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MACRA leaves urologists confused, skeptical


The era of value-based health care has arrived. And while the idea of basing reimbursement on quality and efficiency rather than volume of care is good in theory, the majority of urologists say it will be difficult to carry out, according to Urology Times' 2016 State of the Specialty survey.


Urologists' attitude toward value-based care




National Report-The era of value-based health care has arrived. And while the idea of basing reimbursement on quality and efficiency rather than volume of care is good in theory, the majority of urologists say it will be difficult to carry out.

Commentary: Are you unhappy? Survey reveals why

Nearly half of urologists also admit to not understanding the changes created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the law passed last April that essentially establishes the provisions for physician reimbursement under a reformed Medicare payment system.

Those findings emerged from Urology Times’ exclusive 2016 State of the Specialty survey, which collected responses from 171 urologists on topics ranging from the Affordable Care Act and board certification to reasons for retirement and plans for 2017, to name a few. (Also see, “How the survey was conducted.")



I understand the changes created by MACRA




Despite rejoicing over MACRA’s elimination of the dreaded sustainable growth rate (SGR) formula, many urologists are skeptical about value-based care, according to responses to new survey questions. Given a number of choices to describe their attitude toward value-based care, urologists most often said it was “a good idea in theory but much harder to execute in practice” (59%). About one-fourth said it’s “a bad idea that will not succeed,” 10% said they didn’t know enough to form an opinion, and only 1% described it as “good for the health care system and good for my patients.”

Read - Looking ahead to 2017: A urologist’s wish list

In a write-in option, one urologist described value-based care is a “bad idea that will persist and is not meant to succeed.” Another called it “good for bureaucrats,” while a third said, “Value based should not be determined by patients.”

Asked about their understanding of the law, 45% of urologists disagreed or strongly disagreed that they understand the changes created by MACRA. Only 21% agreed or strongly disagreed with the statement, and 34% were neutral.

Also see: CMS releases pay, Quality Payment Program rules

Urologists’ sentiments about MACRA and value-based care are not unique to the specialty. A recent survey of primary care and specialty physicians by the Deloitte Center for Health Solutions reported that 50% have never heard of MACRA and one-third recognize the law by name but are not familiar with its requirements. Three-fourths of surveyed physicians believe that performance reporting is burdensome and 79% do not support tying compensation to quality, both requirements under MACRA.



The feds and medicine: No change in opinion

The demise of SGR has not appeared to change urologists’ opinion on the government’s role in health care. Given a list of 19 potential issues of concern, survey respondents ranked increasing government regulations second, with 91% of respondents rating it a “5” or “4” on a scale of 1 to 5 (5 defined as “very concerned”). A similar finding was seen in last year’s survey. Also topping the list of concerns were declining reimbursement and increasing overhead/overhead management (92% each), prior authorization requirements (91%), quality metrics/reporting requirements (89%), and new payment models such as bundled payments (87%).

Read - Final rule: Good news, bad news for urologists

More than half (56%) of urologists expressed their displeasure with the Affordable Care Act as well, saying they disagreed or strongly disagreed that it’s been mostly good for Americans in terms of access to care. Only 16% agreed or strongly agreed with that statement.

Other new questions in this year’s survey touched on the controversial subject of maintenance of certification (MOC) and the future of telemedicine.

Recommended: Urologist elected to House, while docs’ numbers in Congress drop

MOC has come under attack in urology and multiple other specialties, and a Urology Times survey conducted in summer 2016 found that 69% of urologists think it should be done away with (see, “MOC: Past, present, future,” October 2016). In the current State of the Specialty survey, however, a full two-thirds of urologists agreed or strongly agreed that “Board certification is necessary to preserve the integrity of urology.” Just 15% of respondents disagreed or strongly agreed. Of concern, 67% of respondents with time-limited certificates indicated that they did not plan to recertify when they reached age 60 or were within 5 years of the end of their career-a figure that’s 14 percentage points higher than the 53% recorded in last year’s survey.




Are prior authorization demands increasing?





Telemedicine, meanwhile, has a viable future in urology, according to 60% of urologists. Fourteen percent disagreed with that statement, while 25% were neutral, perhaps indicating that more information about the logistics of telehealth are needed before an opinion can be formed.

Recommended: Look for MOC changes in 2017, American Board of Urology says

Prior authorization required by third-party payers has been a concern over the last two survey periods. Eighty-six percent of this year’s respondents indicated that prior authorization demands are increasing, nearly the same percentage as in the 2015 survey.

The headaches of practicing medicine may have swayed many urologists to change their career choice if they could. Only 36% said they would still choose medicine as their career. Of those who did say yes, most-86%-would still choose urology as their specialty.

See: Survey reveals urologists’ opinions on MOC

For additional survey highlights on factors influencing retirement, hospital employment trends, plans for 2017, and more, see the charts on the next page.



Do you plan to recertify when you are within 5 years of retirement?







Would you still choose medicine as your career?





Urologists’ primary concerns





Factors influencing timing of retirement




Here are some write-in responses we received for this question:

“Hassle/benefit ratio”

“Spouse is retired and having a great time”

“Inability to understand or fulfill quality metrics”


Have you considered hospital employment?




Reasons for considering hospital employment



Here are some write-in responses we received for this question:

“Too onerous to stay private”

“Unable to compete with the hospital”

“Can’t handle the patient load and can’t get additional urologist into this community”


How will your employment of non-physician providers change in 2017?





Plans for 2017




Plan to change EHR system within the next year?




How did income compare in 2015 vs. 2014?




Does your practice have a men’s health clinic?


How the survey was conducted

The Urology Times State of the Specialty survey was conducted via email in October 2016. Survey recipients, who were subscribers to Urology Times, were required to indicate that they were a urologist or urology resident before responding to questions. A total of 171 responses were obtained, and the majority of respondents (74%) were in the 45-69 age group. As an incentive, those who responded were eligible to enter a drawing to win one of three $100 Visa gift cards.

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