician has not embraced the workflows that characterize modern medical record keeping and encourage patient engagement, such as using a patient portal. Anecdotal complaints and informal counseling have not led to improvement. A new complaint has been lodged by an established patient with gross hematuria, alleging their phone calls have not been returned, they cannot get their urine test results or a prescription, and they have developed a low-grade fever. The patient tried accessing their information via portal, and there is nothing there. They want to transfer their care immediately. You are on call, manage the crisis, and speak to the physician again the next day. Unfortunately, the patient becomes septic, requires hospitalization, is diagnosed with an obstructing stone, and ultimately retains an attorney alleging failure to diagnose a complicated urinary tract infection. In addition, the patient files a complaint with the OCR, alleging the practice violated their rights to access their health information, as well as with the ONC alleging the physician was engaged in information blocking. The practice pays a $40,000 fine and enters a 3-year settlement agreement with the OCR. The ONC complaint is still being investigated. This scenario is fabricated but is not far-fetched.

Numerous federal laws and regulations empower patient access to their health information and impose significant penalties for violations. Compliance with these rules is straightforward but requires a shift from the traditional concept of medical record ownership and a physician audience to the contemporary concept of shared access with the patient and others they designate. As you create and curate your clinical notes, phone messages, letters, and other information related to patient care, you should do so with the full expectation that the patient can and will access this information. Be sure you actively encourage or incentivize enrollment in the portal. Your practice should configure the EHR to promptly release all information to the portal unless it meets 1 of the very narrow exceptions. Your policies for record requests should be refreshed and checked against both HIPAA and the Cures Act for compliance. Update any fee structure and rationale you may have had in place for years. With these building blocks in place, it is likely you will be compliant with these rules and provide the same access to records that you would expect if you were the patient.

1. Resolution agreements and civil money penalties. US Department of Health and Human Services. Updated November 30, 2021. Accessed November 30, 2021. https://bit.ly/3EkroRd

2. Individuals’ right under HIPAA to access their health information 45 CFR § 164.524. US Department of Health and Human Services. Updated January 31, 2020. Accessed November 30, 2021. https://bit.ly/3Gozlpp

3. Information blocking. Office of the National Coordinator for Health Information Technology. Updated March 19, 2021. Accessed November 30, 2021. https://bit.ly/3daOuxO

4. Information blocking FAQs. Office of the National Coordinator for Health Information Technology. Accessed November 30, 2021. https://bit.ly/3ruiEnX

Be sure to check and refresh your practice’s policies for record requests.

Is your practice compliant with patient record access rules?

There are many excellent books and movies about doctors becoming patients. For example, in 

, a neurosurgeon author tells the story of his battle with terminal lung cancer and his perspective when the doctor-patient relationship is flipped. The physician protagonists in these tales frequently develop new perspectives on health care delivery, empathy, suffering, fear, and hope—once they are patients.

I recently became a patient and have new perspective on these matters—especially the safety, quality, convenience, and necessity of care and how caregivers communicate with patients. These views are informed by dozens of visits to primary care and specialist offices, emergency departments, small hospitals, large hospitals and health systems, ambulatory surgery centers, home health care agencies, freestanding laboratory and radiology facilities, and quaternary centers.

I would like to share some thoughts based on my experienceas a patient. Some of my observations can be blamed in whole or in part on systemic dysfunction and inefficiency in our health care delivery system. I will endeavor to focus on factors under the direct control of the provider or the patient.

Communication includes all the ways in which providers or their agents interact with a prospective or existing patient. Agents can include a receptionist, a website, a patient portal or app, an answering service or message on hold, a clinical staff member, a surgery or hospital scheduler, and others. If an agent is professional, respectful, and efficient, it speaks volumes about the provider. If not, it raises doubts.

In my journey, I routinely encountered major obstacles to speaking with a live person when I had a clinical problem. Two of my providers had no mechanism for answering the phone—everything was done by message or secure portal. This is an acceptable standard for my pool company but not for my doctor. Are your policies designed to help the employee or to help the patient? You can do both.

Here is an exercise that might help a provider structure an approach to optimal communications: Pretend you are a prospective patient with gross hematuria and intermittent flank pain, referred by your primary care physician. Call your office number and try to navigate the phone tree. Is it optimized for patient care (in this case, a timely appointment)? Or does the message admonish the listener to: (1) listen carefully because your menu has changed, (2) call 911 if they think they are having an emergency, (3) type the party’s extension if they know it, and so on?

