Health policy is inextricably linked to the practicing urologist; without policy there is no practice. This principle was highlighted by Priya Padmanabhan, MD, MPH, FACS, in her presentation, “Advocacy and Health Policy Update: The Politics of Policy,” during the 2022 Society of Women in Urology Annual Clinical Mentoring Conference. In a recent interview with Urology Times, Padmanabhan shared the main takeaways from this discussion. She is a professor of urology and fellowship director of female pelvic medicine and reconstructive surgery in the Oakland University William Beaumont School of Medicine in Royal Oak, Michigan.
It really comes from the idea that health policy is not created in a vacuum. There are many factors at play, a major one being the politics of the time. So, politics and policy are interrelated. And so, what I want the audience to understand is that politics is central in determining how we as citizens and policymakers will recognize and define the problems within the present social issues and policies. Politics is crucial in facilitating and helping us establish certain health interventions. Politics can also generate challenges for us to implement policy.
We talk a bit about agenda. When we think about agendas, I think a lot of times it's a word that raises suspicion. People assume 'agenda' has a bad meaning, but it doesn't. There is in fact a visible agenda and a hidden agenda. So, the visible agenda are those actors who receive a lot of press and public attention, which would be like the president, high level appointees, prominent members of Congress, [or] election related factions. I think a lot of people feel like these are the individuals and the forces that make a difference. Well, there's the whole hidden agenda. That's the momentum behind the agenda. That's really the hidden influence. And that's us—that's the political assistants…the researchers, the interest groups, and the public. And we're the ones that really create the momentum that can eventually make health policy happen.
To understand this better, I've been reading political science and associated models for health policy formation. One that stands out is Kingdon's model of 3 streams. He talks about the problem stream, the policy stream, and the politic stream, and how when they come together, you meet a “window of opportunity.” To explain what those are, the problem stream is a public issue, which is recognized as a problem by society. The politics stream is really the national mood; it's the pressure groups that are campaigning; [and] it's where things are in relationship to the administrative or legislative turnover. Then you've got the policy stream. These are the proposals that we put for the, wanting change that come from academia or scientific organizations. Now, it's very important to understand that while these 3 streams may be acting independently of one another, all 3 need to come together in order for a policy to emerge. That's the “window of opportunity.” And it's not that the streams just meet by happenstance. It's rather by consistent and sustained action of advocates. So, it's most appropriate I now talk about advocacy and health policy.
Interestingly, from 2006 to 2014, the number of physicians graduating with dual degrees from medical school grew by over 50%. That includes a [juris doctor (JD) degree], a [Master of Business Administration (MBA)], a [Master of public health (MPH)], a Master [of] Hospital Administration. That means that the physician urologists have a much larger knowledge base and level of experience, and this gives them a greater ability to enter health policy and advocacy. Yet, the most daunting step of political engagement is the first one. Time is a large part of the issue. We need time to reach our [relative value units (RVUs)], our research requirements, our family time, our personal endeavors. It’s the threat or a need felt, which then causes us to overcome the obstacle of engagement. And when we do overcome that obstacle, the benefits to that engagement far outweigh the challenge. So, we find an increase in career satisfaction, reduction in burnout, and it also helps strengthen physician leadership skills.
In the state of advocacy, we as leaders help explain complex medical issues to government individuals. We give a real-world lens and provide the potential unintended consequences of their actions. That is critical to their job performance at a regulatory and legislative agency level. As this relationship grows, they view the physicians as a resource, and they actively will seek our input when there's pending legislation or regulation. Even at a more granular level, when a physician leader has this knowledge, they can then translate those complex legislative and regulatory processes to their fellow physicians. So, someone in the group can then be prepared if a new policy is going to be affecting their practice.
There are three urology specialty societies that exist. One is the American Association of Clinical Urologists ( AACU), the [American Urological Association (AUA)], and LUGPA, which stands for the Large Urology Group Practice Association. They do many different activities, but unfortunately, due to the limited exposure of these concepts in medical school, many urologists know nothing about them. For example, the AACU is a health apparatus that focuses mostly on state advocacy, through their state society networks, yet they remain fully engaged with AUA and LUGPA on federal issues. LUGPA, on the other hand, is a highly targeted engagement and they use focus bipartisan political giving to members of key committees of jurisdiction. Now, it used to be that the AACU and AUA would meet together, but around 2017 they changed this so [that] they each meet independently [and] annually. LUGPA, on the other hand, meets in group meetings every 6 to 8 weeks, and all 3 of these societies do collaborate multiple times a month.
