Dr. Rosevear is a urologist in community practice in Colorado Springs, CO. Urology Times blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of Urology Times or its parent company, UBM Medica. Please let your voice be heard by joining the conversation in the comments section of each post.

“High on a hill, it calls to me,” Tony Bennett famously sang. “It,” of course, is San Francisco, and Bennett is not the only one to leave his heart there. Of all the cities where the AUA holds its annual meeting, this is probably my favorite. The food, the bay, the culture, and yes, the conference. AUA 2018 should be grand!

What specifically am I looking forward to this year? After reviewing the program and browsing the 

 site, I made a list of the top 10 reasons I’m excited about this event.

 Like other AUA members, I filled out a survey last year asking about the ideal number of days the conference should be, and the AUA apparently listened to our collective input. Unlike prior meetings that ran 5 days, this year’s is a compact 4 days long. The conference starts on May 18 and concludes May 21. Looking a year ahead, AUA 2019 in Chicago will also be 4 days, though it will be held a couple weeks earlier (May 3-6). The other good news about this year’s dates is that they don’t overlap with Mother’s Day (May 13), which should keep everyone out of trouble!

As far as I can tell, even though the conference is one less day this year, the volume of material being presented is about the same. With that in mind, I intend to once again purchase virtual access to the Instructional Courses. I could spend the entire 4 days in these courses, but there is too much else to learn to do that. For those not familiar with the Instructional Courses, this is a conference within the conference. World-renowned speakers give detailed break-out sessions on a wide range of topics. Three of the courses I’m most looking forward to are:

043IC: Novel Agents and Concepts in the Management of Hormone-NaÃ¯ve and Castrate-Resistant Prostate Cancer. The growth of medications to treat advanced prostate cancer has been rapid and the role of the urologist in this space increasing. I am excited to learn about the next generation of drugs I will be prescribing.

025IC: Robotic Single-Port Surgery: Appropriate Adoption into Your Practice. I grew up with the da Vinci robot and am well aware of its limitations. Single-port surgery is the next step, and I am eager to learn how to incorporate it into my daily work.

022IC: Perioperative Opioid-Sparing Analgesia Strategies for Enhanced Recovery after Urologic Surgery. We are all aware of the ravages that the opioid crisis has inflicted upon society, and I am thrilled that the AUA is presenting a course on options to avoid or minimize the use of opioids after surgery while acknowledging that controlling acute pain is still a priority.

 Sometimes you just need to put your hands on something to learn a skill. With the rise of the in-office use of imaging, especially among physician extenders, the AUA is addressing the need for formal training by offering some great hands-on courses. Two that seem particularly interesting are course 101HO on Urologic Ultrasound and 103HO on MR US Fusion-Guided Prostate Biopsy.

 Having just designed my own website, I can truly appreciate how challenging it is to organize and present as much data as the AUA does on its annual meeting site. The AUA provides not only a PDF of the program but also a way to search for sessions by date, speaker, or topic. One of the best new features that’s worth exploring is the Educational Tracks feature. Have an interest in health policy? Click the link and up pops all of the relevant presentations. Same with a dozen other topics, ranging from various urologic cancers to pediatrics to practice management. Probably the best change to the website this year.

 Lectures about clinical practice guidelines aren’t the “hippest” of talks but provide some of the highest yielding material at the conference. The AUA is the leading organization when it comes to analyzing the literature on a topic and summarizing it in a simple, easy-to-follow format. Two of the guidelines I’m most interested in reading are on LUTS Associated with BPH and the Evaluation and Management of Testosterone Deficiency. The guidelines will be presented as Instructional Courses (additional fee required) and Second Opinion Cases.

 One of my favorite sessions from last year is back again. Two sessions on Friday (1:35-2:15 and 2:15-3:00) will include a malpractice attorney as well as urologic experts as they walk through two tragic cases involving an opioid overdose and sepsis after prostate biopsy and the medicolegal implications thereof. Being sued is not something any of us want to think about, but it is part of our world and we should understand how to protect ourselves.