If you reach an empathetic appointment scheduler, how long did it take? Take the exercise further and schedule an appointment—how far out is it? Is it safe to wait that long? Did the staff offer a mechanism for getting in earlier or speaking to a triage professional? Does the provider know how long it takes to get an appointment? Can you request or schedule an appointment on the website? Does your portal allow patients to reply? Are you communicating with patients the way you would expect if you were one? These things can be easily fixed but may not command your attention—until you are a patient.

I have learned to ask my providers and their staff during my first visit how we should communicate if I have a significant question or concern. Should I call the office, use the portal, or securely text? How long should I expect to wait for a reply? After a provider failed to return my messages, I finally faxed their office and got a return call. These are basic questions, the answers to which can set reasonable expectations for a patient. Remember that if a patient asks to speak to the provider, it is usually with good reason and seldom a yes/no question. Involving an agent is usually less efficient and likely will lead to a cascade of back-and-forth communication—all potentially avoidable if the provider speaks to the patient personally.

Some of my providers have viewed the emergency department as an agent of their practice, or an alternative to a timely appointment. It is neither. I have been appalled at how low the threshold is for agents to recommend going to the emergency department. Visiting it is terrifying, inefficient, and often dangerous; in the COVID-19 era, going there can be life threatening. Unless your condition involves cardiorespiratory collapse, you can face hours of waiting for evaluation, admission or treatment, and discharge. You will be asked the same questions repeatedly by a care team member who has no context for your case and whom you are likely never to see again. You are very likely in pain, or soon will be from recommended testing or treatment. If you are lucky, the emergency department may be able to contact your physician for direction and avoid an unnecessary CT scan or even invasive procedures.

Providers have little control over the inefficiencies of the system but they can avoid sending patients to the emergency department unless necessary—especially established patients. A patient’s expectations are as follows: answer my calls in a timely fashion; speak to me and thoroughly assess my condition before sending me to the emergency department; make my records available so I do not have unnecessary tests or call the department doctor proactively; follow up with me after I leave the department; treat me as you would want to be treated. I feel certain most providers who become patients would bristle at being told to “go to the emergency department.”

Unfortunately, my journey has taken me places that are potentially unsafe—especially hospitals. I am heartened by the attention to fall prevention, infection control, safety protocols, and patient identification that I have witnessed. I have a basic expectation that my blood sample will not be confused with that of another patient, and my experience confirms that a near 0% error rate is highly achievable with inexpensive, reliable systems in place. Sadly, this same culture and discipline are noticeably absent from many outpatient medical practices in my experience. If you were a patient, would you tolerate any potential for your blood, urine, or tissue to be misidentified? Are your staffers still writing labels by hand and getting it right 99% of the time? What if you were the 1%?

The COVID-19 pandemic has raised public awareness about contagion, respiratory illness, and infection control practices. Since early 2020, patients have faced a simple question in deciding whether to get care: how likely am I to contract COVID-19 in a health care setting? This is the calculus for patients seeking preventive care, elective care, and even cancer care. For urgent and emergent care, patients may have no choice. Patients have an expectation and even a right not to be harmed in a health care setting; it can be incredibly comforting to see people attentive to handwashing, proper mask wearing, glove changing, or maintaining sterile technique. Lapses in these areas send a very different message.

In my journey as a patient, I have encountered both ends of the spectrum and wondered how that can happen in 2021 in a health care business. As I write this, most hospitals in my region have mandated COVID-19 vaccines for all providers and employees. Sadly, most medical and dental practices have not—many out of fear that staff will leave. Although many patients do not even think to ask, I can report that some patients who find out their provider or their staff are willfully unvaccinated will also leave. As a patient, I find it unacceptable that providers would elevate the wishes of unvaccinated staff above those of their patients in a pandemic—no matter the cost. If you were a patient, would you insist on your provider taking every reasonable precaution to protect you?

Telehealth is a patient safety tool as well as an efficient method of care delivery (for the patient). Most of my providers have a telehealth option; I appreciate the benefit of receiving advice and care without the risk of contracting COVID-19 when appropriate and for as long as my insurance company will cover. Other providers have suspended telehealth after characterizing it as “too complicated.” If you haven’t embraced telehealth, please consider whose interests you have prioritized—is it the patients’? Would you rather have a consultation from your provider on terms that are convenient for them, or safe for you?

