Members of the urology community who participated in the Annual Urology Advocacy Summit in Washington early last month urged lawmakers to support initiatives to improve patient care, including in minority populations, increase support for urologic research, and ease regulatory burdens.

More than 200 members of the urology community participated in the Summit, which included educational sessions on advocacy topics such as work force issues, urologic care for veterans, and other critical access-to-care concerns.

Attendees participated in meetings with lawmakers from 112 House districts and 74 Senate offices and discussed three primary concerns: prostate cancer screening in high-risk populations, increased funding for urologic research, and the regulatory burden of prior authorization and its impact on urologic practices and patients.

“The AUA Summit confronts and obliterates the myth that physicians can’t make a difference in Washington. It offers an opportunity for urologists to use their intelligence, problem-solving skills, insight, and passion for patient care to shape and redirect health care legislation and regulations in our and our patients’ favor,” said Thomas Rechtschaffen, MD, chair of the AUA’s Legislative Affairs Committee.

“During our meeting this year, we discovered new avenues to access research funds and rollbacks on harmful regulations. We were a loud voice, added to other physician groups, to rally against prior authorization burdens. Congress is hearing us and paying attention. We obtained support to direct funding to research how prostate cancer affects people of color more specifically and for renewal of PCORI [Patient-Centered Outcomes Research Institute] legislation, which is another source of research funding that our academic urologists and trainees depend upon.

A call for more research on PCa in African-Americans

Lawmakers were urged to encourage the National Cancer Institute to direct additional research efforts toward better understanding prostate cancer among African-American men and other populations at high risk for the disease.

The AUA pointed out that in 2018, after being pressed for years by the urologic community, the U.S. Preventive Services Task Force (USPSTF) released upgraded recommendations for prostate cancer screening but was unable to make specific recommendations for African-American men, citing a lack of available research evidence of the benefits to these patients.

The USPSTF has called for additional studies “to explore the optimal screening frequency and whether beginning screening before age 55 years provides additional benefits to African-American men.” The AUA’s clinical practice guidelines on early detection of prostate cancer support this statement, the association said in a briefing paper provided to members of Congress.

Summit attendees urged Congress to support increased funding in fiscal year 2020 for the Department of Defense Congressionally Directed Medical Research Programs, which since 1992 has funded 16,350 research grants and projects totaling $11.6 billion.

In FY 2019, prostate cancer research in the program received $100 million and kidney cancer research received $20 million, and since FY 2016, Congress has provided bladder cancer funding through the program as well.

The AUA also urged lawmakers to support pending legislation to reauthorize the PCORI to avoid a lapse in its research efforts. Created in 2010 by the Affordable Care Act, the Institute is an independent, non-profit research agency that facilitates comparative clinical effectiveness research to help patients make informed decisions about their care.

Since 2017, the Institute has invested nearly $2.4 billion in more than 600 research-related projects, including more than $32 million for nine different urologic disease research initiatives. Congressional authorization for the program expires in 2019 unless the program is extended.

In addition, the AUA joined with the Ad Hoc Group for Medical Research Funding in requesting that Congress provide $41.6 billion for the National Institutes of Health, a 6.4% increase over current funding.

“NIH funding has already improved the lives of Americans with urologic diseases, including those with [BPH],” the AUA said in its congressional briefing paper.

In addition, the AUA said, NIH research has shed light on potential health care savings with better treatment options for urinary incontinence, which costs more than $7.5 billion annually to evaluate and treat.

Summit attendees encouraged members of Congress to support the introduction of bipartisan legislation to address prior authorization issues and include consensus recommendations by the AUA and other leading national physician organizations.

The AUA noted that on Feb. 5, the American Medical Association released the results of a survey indicating more than one-quarter of physicians said the prior authorization process has led to serious or life-threatening events for their patients.

Telemedicine policies advance with technology

The AUA and more than 100 other health care organizations have endorsed the “AMA Prior Authorization and Utilization Management Principles,” intended to “ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens.”

The AUA also has joined with the Regulatory Relief Coalition, which includes specialty provider organizations, in working with key lawmakers to address the issues physician organizations and patients face because of prior authorization.

Articles

AUA lobbies Congress on PCa, prior auth

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: 

Who should own medical records-the doctor or patient?