 Always a favorite. Three or four renowned experts presented with a less than straightforward situation debate the options. It always makes me feel better knowing that even the experts sometimes disagree on what to do next. The one session I’m most interested in will discuss “PSA of 4-10 gets an MRI not a Biopsy” (Monday, 1-1:30). I am certainly leaning toward the idea that MRI for an elevated PSA with no past biopsy is ready for prime time, and I hope the experts are too!

 Quite simply, everything is great in the plenary session. If an attendee simply grabbed a cup of coffee, found a seat here, and stayed the entire time, it would be very good use of their time. With the understanding that you will need to time restroom breaks, here are some of the highlights you don’t want to miss:

Setbacks and Operative Solutions: Robotic Prostatectomy (Friday, 9:00-9:30). We all do this case and we all run into challenges. I’ll be here to learn how the experts navigate these unfortunate complications.

Presidential Address: Artificial Intelligence, Robotics and the Future of Urology (Saturday, 10:55-11:15). I believe the next generation of urologists will be able to more fully integrate artificial intelligence into both diagnosis and treatment of our conditions, and I am excited to hear how the AUA president thinks this will occur.

State-of-the-Art Lecture: Prostate Cancer: What PET to GET? (Sunday, 1:30-1:45). As our ability to effectively treat M0 and M1 castration-resistant prostate cancer increases, the need to be able to better diagnoses these conditions increases. This session promises to walk me through the numerous PET options available.

Panel Discussion: Where is the VALUE in CAP Active Surveillance Monitoring? Cost and Quality (Monday, 1:30-2:00). With the recent denial of the LUGPA localized prostate cancer APM by the government (a tragedy in my opinion given the quality of that APM), I am eager to learn more about how active surveillance of prostate cancer can help decrease overall costs without compromising the care of our patients.

 The latest and greatest in basic science and clinical research at your fingertips. If you aren’t busy enough with everything else, here are the two sessions I thought would be most interesting.

MPO4 Benign Prostatic Hyperplasia: Epidemiology and Evaluation (Friday, 7:00-9:00). BPH is one of the most common conditions we treat and ensuring that we stay up to date on its management is vital.

MP31 Stone Disease: Medical and Dietary Therapy II (Saturday, 9:30-11:30). If BPH is the most common condition we treat, stones are what pay the mortgage. Session co-moderator Margaret Pearle, MD, PhD, is one of our leading minds on this topic, and a refresher on how to counsel patients on prevention sounds perfect.

 Let’s not forget the city itself. I’m sure I’ll find myself at The Stinking Rose for dinner one night (a great restaurant if you enjoy garlic as much as I do). A good friend who lives in the Bay Area has been raving about a tap house called Cellarmaker Brewing as having the best beer in town (which says a lot given the options available), and my wife has already purchased tickets to the San Francisco Museum of Modern Art.

Finally, don’t forget to take some time to wander the Science & Technology Hall and catch up with old friends and colleagues. As always, this conference promises to be a whirlwind tour of urology, and I love it!

Articles

Urologist Henry Rosevear, MD, shares what he's most looking forward to at the AUA annual meeting in San Francisco.

Much to love and learn  in San Fran: A top 10 list for AUA 2018

 is chief resident of urology at the University of Texas Southwestern Medical Center, Dallas. 

 blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of 

 or its parent company, UBM Medica. Please let your voice be heard by joining the conversation in the comments section of each post.

	The shift that occurs during medical school from the classroom to the clinical setting undoubtedly marks an important transition. The radical change in the learning environment is perhaps most apparent in that we no longer rely solely on textbooks and lectures to acquire knowledge, but rather contextualize the clinical questions that we encounter daily and integrate the dynamically evolving body of literature into the care of patients.

	Beyond redefining the approach to learning, this transition also symbolizes a shift in our primary focus from ourselves (the student) to the patient. No longer is our education simply centered on passing examinations and advancing to the next career stage, but rather on improving outcomes for the patients we encounter and treat.

Life after residency: Is a fellowship in your future?

