From Dr. Rosevear: What I learned about urology in 2020

November 16, 2020
Henry Rosevear, MD

Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.

"The COVID-19 pandemic exposed shortcomings in all current business models of urology," writes Henry Rosevear, MD.

Rosevear, a member of the Urology Times® Clinical Practice Board, is a urologist in community practice in Colorado Springs, Colorado.

2020, I’m not going to miss you. That said, the toughest teachers are often the best, and here are a few lessons I learned in 2020 that will make me a better independent urologist.

First, I learned that employment in the medical field is not as guaranteed as we thought it was. Until now, the health care field had enjoyed one of the longest and most consistent rises in employment in this country. In fact, health care had not seen a decrease in job growth as far back as 1991.1 However, we were not only not immune to the effects of the pandemic, we were doubly hit by it. Not only did we see the ravages of coronavirus disease 2019 (COVID-19) on our patients while performing medical roles that we were not necessarily comfortable doing, but we also saw our own livelihood threatened.

The financial threat associated with COVID-19 did not spare any particular health care model: hospitals furloughed doctors, independent clinics shut down, and private equity-backed firms lost money. The crisis shook the foundations of the business of medicine. In 2021, I will be closely reviewing the underlying financial structure and practices of my business to better prepare for another “black swan” event.

We also discovered that telemedicine has a real role in the clinical practice of urology. It’s important to think about why telemedicine wasn’t widely accepted before this year and what changed. The answer, simply put, is that the rules changed. Before the crisis, in order to be paid to do a telemedicine visit, both you and the patient had to be at an approved location, using Health Insurance Portability and Accountability Act-compliant equipment, and in a region of the country deemed appropriate by the government.

During the crisis, you simply needed to pick up your phone and talk to the patient. Clinical urology is exceptionally well-suited to adopt telemedicine because so many of our diseases can be diagnosed without a physical exam. During virtual visits, we could diagnose frequency, kidney stones, even to some degree a renal mass. Listening to a patient’s story and reviewing an image is usually enough to begin the treatment process. I’m not discounting the role of a physical exam; I’m just being realistic about what it adds in many circumstances. In 2021, I will be closely monitoring what the Centers for Medicare & Medicaid Services (CMS) learns from the ongoing natural experiment in widespread adoption of telemedicine and what rules it implements going forward.

Another lesson I learned is that urology continues. During this year alone, our ability to treat advanced prostate cancer and metastatic urothelial cancer was advanced. New drugs and office-based options for neuromodulation of overactive bladder came online. Lasers for the treatment of kidney stones became stronger, changing how we treat patients. Office-based surgical approaches for the treatment of benign prostate disease gained traction as their longer-term efficacy was shown. Other advances included oral testosterone replacement, genetic-based urine cultures, and shock wave treatment of the penis for erectile dysfunction; the list goes on. In 2021, not only do I expect more basic science advances, but I look forward to seeing how the above treatments are incorporated in the trenches of small-town urology.

Lastly, the COVID-19 pandemic exposed shortcomings in all current business models of urology. Of those models, the independent private-practice urologist faces the most serious long-term headwinds. Throughout all fields, 2020 saw the ongoing march of large hospitals systems consuming small practices and turning what were entrepreneur physicians into simple cogs in large systems. Insurance companies also continue to directly purchase medical groups in an attempt to control costs. Both pure private-equity models and large urology specific management-service organizations continue to expand across the country. In 2021, I expect many more urology groups to choose sides between what I envision as a future of medicine controlled by large corporate interests or remaining independent. As a wise urologist once told me, the key point in that decision is not the details of the immediate deal; rather, it is how life after the deal is structured.

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