"That’s a good question. Clearly, the doctor has to. Then the question is, does the patient own the records as well? I would say the patient owns the record too-so I would say both.

Patients get an after-visit summary that has the salient points discussed during our office visit. In our institution, they’re also encouraged to sign up for an online service called ‘MyChart,’ where they can get into their medical records electronically and remotely.

That has more detail than the after-visit summary, information like laboratory tests another doctor ordered-things outside of our specific appointment.

What are your thoughts on the use of medical marijuana?

If a doctor wants to make notes for himself, the chart isn’t the place to put them. The chart can be subpoenaed and so forth, so if a physician wants to leave private comments, that should be a separate location.

Some systems provide the opportunity to make notes in part of the chart that are not literally part of the patient’s medical records. Patients can’t get into that. It’s not part of the after-visit summary, but it’s part of the records that doctors leave for themselves. I don’t use those. Everything I think about, I share with the patient, and therefore it goes into my notes. I may say things like, ‘Bring the patient back in 6 months to talk about these other issues, and I introduced the first two concepts today.’

It helps you to know what’s going on, and obviously the health care team needs to know everything to provide the best possible care. That’s pretty self explanatory. In today’s world, patients are demanding increased participation in the process… and secrets don’t really help anybody.”

"State laws vary throughout the country, so sometimes it’s not our choice."

"State laws vary throughout the country, so sometimes it’s not our choice.

How concerned are you about patients taking counterfeit meds?

In my opinion, medical records are the work product of the doctors, and if employed by an institution, a combination of the doctor and the institution. That doesn’t mean that patients shouldn’t have complete access.

There could be issues, however, for which doctors must be prepared. ‘Complete’ is probably the definitional issue. Sometimes it’s complete access to an ‘edited’ record. That may be better for some patients because of the confusing nature of the information.

It might be better, and less confusing, if patients had access to a layman’s edited record, rather than the current system where they have complete access to the unedited record.

We have a web portal where patients can access their records. They can request copies of office and operative notes, but don’t actually have complete access. They have open records except for specific areas, like psychiatric reports or HIV testing. Patients can get that information, but not immediately through the portal.

In Pennsylvania, all x-ray abnormalities have to be reported directly to the patient with a recommendation to call their doctor. That becomes a huge burden because although you’ve told a patient about a benign cyst on his kidney, he thinks something else is wrong because the letter reported an abnormality. You spend significant time educating patients about the practice of medicine.

I’m not professing having secrets from the patients. Transparency is good, but when information is delivered without editing, it can be more confusing than helpful.

 How do you counsel patients about at-home genetic tests?

Editing information means extra work, but when interpretation of the information is necessary, the record is not designed for the patient. We may have to dictate like our patients will read it, as opposed to dictating for a doctor. That may be the solution.”

"The medical record itself, in my opinion, is the possession of the patient."

"The medical record itself, in my opinion, is the possession of the patient.

The responsibility for maintenance of that record would fall on us as providers obviously. But the rights of access, without question, belong to the patients.

What has been your experience with ERAS pathways?

As far the contents of the records, the onus comes back on us as providers to be able to communicate that in a way patients understand, which in certain circumstances might require us to use terminology that is slightly more layman’s language. Are there always going to be situations where there is a misunderstanding and will further communication be required? Yes, without question. It’s an imperfect system, but patients should have full access to those records.

If doctors want to remind themselves of something, they need to be willing to clarify those comments to the patients. If they’re not willing, then obviously they have to develop a different means of self-reminding than medical records.

Whether we like it or not, we’re legally required to make the information available. So if we’re willing to put it in the medical record, we need to be ready to give full disclosure, interpretation, and explanation to the patient.”

“Clearly, the doctor has to. Then the question is, does the patient own the records as well? I would say the patient owns the record too-so I would say both,” says one urologist.

A 56-year-old male retired truck driver presented to the ER with a chief complaint of fever, chills, and body aches for 2 days. His prior medical history was positive for a urethral stricture for which he began receiving treatment when he was 24.

Prior to his urethral injury, the patient underwent several procedures to dilate his urethra and had been seen in the ER on numerous occasions for urinary tract infections. On presentation to the hospital, he reported to the ER physician that he had had trouble catheterizing himself at home. The ER nursing staff made several attempts to catheterize the patient, but to no avail. A urologist was consulted, who recommended that if the patient was able to void, there was no need to place a catheter in the ER.