	While medical school serves as a transition point, residency is a transformation. In the 5-6 demanding years that it takes to become a board-eligible urologist, we learn the foundational knowledge of a unique specialty, how to answer consults effectively, how to counsel patients based on the latest research in our field, and how to operate as surgeons and perform procedures skillfully. In short, we learn the skills needed to become a practicing urologist.

	Aside from the technical aspects of training, residency offers many lessons along the way. There is a particular maturity that develops throughout residency that extends beyond the curriculum.

	Now in the final year of my own residency training, perhaps the most important lesson I have learned is the value of responsibility. This may seem obvious at first glance, as patient care sits at the core of shared responsibility for the health care team.

	As a chief resident, though, I have come to appreciate that responsibility assumes many forms and should not be underestimated. Understanding the meaning of responsibility is crucial to effectively transition from a trainee to a urologic surgeon.

	In the context of patient accountability, it is worthwhile to revisit one of the basic tenets of medical ethics frequently cited: Primum non nocere, or first, do no harm. As surgeons, and particularly as surgical trainees, we must respect the privilege that we have been granted by our patients. They entrust their lives to us and surrender their bodies to allow us to operate on them to our discretion.

	As trainees, we are indebted to these patients for supporting our surgical education and enabling us to learn from them. We must further respect the legal liability that our attending surgeons are willing to risk for their patients in order to provide us with education and train the next generation of urologists.

	In return, we owe it to both our patients and our teachers to assume full ownership for our patients’ care and well-being. This means not only reading about, practicing, and preparing for operative cases, but also ensuring medical optimization for the operating room, paying attention to details in postoperative management (eg, intravenous fluids, thromboembolic chemoprophylaxis, social issues) and feeling a sense of personal accountability when complications arise.

	In hospital settings where immediate supervision is less direct, resident autonomy may be celebrated but comes with even greater responsibility. In such settings, perhaps more important than learning how to operate is recognizing when not to operate in the interest of upholding the principle of non-maleficence during the evaluation and counseling of patients.

Next - Promotion to chief resident: Paying it forward

Promotion to chief resident: Paying it forward

	Promotion to the chief resident year comes with yet another form of responsibility, in that we inherently become responsible for our junior residents and medical students. We assume the guise of leaders and role models for our mentees and transition into teachers-in conferences, in the clinic, on rounds, and in the operating room. I have gained an increasing appreciation for the patience that my own mentors and attending surgeons have demonstrated for me, and now I have the opportunity to pay the debt forward.

Visiting professorships offer unique benefit to residents

	By assuming the administrative responsibility of distributing operative case assignments among residents and dictating the content of educational conferences, I share the responsibility of ensuring that junior residents are progressing appropriately in their training.

	Indeed, the journey to become a urologist has taught me several valuable lessons that extend beyond the curriculum found in our textbooks. Certainly, the knowledge and technical skills that we learn as trainees are imperative for clinical practice. However, we must also learn to appreciate the privilege that we are gifted as physicians and surgeons. In order to complete our transformation into urologists, we must learn to understand and respect the multifaceted importance of responsibility for our patients, our teachers, and our mentees.

How to command patient trust while building experience

Consider Choice E: Effective learning during residency

Quality improvement: Why residents should get involved

 to get monthly news from the leading news source for urologists.

"In order to complete our transformation into urologists, we must learn to understand and respect the multifaceted importance of responsibility for our patients, our teachers, and our mentees," writes Nirmish Singla, MD.

Lessons of residency extend beyond the technical

 reached out to three urologists (selected randomly and asked them each the following question: What new clinical guidelines would you like to see?

"I’d like to see new guidelines on the management of advanced prostate cancer. Right now, there’s kind of a gap in the treatment of advanced prostate cancer once patients have become hormone refractory. Some of the medications are only FDA approved if patients have proven metastatic prostate cancer. So we have some men who are in a gap where their PSA is rising, but they don’t necessarily have a treatment for that.

Even though these treatments would be beneficial for before metastasis, they aren’t necessarily used off-label because insurance companies won’t pay for them and they cost $4,000 to $5,000 a month. If the AUA came up with practice guidelines on when and how to treat men with advanced prostate cancer as they progress, those medications could then potentially be covered by insurance.