Having spent most of my professional career trying to understand and improve quality of care delivery in physician practices, I now have the perspective of a patient. Patients have few objective tools with which to evaluate quality when choosing a provider; they typically rely on reputation, word of mouth, and other subjective measures. Patients have no access to process metrics or outcomes like readmission rates, complication rates, etc. When I logged onto Physician Compare, I could find out almost nothing about my providers. Choosing a doctor or hospital in 2021 is largely a leap of faith, not of transparency. Once you become a patient this is frustrating, especially if you have a complex problem.

After you have chosen a doctor or hospital, you will probably be invited to evaluate them with a survey instrument but you may wonder whether your contribution will be noticed. The survey is an assessment of their communication skills and perhaps their customer service. One of my providers implored me to give them “a good rating” because their compensation depended on it. Another said to me, “You know Big Brother is watching.” Patients would welcome a system that rewards their providers for spending time with their patients, listening to their concerns, and explaining things clearly—a system that providers embrace, not disdain. I hope today’s exception is tomorrow’s rule.

I made some incorrect assumptions during my journey. One was that my surgeon would care for me postoperatively; instead, I was transferred to a hospitalist service. I don’t know how common this is across the United States in surgical care, whether there is information about the quality of care in one model vs another, or whether it affected my outcome. I think most patients would expect their surgeon to be in charge after an operation.

When patients have bad outcomes, their needs and perspective about quality change profoundly. A treatment failure, complication, or bad outcome is deeply personal for a patient; it can lead to fear, depression, and worse. Their provider may show empathy or even regret and strengthen the patient’s confidence. On the other hand, the provider may distance themselves, destroying patient confidence. These behaviors might be part of a “risk management” approach for providers, but I can report that they are very real determinants of whether a patient will trust their provider going forward.

A word about “informed consent”—to a provider, informed consent is a legal doctrine including a documentation process that, properly done, may protect the provider from liability for a bad outcome. To patients, informed consent is a counseling standard that ensures they know why a treatment has been recommended, the expected outcome, the risks of an unexpected outcome or complication, and any reasonable options. Informed consent may involve a form, but it is not only the form. In my journey as an outpatient and an inpatient, I was routinely subjected to medical and surgical procedures and treatments where the consent was: (1) handled by an agent, (2) disclosing major risks that had not been discussed with me, (3) on a form I was asked to sign minutes before the procedure with no ability to ask questions of the provider or change my mind, and (4) usually when I was lying down. My perspective is that the consent process has refined all the elements to protect providers and none of the elements to reassure patients that they have been thoroughly counseled. This is unnecessary and permitted for the convenience of providers. I hope you will look at “informed consent” in your practice and see whether it considers the interests of an anxious or frightened patient who has placed trust in you.

Bottom line: Being a patient has convinced me that providers do not always treat patients the way they would want to be treated. Some may see this as an unavoidable compromise in a dysfunctional system over which they have no influence; I see that as an excuse, or maybe a symptom of burnout. My experience has taught me there are many opportunities for positive change that require no significant investment of money or time—only for the provider to wear the patient’s shoes. Take a fresh look at how you communicate, maintain a safe environment, and ensure optimum quality in your practice—you could be the next patient.

"Being a patient has convinced me that providers do not always treat patients the way they would want to be treated," writes Robert A. Dowling, MD.

A urologist's experience on the patient side of care

Most of the demographic information about urologists in the United States today comes from the American Urological Association (AUA), an organization with 7415 active members.

 The self-reported information has been used to support concerns about urology manpower needs, the aging urology workforce, and other policy matters of interest to the specialty. The publicly available information cannot reliably describe other details of the contemporary urology practice: level of activity, who practices in a group setting, how large the group is, the number of specialties practicing in the same organization, etc. In this article, I will summarize data from another source of information that can begin to answer some of these questions and what it might mean for your practice.

The Centers for Medicare & Medicaid Services (CMS) maintains several data sets of clinicians who participate in Medicare. Historically, it has been challenging to link providers to each other and to parent organizations in the National Provider Identifier (NPI) fileswhere information has been inconsistently populated. CMS is now publishing a robust downloadable file associated with the Quality Payment Program (QPP).

 Updated every few weeks, this file is an alternative source of information about urology practice and may better reflect real-world practice circumstances because most of the included clinicians have participated in the QPP. CMS needs to identify relationships between organizations (essentially tax ID numbers) and clinicians (NPI numbers) to properly calculate scores and fee schedule adjustments. Those relationships can be derived from the downloadable file and inform us about urology practice. The data cannot tell us about supergroups (groups of groups), networks, or subgroups.