The patient was subsequently given IV fluid and was able to void; however, he began to demonstrate tachycardia and hypotension. An internal medicine doctor then admitted the patient for a suspected UTI and to rule out sepsis. Urine and blood cultures were ordered and the patient was started on antibiotics for possible sepsis.

The man was seen for the first time by the internal medicine doctor the day after his admission. After testing, the patient was discharged 4 days later with instructions to continue on his antibiotic therapy for 7 days and follow up with his primary care physician. Later that day, the patient presented to the ER again with a chief complaint of hematuria and difficulty voiding. He was advised to make an appointment with a urologist.

Soon after, the patient was seen by a urologist. The urologist attempted to perform a cystoscopy, but he was unable to pass the scope beyond the stricture due to the presence of multiple false passages. The urologist opted to place a suprapubic catheter under general anesthesia. The plan was to leave the suprapubic catheter in place as long as necessary to allow for decreased swelling and healing of the urethra.

The patient later sued the hospital, the internal medicine physician, and nursing staff. The case proceeded to trial against the internal medicine doctor only.

"The plaintiff claimed that because of the defendant-doctor’s negligence, he had to undergo placement of a suprapubic catheter, which remained in place for 7 months"

The plaintiff claimed that because of the defendant-doctor’s negligence, he had to undergo placement of a suprapubic catheter, which remained in place for 7 months. He claimed that he presented to the ER with a chief complaint of a UTI and did not request to be catheterized. He argued that because of the multiple attempts at catheterizing him in the ER, he suffered injury to his urethra.

Plaintiff’s expert internist opined that the defendant fell below the standard of care due to his failure to be aware of the nature and extent of the urethral injury the plaintiff had suffered by the time he was admitted. The expert found that the defendant failed to adequately take a history of the urethral injury and did not perform a genitourinary exam at any time during the plaintiff’s hospital stay, negligently failed to request a consultation with a urologist while the plaintiff was an inpatient, and at discharge did not refer the plaintiff to a urologist.

Plaintiff’s expert urologist testified that the failure to consult a urologist while the plaintiff was an inpatient resulted in a lost opportunity to avoid suprapubic catheter placement. The expert noted that, due to the urethral injury, the plaintiff was not voiding well.

The expert concluded that the defendant’s opinion regarding urinary retention was supported by the findings of the renal ultrasound, which revealed a distended bladder, and had a urologist been consulted, additional attempts at placing a Foley catheter using a guidewire would have been made in an effort to relieve the retention and thereby avoid the need for the suprapubic catheter that remained in place for 7 months. 

Positional injuries pose medicolegal risks

The defendant claimed that his inpatient care and treatment of the plaintiff was well within the standard of care and that nothing he did or failed to do caused the need for the suprapubic catheter placement.

The defense’s expert internist opined that the defendant complied with the standard of care throughout the plaintiff’s hospitalization. The expert proffered that the primary reason for hospital admission was a life-threatening UTI that was adequately treated, and that the standard of care did not require a urology consult under the circumstances because any further catheterization attempts would have been contraindicative due to the plaintiff’s serious infection.

The defense’s urologist opined that the plaintiff had a chronic problem with a urethral stricture. The expert concluded that nothing that the defendant did or failed to do caused the need for the suprapubic catheter. In addition, on exam 3 years after discharge, the plaintiff had no residual problem with his ability to urinate.

Following a 7-day jury trial, the jury deliberated for 1.75 days. Ultimately, the jury returned a defense verdict, finding that although the defendant-doctor was negligent, his negligence did not cause the plaintiff harm.

 To succeed in a malpractice claim, a plaintiff must establish, by the greater weight of the evidence, both negligence and causation. In this case, plaintiff succeeded on establishing the defendant-doctor’s negligence, but failed to establish causation by the greater weight of the evidence.

"The expert concluded that… had a urologist been consulted, additional attempts at placing a Foley catheter using a guidewire would have been made in an effort to relieve the retention," writes Acacia Brush Perko, Esq.