Are you using telemedicine or plan to use it?

It’s a work in progress because there are newer medications that have been developed and released in the past 6 months that are FDA approved for that indication but the AUA has not endorsed them. So whether they are FDA approved or not, they need to be considered by the AUA. I’d like to see the treatments that are FDA approved added to the AUA guidelines.

And I think it would be beneficial to get AUA guidelines for earlier use of the newer agents for advanced prostate cancer, that are not FDA approved for those nonmetastatic patients. That could help them get the FDA approval sooner.”

Next: "I feel that there already exists plenty of guidelines for most of the things I deal with in urology"

“The answer, to be honest, is no, not really. I feel that there already exists plenty of guidelines for most of the things I deal with in urology. So I’m really not looking for any new guidelines.

What new technology will you adopt in 2018?

I’m familiar with a number of the guidelines and there are a lot of them out there, but I don’t look at a whole lot of the guidelines.

I use guidelines for cancer, but there I use the National Comprehensive Cancer Network [NCCN] guidelines. I don’t know why; that’s just what I do. When I’m dealing with cancer, I go to the NCCN websites for those.

When it comes to the benign processes like BPH and incontinence, I don’t use a lot of guidelines. I rely more on my experience.

I am still glad the guidelines are there. I’ve been doing this for 20 years and I’m kind of set in my ways. I think my management protocols are pretty consistent with the guidelines; at least I’m pretty sure they are any time I see the guidelines.

How important is urology/gynecology collaboration?

If the AUA does come up with new guidelines, I may take a look at them, but I don’t expect there to be anything there that I’ll really need.”

Next: "I would like to see some guidance on is what to do about patients who use marijuana recreationally" 

“A couple of things come to mind. One thing I would like to see some guidance on is what to do about patients who use marijuana recreationally. What are guidelines for saying it’s a problem or not a problem with surgery, anesthesia, consent, and compliance? Like the statement on medical marijuana-related things, I think we need something on recreational marijuana.

What steps do you take to avoid surgical complications?

I practice in Washington, so it does come up more often now. And more states are adopting legalized recreational marijuana, so it would help to have something kind of defining our role.

There is the also the opioid crisis and uses specifically in urology. Where can we use more alternatives like ketorolac for ureteral colic, and initial IV doses then switching to oral equivalents?

So marijuana and opioids-those are two areas where it would be good to have AUA guidelines.”

What are you doing to work smarter, rather than harder?

Does shock wave therapy have a future in the treatment of ED?

How will immunotherapy change the future of bladder Ca care?

"One thing I would like to see some guidance on is what to do about patients who use marijuana recreationally," says one urologist.

What new clinical guidelines would you like to see?

	The definition of nocturia has been as nebulous as its etiology and management. In 2002, the International Continence Society defined nocturia as waking up at night at least once to void 

 However, clinically relevant nocturia is generally accepted among urologists to indicate two or more voids that are preceded and followed by sleep. It is worthy to note that neither definition accounts for the patient’s degree of bother from nocturia, though waking twice or more from sleep to void has been associated with impaired quality of life 

	The economic burden of nocturia is substantial and includes injuries from falls, lost work productivity, and intangible losses such as distress, behavior changes, and confinements. The estimated financial impact is considerable, as indirect costs have been estimated at $61 billion per annum 

Beta-3 agonist significantly reduces urge incontinence

	In this article, we review the underlying causes of nocturia and outline an approach to its diagnostic evaluation and treatment.

