Q&A: Gary Kirsh, MD, on health policy for independent urology

Independent urology practices head into 2027 facing a scheduled Medicare conversion factor cut, ongoing prior authorization burdens, and Medicare price negotiation for Part B drugs beginning in 2028. The Centers for Medicare & Medicaid Services (CMS) has also finalized changes to 340B and site-neutral payment policy, which advocates for independent practice view as favorable. Turnover in Congress after the recent election adds uncertainty to the health policy outlook.

Gary Kirsh, MD, president emeritus of The Urology Group and chair of health policy for LUGPA, spoke with Urology Times^® at the 2026 LUGPA Annual Meeting. He discussed the most consequential health policy developments of 2026, the outlook for Medicare payment reform and prior authorization legislation, and policy approaches to the urology workforce shortage. Kirsh also outlined LUGPA’s 2027 advocacy priorities, including Medicare price negotiation for Part B drugs, along with practical ways for urologists to support advocacy and why health policy requires a long-term view.

This Urology Times Q&A has been edited and consolidated from a recorded interview to improve readability while preserving the substance of the original conversation.

Urology Times: Looking back at 2026, what were the most consequential health policy developments for urology and independent practices?

Kirsh: 2026 was not a year of monumental change in health policy, especially when it comes to independent practice, which is the perspective that I come from representing LUGPA. I’d say there were some incremental changes. The reason I make the clarification about independent practice is some of these incremental changes are, in our mind, in favor of independent practice, not necessarily in favor of hospital reimbursement. As you know, hospitals have hired a lot of urologists, and the mission of LUGPA [is] to try to maintain independent practice in the specialty. So, policies that level the playing field between independent practice and hospital practice are things that we’re naturally in favor of.

In fact, this is a very timely interview, because just a day or two ago, the final rule came out. Several things in the proposed rule were finalized that we think are favorable to independent practice. Those include reforms to 340B. It’s a program [providing] funding to hospitals out of proportion to the program’s initial mission, and therefore [it] facilitates the hiring of physicians.

There are also advances in site-neutral payment. Site-neutral payment has been extended over the last several years to physician services that are off campus, in terms of E&M [evaluation and management] services, and then, some time ago, drug infusion services. Now, in the final rule, this year this will extend to non-contrast imaging services, so we’re in favor of that as well.

With respect to the legislative landscape, we haven’t seen any major breakthroughs, but we’ve seen some incremental progress on raising awareness and support for several initiatives. Those include physician reimbursement, prior authorization reform, and…access to complex therapies like cancer therapy.

Urology Times: What progress has been made toward sustainable Medicare physician payment reform, and what changes are still needed?

Kirsh: The progress toward sustainable physician payment reform has been weak. As you know, there’s a structural problem in physician payment due to budget neutrality. It does not keep up with inflation as we measure [it] by the Medicare Economic Index, and it doesn’t keep up with hospital updates, which have been right along the Medicare Economic Index.

We used to have every year a crisis around the old SGR [sustainable growth rate] formula and run to Congress and get that fixed. They fixed SGR, to their credit, some years ago, but now we have a new crisis every year where we don’t get positive updates. In fact, this year, as you know, it’s a minus 2.5% conversion factor change, which is not helpful.

In terms of comprehensive payment reform, there is a broad recognition on both sides of the aisle that this is needed, but there’s a big problem: It’s very expensive, and nobody knows how to pay for it. So, where we are now is each year trying to get the conversion factor [to a] neutral or slightly positive update. We did accomplish this at the end of the congressional session last year.

This year, I think the prospects are a bit murkier due to the “blue wave” we just saw in the last election. It’s not that this is not a bipartisan issue; I’m not trying to suggest that. But it’s going to lead, we think, to some lack of action during [the] lame duck, and so the current cut may go into effect if we can’t get the lame-duck Congress to act on that going into next year.

So, the answer to your question is sustainable reform is the whole house of medicine’s top priority, and it just has been very difficult to come by because of the structural problems of budget neutrality.

Urology Times: Has there been progress on more limited fixes to the physician fee schedule?

Kirsh: We have made progress on some more minor adjustments to the PFS, the physician fee schedule. There are some technical problems with it, and there is a bill that’s gotten a lot of support. Again, [it’s] probably going to be derailed in [the] lame duck, to be [tackled] again next year. That [bill] limits the conversion factor swing to no more than 2.5% negative in a year and also makes some technical fixes. This is a much more limited fix than true comprehensive reform, but we made a lot of progress, bipartisan progress, with that approach this year.

Urology Times: What progress are you seeing in efforts to streamline prior authorization?

Kirsh: Health policy is a long game, not a short game. There is increasing bipartisan awareness of the need for prior auth reform. There are serious bills in Congress, and we’re getting there.

They’ve had a lot of positive action in the House, [but] not as much consideration yet in the committees of jurisdiction in the Senate. These bills would require Medicare Advantage plans to measure the delays and provide electronic means for prior authorization, and other reforms that the physician community broadly, not just urology, will very much welcome.

I do think it’s on the docket for the upcoming Congress. I think with the Democrat majority, there’s going to be an interest in enhancing access to care, and I think this falls right into that. So, we’re hoping to see additional movement on that next year.

Urology Times: Which policy changes matter most for strengthening the urology workforce and improving access in rural and underserved areas?