The CMS data include 9324 unique clinicians identified as urologists in 1921 unique organizations (1268 urologists are associated with more than 1 organization). A total 6672 of these clinicians in 1609 organizations received a final Merit-based Incentive Payment System score in 2019 (ie, were actively seeing Medicare patients). The file does not include age or birth year but does include the year of graduation from medical school—a rough proxy for age. Over two-thirds of the urologists in this Medicare data set graduated from medical school after 1990; 11% are women, and 89% are men. Fifty percent of urologists in this database practice in just 10 states (some urologists are associated with more than 1 state), and the average distribution of all urologists based on 2019 population estimates is 1 urologist per 34,323 people.

A total of 3285 urologists are associated with 408 organizations where urology is the dominant specialty (there are more urologists in the organization than any other single specialty). In 373 (91%) of these groups, urologists constitute at least 50% of the clinicians. The number of urologists in these 408 groups ranges from 1 to 118 (mean, 8.4; median, 4); only 43 groups have 20 or more urologists. The most common other specialties represented in the groups where urologists are the dominant specialty are physician assistants, nurse practitioners, radiation oncologists, and pathologists. A total of 210 organizations have advanced practice partners (APPs; mean, 5 clinicians), 67 organizations have radiation oncologists (mean, 3.5), and 99 organizations have pathologists (mean, 1.7); 35 urology-dominant organizations have all 3 specialties. The size of these groups ranges from 2 to 281 clinicians (mean, 13; median, 5.5).

More than 5500 urologists are associated with organizations where urology is not the dominant specialty. These include very large organizations, such as health systems and universities, and much smaller organizations. The most common dominant specialties in these groups are primary care, APPs, and general surgery. The size of these groups ranges from 43 to 7478 clinicians (mean, 486; median, 255); the urologists’ number ranges from 1 to 104 (mean, 6.5; median, 4).

Finally, the data include all unique practice locations for an individual clinician. The number of unique locations associated with 9234 unique urologists ranges from 1 to 55 (mean, 2.4; median, 2). Those urologists associated with urology-dominant groups have fewer unique locations per clinician (range, 1-12; mean, 2.0; median, 1) than those urologists associated with organizations where urology is not dominant (range, 1-55; mean, 2.5; median 1). Twenty-one percent of urologists in urology-dominant practices were associated with more than 3 addresses vs 29% of urologists in the other practices.

This analysis comes with caveats. First, the information may not be generalizable to the entire specialty, as some providers may not participate in Medicare. Second, many individual clinicians are associated with more than 1 organization—it isn’t possible to know which of the associations are primary in these cases. Similarly, it isn’t possible to know which of the associated practice addresses are active or inactive. It isn’t possible to reliably identify solo practices in these data—some urologists practicing by themselves may be part of a common billing organization. Finally, most of the information in this file is self-reported, such as year of graduation from medical school and name of medical school, and some clinicians have incomplete data. It is not possible to verify the accuracy of self-reported data.

What does this mean for your practice and your patients? The CMS downloadable file provides interesting food for thought. Physicians may be best positioned to control the clinical and business aspects of their practice if they are the dominant group in the parent organization. The Medicare data suggest that about 35% of urologists are in organizations they dominate (what might have once been called single-specialty groups). This compares favorably with general surgery (17%), cardiology (28%), and orthopedic surgery (31%). Many providers are probably familiar with factors that have caused specialists to consolidate, and these data help quantify that consolidation—at least among Medicare providers. Urology-dominated groups appear to have a foothold, which is good news for those who prefer this model of practice. Others might argue that a multispecialty model offers the potential for better care coordination and value-based care. These data do not help answer that question but suggest that a majority of urologists practice in organizations where they are not the dominant specialist—at least among Medicare providers. One size does not fit all [urologists] today, but the demands of patients and payers are likely to shape the landscape of tomorrow.

1. AUA member profile. American Urological Association Inc. Updated April 2021. Accessed August 3, 2021. https://www.auanet.org/documents/about/Member-Profile%280%29.pdf

2. Doctors and clinicians: national downloadable file. Centers for Medicare & Medicaid Services. Updated June 4, 2021. Accessed August 3, 2021. https://data.cms.gov/provider-data/search?theme=Doctors%20and%20clinicians

3. State population by rank. Infoplease. Accessed August 3, 2021. https://www.infoplease.com/us/states/state-population-by-rank

More than a third of urologists work in a urology-dominant practice.