	Nocturia is a gender-neutral entity with multifactorial underlying causes. While many studies have investigated the epidemiology of nocturia, the lack of standardized terminology has obscured research results. In a large population-based study, Tikkinen et al concluded that nocturia is more common in women under age 50, has about the same prevalence among men and women ages 50-59, is more frequent in men above age 60, and increases in prevalence more rapidly with age in men than it does in women 

	McVary et al found that most men with LUTS identify their chief LUTS complaint as nocturia and that, importantly, this symptom persists without improvement in nearly half of men 

 Echoing this unmet need in LUTS, the AUA guidelines for non-neurogenic overactive bladder (OAB) note that most of the reviewed studies included robust data on urinary frequency and incontinence, but “only a handful reported nocturia data” 

Next: "The relationship between sleep and LUTS deserves special mention given the role of sleep in overall health and quality of life

	The relationship between sleep and LUTS deserves special mention given the role of sleep in overall health and quality of life. Nocturia by definition disrupts the normal sleep cycle by interfering with sleep efficiency and prolonging sleep latency. Importantly, nocturia has been associated with increased mortality risk. The underlying mechanism for this is conceivably the greater risk of metabolic syndrome in nocturic patients as well as increased nighttime falls and fractures en route to the toilet 

	Along these lines, it is essential to recognize and rule out sleep disorders that can contribute to nocturia. Commonly encountered sleep disorders include sleep apnea, insomnia, parasomnias, and restless legs syndrome.

	As clinicians who frequently encounter this vexatious entity, it is essential for urologists to approach patients with nocturia systematically. A complete history and physical should be obtained, with particular attention to medical history (hypertension, diabetes, heart disease, kidney disease, sleep disorders) and common medications that can incite nocturia (table).

Investigational device shows promise for OAB

	One must then assess the extent of the patient’s bother and whether or not he or she desires treatment for nocturia. In the authors’ experience, some patients with a seemingly high number of nighttime awakenings are indeed not bothered by their nocturia; these patients do not warrant further nocturia treatment, although this is not to say that potential underlying holistic medical problems should be discounted.

	If the patient does desire treatment, a urinalysis should be considered to evaluate for proteinuria, glucosuria, or other abnormalities. As well, a post-void residual may also be obtained to evaluate for incomplete emptying. A 24-hour voiding diary is a valuable and cost-friendly objective tool that should be used to evaluate OAB symptoms, the quantity and type of liquid intake, and frequency and volume of voids 

	The urologist should be aware of the four main categories that nocturia falls under: global polyuria, nocturnal polyuria, reduced bladder capacity, and mixed (“Campbell-Walsh Urology,” 11th ed. Philadelphia: Elsevier, pp.1821-35).

	Global polyuria is defined as 24-hour urine output of >40 mL/kg and is caused by primary polydipsia, diabetes mellitus, or diabetes insipidus. On the other hand, nocturnal polyuria lacks a standardized definition, though commonly used criteria include nocturnal diuresis >90 mL/hr or >33% of daily urine. Nocturnal polyuria has numerous causes such as increased presomnial fluid intake, congestive heart failure, peripheral edema, sleep apnea, or diabetes mellitus or insipidus 

 Decreased bladder capacity is an umbrella term that includes prostatic obstruction, nocturnal detrusor overactivity, learned voiding dysfunction, neurogenic bladder, ureteral or bladder calculi, or cancer of the bladder, prostate, or urethra.

	The figure depicts a comprehensive diagnostic evaluation for a patient presenting with a complaint of nocturia.

	Treatment for nocturia should begin conservatively regardless of the underlying cause. One should start with behavioral techniques and only move to medications and/or procedures if clinically justified. The intervention should be tailored to the individual by aiming at the underlying problem: global polyuria, nocturnal polyuria, reduced bladder capacity, or mixed.

	Behavioral techniques to attenuate nocturnal polyuria include decreasing bedtime fluid intake, minimizing caffeine and alcohol intake, or using compression stockings or late afternoon recumbency to mobilize retained fluid for edematous conditions. Nocturia in those with sleep apnea can be improved with the use of continuous positive airway pressure. The judicious administration of medications, such as diuretics earlier in the day or antidiuretics at bedtime, may be helpful in select individuals.

General urologists less likely to utilize third-line OAB treatments

	Though frequently prescribed by many urologists, by and large, alpha-blockers, 5-alpha-reductase inhibitors, and antimuscarinics have a marginal effect on reducing nocturic episodes and should be avoided in patients with a sole complaint of nocturia. However, the role of these medications in patients with bladder outlet obstruction and OAB remains valuable. Conversely, mirabegron (Myrbetriq), a beta-3 adrenergic agonist, may be effective not only against OAB but nocturia as well 

 For this reason, we advise keeping an eye out for future studies involving mirabegron as well as other beta-3 adrenergic agonists in development.