Failure to consult urologist at heart of case

My account really fluctuated during the last 3 months of 2018. Should I have been more proactive about protecting my investments from losses?

The fourth quarter of 2018 did not reward equity investors. The S&P 500 (Large Cap Index) was down 13.52%, the Russell 2000 (Small Cap Index) was down 20.20%, and the MSCI EAFE (International Index) was down 12.54%.

When markets are down significantly, investors commonly feel a sense of panic or fear they are losing everything they have accumulated. They obsess over the financial news and are tempted to sell to preserve what is left. However, these moves typically provide short-term comfort at the expense of long-term goals.

Selling after the markets are down may significantly reduce your ability to make up those losses in the rallies that historically occur after a sharp decline. For example, after the 2008-’09 financial crisis, in which the S&P 500 was down as much as 51%, the following rally lasted 118 months and was up over 300%.

Following the dot-com crash in 2000, when stocks were down 45%, the following rally lasted 61 months and was up over 100%.

In fact, every sustained down market has been followed by a significant and sustained upward rally.

How to make sense of the IRA aggregation rule

Benefiting from these rallies requires being invested in the market. If you sold previously, you may miss out on all or a significant portion of the rally. You may be thinking, “But what if I sold when things started going down and then bought back in at the bottom?” Timing the market is incredibly difficult to do. How will you know when the market is headed for a sustained downward slide, and how will you know when the market has reached bottom? These are nearly impossible things to predict, and guessing wrong can negatively impact your investment success.

Surviving a down market requires some key behaviors: faith, patience, and discipline. You need to have faith that markets will turn and, over the long term, move in an overall positive direction. Patience means not chasing the hottest trends and trusting that your investment strategy will produce the results you desire long term. Discipline means continuing to adhere to an asset allocation strategy and diversified investment mix that can help you reach your financial goals.

How big of an impact can selling when the markets are going down and buying back in have on my account balance?

If we look at an example from the 2008-’09 financial crisis, we see that selling and then guessing when to get back in the market had a negative effect. Assume someone with a $1 million diversified portfolio panicked and sold in March of 2009, at the bottom of the market crash. After the markets started recovering, they bought back in after 3 months with the same portfolio. Today, their account would be worth approximately $2.64 million.

If they had waited a full year to get back into the market, their account value today would be only $2.20 million.

Flexible spending vs. health savings accounts: How to choose

But if they had stayed invested throughout, their account today would be worth $3.28 million.

Panicking and selling, then trying to guess when to get back in the market, is not something most investors are regularly successful at.

1. Morningstar Dec. 31, 2018 data. All indices referenced are unmanaged indices of various asset classes within the investment markets. None are available for direct investment.

3. Dimensional Funds. Benchmarks used in calculation; S&P 500 (30%), Russell 2000 (20%), Dow Jones Select REIT (10%), MSCI EAFE (18%), Barclays US Agg Bond (12%), Barclays Global Agg Bond (7%), Cash (3%).S&P data are provided by Standard & Poor's Index Services Group; Russell data © Russell Investment Group 1995-2019, all rights reserved; Dow Jones data by Dow Jones Indexes; Barclays indices © Bloomberg Barclays 2019; MSCI data © MSCI 2019, all rights reserved. Referenced indices are not available for direct investment. This is a hypothetical illustration only, and its performance is not indicative of any particular investment. Investments with potential for higher returns carry greater risk of loss.

4. S&P data provided by Standard & Poor's Index Services Group; Russell data © Russell Investment Group 1995-2019, all rights reserved; Dow Jones data provided by Dow Jones Indexes; Barclays indices © Bloomberg Barclays 2019; MSCI data © MSCI 2019, all rights reserved.

Mr. Witz is educational program director at MEDIQUS Asset Advisors, Inc. in Chicago. He welcome readers’ questions and can be reached at 800-883-8555 or 

The information in this column is designed to be authoritative. The publisher is not engaged in rendering legal, investment, or tax advice.

"When markets are down significantly, investors commonly feel a sense of panic or fear they are losing everything they have accumulated," writes Jeff Witz, CFP.

Vol. 47 No. 4

AUA lobbies Congress on PCa, prior auth

Who should own medical records-the doctor or patient?

Failure to consult urologist at heart of case

Why you should resist the urge to sell in a down market