Kirsh: Rural and underserved areas is a tremendous problem that will not be solved quickly or easily. As of a year or two ago, and I’m not sure [of] the most recent statistic, about 60% of the counties in America had no urologist at all. That is a problem of residency positions, and that is a problem that goes back to GME, graduate medical education, and that is a problem that goes back to funding. So ideally, we would be training more urologists. Now, that takes a long time.

I think there are some system-wide solutions that we need to be looking at as far as advanced practice providers, nurse practitioners, and physician assistants are concerned. They are rapidly coming along as critical elements of the urology workforce, but I think there’s a need to have more robust and possibly standardized training programs, so that we can get these advanced providers up to speed. And perhaps even down the line, [there could be] some sort of certification, not required to practice, but to highlight expertise and advanced training.

I think those are solutions we need to look at more seriously to really get to the underserved communities. And some of [those] underserved communities are also urban, because we just have a terrible national shortage of urologists.

Urology Times: What are LUGPA’s most important advocacy priorities for 2027, and where do you see the greatest opportunities?

Kirsh: There are several avenues we want to pursue, some of which I’ve touched on, and some I haven’t. Of course, we want to pursue comprehensive Medicare payment reform. As I said earlier, that’s a very difficult problem because it’s a massive cost problem for the system. We wish to continue to encourage site-neutral payment reform, which is coming along.

We wish to promote transparency around the issue of tax-exempt hospital entities, and there is legislation, and I think this will have some legs. There have been a number of studies that have come out in the last year or so, some that indicate that actually for-profit hospitals give away more free care than so-called not-for-profit health care systems. There is a bipartisan consensus that we need to get our arms around this and really understand what it means to be “tax-exempt.”

We want to continue our work on prior auth.

Urology Times: Why is Medicare price negotiation for Part B drugs such a concern for independent urology practices?

Kirsh: There is something for urology that’s more narrow and not the whole house of medicine. It’s very important to independent urology, [so] I wanted to be sure I touched on [it], and that is the looming issue of Medicare price negotiation for Part B drugs, infusion drugs, which is going to begin in early [‘28], so it’s only about a year away.

To explain this briefly: The system for reimbursement of these critical therapies is an ASP [average sales price] plus a markup system. It was ASP plus 6, and there was something called sequester, so it’s ASP plus 4.3%. Some of these therapies are very expensive. Without that margin, independent practices will not have the ability or motivation to take the risk of buying them, stocking them, [and] infusing them.

If you think about it, when we go to a negotiated price on these products with the government, and the price comes way down, that margin gets cut in half if the price gets cut in half. That’s going to make it unsustainable for some of our practices that are independent to continue to offer these therapies.

We have a very eloquent solution to this that has really been LUGPA-pushed in the Congress. I won’t get into the solution because it’s technical and complex. I will say that it has bipartisan support, and the core of it is to keep the doctors whole on this margin and to have the pharmaceutical companies come [in] on the back end via a rebate system to Congress to keep the doctors whole. What’s very interesting is the pharmaceutical companies are all in favor of it.

So, this is something I think really does have [legs]. We’re hoping still to get this through in [the] lame duck. That’s becoming a little problematic based on the recent events in DC; the Congress is a little bit paralyzed right now. But we’re hoping to really highlight this issue before [‘28].

Urology Times: How can urologists not directly involved in organized advocacy make their voices heard on health policy?

Kirsh: The rank-and-file urologist is busy seeing patients and may not understand or really be interested in advocacy and health policy in the health care system, and that’s okay. The most important thing they can do is support our efforts. We at LUGPA are here for them. We have a whole infrastructure of policy advisors and legal staff in Washington, DC, working for them all the time.

What can they do to support our work? They can contribute financially to our advocacy efforts. This is really critical because, you may or may not like it, but you really don’t get the time of day unless you support the people that support our goals on both sides of the aisle. This is not a partisan statement.

They can support us financially. They can come to our fly-ins; we have at least 3 fly-ins a year. Those who are interested in helping advocate for their practices firsthand with members of Congress and their staffs can come and work with us on the Hill. It’s quite eye-opening if you haven’t done it. I’ve been doing it for 20 or 30 years.

And the last thing they can do is respond to our requests for grassroots letters. Often, we will send out a communication: “Hey, we really need you to write your congressman or your senator,” sometimes specifically in a certain state, because we’re really trying to get X, Y, [or] Z over the finish line.

If they can do those 3 things, support our work financially through advocacy contributions, come to fly-ins, and respond to grassroots efforts, then we’ll be really happy.

Urology Times: Is there anything else you’d like our audience to take away?

Kirsh: The only thing I would add is to emphasize something I said earlier, and that is [that] health policy advocacy, and the work we do not just in Congress but in the administration on CMS’s side, is a very long game. We [don’t] see progress[, necessarily,] certainly not over 1 year all the time, [and] not even [over] several years. Sometimes, it takes a decade, and you can’t get frustrated. You can’t say, “Oh, we haven’t done anything for you lately. What’s going on?”

It takes a long time to move the machine of Congress and the machine of government. It requires constant attention, and particularly after this big election we just had, there’s going to be a ton of new faces in Congress and a big power dynamic shift, and that’s okay. But it requires redoubled attention on our part to educate new members and new committee members on the health care committees of jurisdiction as to all the issues that matter to us.

So don’t lose faith. We play the long game. You need to as well.