	Of particular recent interest is the low-dose intranasal form of desmopressin acetate (Noctiva), which was approved by the FDA in March 2017 for nonpregnant adults with nocturnal polyuria 

 Potential advantages of the intranasal formulation include direct access to the circulation, more precise administration, and speed of onset of action. One must be mindful to closely monitor sodium levels in these patients, as desmopressin does predispose to hyponatremia. As a further point of caution, desmopressin should not be used in patients with underlying congestive heart failure (NYHA class II-IV), concurrent loop diuretics, or uncontrolled hypertension.

	Surgical options for nocturia should be approached with restraint. Caveats for surgery primarily include situations where enlarged prostate or OAB are established as the primary culprit or in less common cases where tumor or calculi are contributing to nocturia. Surgery for benign enlarged prostate may be pursued as a last resort via the conventional TURP or other, less invasive modalities (eg, PVP, minimally invasive surgical therapies). Patients with refractory OAB who suffer from significant nocturia may benefit from botulinum toxin A (Botox) injections, sacral neuromodulation (InterStim), or in severe refractory cases, bladder augmentation procedures.

	There remain many unmet needs in the treatment of nocturia. It is arguably the most bothersome lower urinary tract symptom and necessarily imposes a considerable burden on quality of life. The often-multifactorial etiologies contributing to nocturia obscure the establishment of a reliable diagnosis. As urologists, we focus on the genitourinary system and perhaps too often overlook the reality that nocturia may in fact be a pelvic expression of a holistic medical problem. The various façades of nocturia (global, nocturnal polyuria, reduced bladder capacity, mixed) further muddy treatment options. In a word, we often fail to recognize nocturia as a unique disease or symptom complex requiring special concern and judicious evaluation. While there have been some hopeful advances in recent years, there continues to be a gaping need for more funded research on the management of nocturia.

Guideline linked to reduction in urodynamics testing

Complications after sling repair lead to lawsuit

 is professor and chairman of urology at University Hospitals Case Medical Center and Case Western Reserve University School of Medicine, Cleveland.

In this article, we review the underlying causes of nocturia and outline an approach to its diagnostic evaluation and treatment.

Management of nocturia: An unmet need in LUTS

Bob GattyUrologists can claim substantial victories as a result of the Bipartisan Budget Act of 2018, signed into law by President Trump in February-including an end to the Independent Payment Advisory Board (IPAB), which had been established by the Affordable Care Act to help control Medicare spending.

	“That’s a tribute to the tireless work of urologist volunteers who went to Capitol Hill every year and to our staff in Washington, DC,” said Tom Rechtschaffen, MD, chairman of the AUA Legislative Affairs Committee. “This is a huge moment because of the tireless work that they did.”

	Ending the IPAB had been the objective of the AUA as well as the American Association of Clinical Urologists (AACU) and LUGPA, whose leaders hailed its demise.

Lawmakers take divergent paths on referral laws

	“While this agency was never empaneled, it served as a looming threat to Medicare reimbursement for independent physicians,” said LUGPA President Neal D. Shore, MD. “We believe that restoring this authority to Congress is the right way to maintain oversight of Medicare costs.”

	“Today, along with the stability engendered by having a federal budget that spans more than a few weeks, Medicare payments have an opportunity to achieve some steadiness now that IPAB has been repealed,” said AACU President Patrick McKenna, MD.

	The IPAB was to recommend specific savings if Medicare spending per beneficiary was projected to grow faster than certain benchmarks. Congress could have blocked the recommendations, but they did not need congressional approval to take effect. Opponents said that placed too much power in the hands of unelected board members whose decisions could affect their livelihoods.

Next: “This gives us back some say in the process"

	Indeed, urology organizations had fought IPAB virtually since its inception. Dr. Rechtschaffen recalled calling on Congress in 2010 and urging its repeal.