Another key thing in making health policy possible is the fundraising component. Now, this may sound distasteful to some people, but it's important. There are 2 mechanisms for fundraising. One is via representative entities, such as a political action committee, or PAC, or by direct giving. There are 2 PACs in urology: one is the AUA pack, which is associated with AUA, and there's a UROPAC that's administered by the AACU. LUGPA also engages in giving, but they use it typically by asking member group practices to donate individual fundraising events to specific congressional members. And this is, again, with no specific partisan focus. But the key thing to remember is these groups have to act independently and they cannot coordinate their giving. These are opportunities to interact with elected officials during a fundraising event. That is just an opportunity to engage in a smaller social forum. So, it's never a suggestion or an expectation that the contribution will lead to a legislative quid pro quo, but it's an opportunity to present a point of view that would not be otherwise heard. And so, it's important to realize that these PACs are not partisan in respect to political parties, but they're very partisan in respect to the interests of our patients and the urology members.
It is important to understand the meaning of effective advocacy. This requires credible information on different conditions, policy options, and impacts that it'll have. It does require interaction with policymakers [and] it should include a large and geographically dispersed membership. You want to see people on the same page, so you want to see group cohesion and a unified position on priority issues. You need resources available, and you want to make sure there's a thought leader who's strategically placed in political niches so [that] they're recognized and heard. So, if we look at the face of the urologic advocate at this moment in time, it's a major challenge. One of the major challenges is the demographic makeup of our specialty. Historically, the physicians who engage in advocacy tend to be older white males. That's especially important because much of the legislative work [is] being done by legislative assistants, [who] tend to be younger and from more diverse backgrounds. So, we need messaging to be impactful. And it is if it's presented from varied backgrounds, and from varied practice environments. If we look at the AUA and some of the other organizations' efforts, there is a real push to enlist a more diverse group. If we look at the 2020 Advocacy Summit, 27% of the attendees were students, residents, fellows, and young urologists. That was the largest number to date. There are [also] programs in place to encourage individuals to participate, such as the LUGPA Forward program, the AUA Holtgrewe fellowship for residents and fellows, as well as the AUA Gallagher Health Policy Scholarship for those in practice.
One of the key ones is telemedicine. Telemedicine has really taken a stronghold with the pandemic, with help [from] the CARES Act. But what we would like to see and achieve is reimbursement for telemedicine, especially audio-only visits, at the parity of regular visits, [or] in-person visits. We want to eliminate restrictions on the location to the payment, and make sure this extends well beyond the pandemic.
Another initiative is put forthe by specialty physicians advancing rural care, and it's called the SPARC Act [Specialty Physicians Advancing Rural Care], which is a bipartisan support. And the idea is that this will increase the number of specialists in the respective states, specifically in rural areas, and help decrease the burden on patients in need of care. Associated with this is the HR 944, which would establish a loan repayment program.
Another area of significance is that the AUA [is] supporting a regulatory amendment that would protect individuals from discrimination based on sexual orientation and gender identity. This proposed rule would add gender identity and sexual orientation back to a list of anti-discrimination protections under Section 1557 of the Affordable Care Act. The AUA is hoping this will remove barriers [to] acquiring health care insurance coverage for health needs, and specifically help reduce the disparities faced by the LGBTQ population.
I think it's important to talk about not [only] what exists, but what can we do to make it better? So, I think it's really important that we as urologists incorporate health policy teaching into medical school curriculum and residency curriculum. I think it's crucial for us to understand how important this is not only for patients, but for ourselves, as we participate in our careers and in teaching and advocating. I think it's important to provide mentorship to young faculty, residents, and medical students, so they gain knowledge and exposure. The hope is that then those trainees will return to their cohort and provide the lessons that they've learned. Like other [Continuing Medical Education (CME)] activities, we should support faculty to attend and participate in health policy and advocacy activities. They shouldn't be penalized for missing work or not meeting their RVUs because this is such an important thing. I hope that we can continue to have a virtual platform [for] many of the major health policy meetings, because as we saw in 2020, I think this will continue to increase the participation by a larger number of younger and more diverse individuals. As a member of [the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU)], I think it's really important that other specialty societies will create health policy fellowships like we did, to ensure that rising talent actually has a seat at the table.