ABU exams: A look inside the question-writing process

	“This gives us back some say in the process,” Dr. Rechtschaffen said, “because it gives us the ability to bring solid data to the Centers for Medicare & Medicaid Services (CMS) and MedPAC (the Medicare Payment Advisory Commission) when reimbursement cuts are proposed to demonstrate what impact that would have on our patients.”

	The new budget also removes Part B drugs from penalties and bonuses under the Merit-based Incentive Payment System (MIPS), established by the Medicare Access and CHIP Reauthorization Act (MACRA)-another objective of the key urology organizations.

	That action, Dr. Shore explained, means that providers will not be financially penalized for administering Part B drugs to patients.

	“In the original plan, we would have been on the hook for the cost of those drugs, which was absolutely unfair,” said Dr. Rechtschaffen. “The new budget law removes that provision so we will not be charged (in MIPS calculations) for Part B drugs.”

	Another victory gained in that legislation, he added, is a 2-year extension from 2021 to 2023 of the deadline for providers to comply with electronic medical records and quality reporting requirements.

	“They heard us,” Dr. Rechtschaffen said, referring to members of Congress with whom urologists and AUA representatives had met to express concerns about the burden faced by physicians. “We asked for relief and they heard us.”

	Dr. McKenna noted that the AACU last year filed formal comments asking that urologists be given more flexibility in terms of EHR adoption.

	“The new budget removes a mandate that meaningful use standards become more stringent over time,” he said. “This will ease the burden on physicians as we will no longer have to ask federal regulators for a hardship exception if we fall slightly short.”

	Dr. Shore said LUGPA welcomes a provision in the new budget law that extends the reimbursement rate freeze for radiation oncology, which the organization had supported.

	“The rate freeze extension will allow for additional time to develop an alternative payment model for radiation services, a process LUGPA stands ready to support with our expertise,” he said. “The rate freeze also reinforces the importance of site neutrality in reimbursements, which will preserve patient access to radiation oncology services in the setting of their choice.”

Congressional retirements promise to make waves

	In addition, Dr. Shore said the budget law’s improvements in the alternative payment model review process within the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “will allow fluid communication between the committee, organizations like LUGPA, and the secretary of CMS. We anticipate it will increase participation in APMs under the QPP (Quality Payment Program).”

	Yet another positive result from the budget bill ends an effort by CMS to reclassify radiation for prostate cancer, resulting in reduced reimbursement rates for prostate cancer radiation only.

	“The budget deal freezes that discussion so the current state of affairs remains in effect. It’s a very happy day for us,” Dr. Rechtschaffen said.

	The AACU’s Dr. McKenna noted that the budget accelerates the elimination of the Medicare Part D coverage gap, or “donut hole.” The new law requires drug manufacturers to give larger discounts to beneficiaries in the coverage gap, starting in 2019.

	“All of this is very affirming for all of the work that’s been done and it emphasizes the value and importance of urologists having a presence in Washington,” Dr. Rechtschaffen said. “These victories are worth literally hundreds of millions of dollars for AUA members. It’s a clear indication of why our Washington office is so important.”

	Now, it’s time to look ahead, he said, and focus on new initiatives that include prostate cancer testing and prevention, research, and establishing a new Office of Men’s Health.

	At the AACU, Dr. McKenna said, “Urologists will push for polices that reduce administrative burdens imposed by public and private payers, as well as sound the alarm on work force shortages that threaten access to care.”

	He said President Trump’s proposed budget for 2019 “would be catastrophic: cutting GME funding by $48 billion over 10 years and moving all training programs under the same roof, with no specifics on where funding will come from or how shortage areas will be determined.”

Survey: Urologists weigh in on MIPS, APMs, burnout

Setting up an emergency fund: What you need to know

Urologists can claim substantial victories as a result of the Bipartisan Budget Act of 2018, signed into law by President Trump in February-including an end to the Independent Payment Advisory Board, which had been established by the Affordable Care Act to help control Medicare spending.

Urology groups hail recent policy victories

Association of Clinical Urologists (AACU)

 provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or 

	Alternative payment models. Integrated delivery systems. Provider and payer consolidation. Each of these trends reflect the evolution of our nation’s varied health care delivery and financing systems toward the common goal of better care at lower cost. Laws and regulations in most states, however, have failed to keep up with these practical developments, and some policymakers would further inhibit patient-centered care with proposals to impose new referral restrictions.

	Although physician self-referral is regulated at the federal level through the Stark law, its application is limited to public payers such as Medicaid and Medicare. At least 35 states have their own laws or regulations restricting referral arrangements. The American Medical Association's Advocacy Resource Center identifies three "significant differences" between the Stark law and state statutes:

		State laws may apply to more providers.

		State laws may encompass a broader range of services.

	In recent years, lawmakers in several states considered legislation to conform their laws and exceptions to those outlined in the Stark law. Gov. Andrew Cuomo of New York vetoed legislation in 2012 that would have brought the state's statutes in line with federal law by limiting their application to public payers and adding a few designated health services to the list of exceptions. 

, a law firm specializing in health care transactions, in vetoing the bill the governor took "the position that a more restrictive statute... outweighs the functional benefits of consistency with its federal counterpart."

	Fast forward to January 2018, when Colorado State Sen. Irene Aguilar introduced legislation to extend the state's "mini-Stark law" to services reimbursed by private payers (

, Rocky Mountain Urological Society, and Colorado Medical Society, a Senate committee indefinitely postponed consideration of this bill on Feb. 14. Pennsylvania State Rep. Anthony DeLuca, meanwhile, has repeatedly introduced a bill to extend the current prohibition for "self-referrals" that exists for the Commonwealth's workers compensation system to all medical services. His version for the current legislative session has remained stagnant since being referred to the House Health Committee in early 2017 (

Next: "An attempt to adapt to modern day realities recently achieved a level of success in Maryland"

	An attempt to adapt to modern day realities recently achieved a level of success in Maryland. Modifications to the state's strict prohibitions were needed in light of the state's unique all-payer model contract with the federal government. A state commission advised lawmakers that shared savings compensation arrangements between hospitals and physicians approved by the feds could violate state statutes. The legislature passed and Gov. Larry Hogan signed a bill that exempts transactions between providers if the arrangement is funded by or paid under:

		a Medicare Shared Savings Program accountable care organization (ACO)

		an advance payment ACO model, a pioneer ACO model, or a next generation ACO model, as authorized under federal law

		an alternative payment model approved by the federal Centers for Medicare & Medicaid Services (CMS)

		or another model approved by CMS that may be applied to health care services provided to both Medicare and non-Medicare beneficiaries (

	The federal government itself is taking steps to modernize the law restricting integrated care. The AACU, as a member of the Coalition for Patient-Centered Imaging, expressed strong support for the Medicare Care Coordination Improvement Act of 2017, which in part, provides CMS the same authority to waive Stark and anti-kickback laws as was provided to Accountable Care Organizations in the Affordable Care Act (

). What's more, CMS Administrator Seema Verma acknowledged that the Stark law can slow the transition to value-based care, according to a

. An interagency group has therefore been formed to examine regulatory barriers posed by federal anti-kickback laws (

Urologists, lawmakers share experience, expertise at AACU event

	The most prevalent health system reforms launched by governments and payers alike are predicated on an integrated delivery model. State laws and regulations often impose strict restrictions on the provision of such patient-centered care. As policymakers examine and adapt statutes to align with practical reality, the AACU will advise urologists on the most effective and efficient ways to make their voice heard.

	To get weekly news from the leading news source for urologists, 

"In recent years, lawmakers in several states considered legislation to conform their laws and exceptions to those outlined in the Stark law," writes the AACU's Ross E. Weber.

Vol. 46 No. 04

Much to love and learn in San Fran: A top 10 list for AUA 2018

Lessons of residency extend beyond the technical

What new clinical guidelines would you like to see?

Management of nocturia: An unmet need in LUTS

Urology groups hail recent policy victories

Lawmakers take divergent paths on referral laws