More than a third of urologists work in a urology-dominant practice.
Most of the demographic information about urologists in the United States today comes from the American Urological Association (AUA), an organization with 7415 active members.1 The self-reported information has been used to support concerns about urology manpower needs, the aging urology workforce, and other policy matters of interest to the specialty. The publicly available information cannot reliably describe other details of the contemporary urology practice: level of activity, who practices in a group setting, how large the group is, the number of specialties practicing in the same organization, etc. In this article, I will summarize data from another source of information that can begin to answer some of these questions and what it might mean for your practice.
The Centers for Medicare & Medicaid Services (CMS) maintains several data sets of clinicians who participate in Medicare. Historically, it has been challenging to link providers to each other and to parent organizations in the National Provider Identifier (NPI) fileswhere information has been inconsistently populated. CMS is now publishing a robust downloadable file associated with the Quality Payment Program (QPP).2 Updated every few weeks, this file is an alternative source of information about urology practice and may better reflect real-world practice circumstances because most of the included clinicians have participated in the QPP. CMS needs to identify relationships between organizations (essentially tax ID numbers) and clinicians (NPI numbers) to properly calculate scores and fee schedule adjustments. Those relationships can be derived from the downloadable file and inform us about urology practice. The data cannot tell us about supergroups (groups of groups), networks, or subgroups.
The CMS data include 9324 unique clinicians identified as urologists in 1921 unique organizations (1268 urologists are associated with more than 1 organization). A total 6672 of these clinicians in 1609 organizations received a final Merit-based Incentive Payment System score in 2019 (ie, were actively seeing Medicare patients). The file does not include age or birth year but does include the year of graduation from medical school—a rough proxy for age. Over two-thirds of the urologists in this Medicare data set graduated from medical school after 1990; 11% are women, and 89% are men. Fifty percent of urologists in this database practice in just 10 states (some urologists are associated with more than 1 state), and the average distribution of all urologists based on 2019 population estimates is 1 urologist per 34,323 people.3
A total of 3285 urologists are associated with 408 organizations where urology is the dominant specialty (there are more urologists in the organization than any other single specialty). In 373 (91%) of these groups, urologists constitute at least 50% of the clinicians. The number of urologists in these 408 groups ranges from 1 to 118 (mean, 8.4; median, 4); only 43 groups have 20 or more urologists. The most common other specialties represented in the groups where urologists are the dominant specialty are physician assistants, nurse practitioners, radiation oncologists, and pathologists. A total of 210 organizations have advanced practice partners (APPs; mean, 5 clinicians), 67 organizations have radiation oncologists (mean, 3.5), and 99 organizations have pathologists (mean, 1.7); 35 urology-dominant organizations have all 3 specialties. The size of these groups ranges from 2 to 281 clinicians (mean, 13; median, 5.5).
More than 5500 urologists are associated with organizations where urology is not the dominant specialty. These include very large organizations, such as health systems and universities, and much smaller organizations. The most common dominant specialties in these groups are primary care, APPs, and general surgery. The size of these groups ranges from 43 to 7478 clinicians (mean, 486; median, 255); the urologists’ number ranges from 1 to 104 (mean, 6.5; median, 4).
Finally, the data include all unique practice locations for an individual clinician. The number of unique locations associated with 9234 unique urologists ranges from 1 to 55 (mean, 2.4; median, 2). Those urologists associated with urology-dominant groups have fewer unique locations per clinician (range, 1-12; mean, 2.0; median, 1) than those urologists associated with organizations where urology is not dominant (range, 1-55; mean, 2.5; median 1). Twenty-one percent of urologists in urology-dominant practices were associated with more than 3 addresses vs 29% of urologists in the other practices.
This analysis comes with caveats. First, the information may not be generalizable to the entire specialty, as some providers may not participate in Medicare. Second, many individual clinicians are associated with more than 1 organization—it isn’t possible to know which of the associations are primary in these cases. Similarly, it isn’t possible to know which of the associated practice addresses are active or inactive. It isn’t possible to reliably identify solo practices in these data—some urologists practicing by themselves may be part of a common billing organization. Finally, most of the information in this file is self-reported, such as year of graduation from medical school and name of medical school, and some clinicians have incomplete data. It is not possible to verify the accuracy of self-reported data.
What does this mean for your practice and your patients? The CMS downloadable file provides interesting food for thought. Physicians may be best positioned to control the clinical and business aspects of their practice if they are the dominant group in the parent organization. The Medicare data suggest that about 35% of urologists are in organizations they dominate (what might have once been called single-specialty groups). This compares favorably with general surgery (17%), cardiology (28%), and orthopedic surgery (31%). Many providers are probably familiar with factors that have caused specialists to consolidate, and these data help quantify that consolidation—at least among Medicare providers. Urology-dominated groups appear to have a foothold, which is good news for those who prefer this model of practice. Others might argue that a multispecialty model offers the potential for better care coordination and value-based care. These data do not help answer that question but suggest that a majority of urologists practice in organizations where they are not the dominant specialist—at least among Medicare providers. One size does not fit all [urologists] today, but the demands of patients and payers are likely to shape the landscape of tomorrow.
1. AUA member profile. American Urological Association Inc. Updated April 2021. Accessed August 3, 2021. https://www.auanet.org/documents/about/Member-Profile%280%29.pdf
2. Doctors and clinicians: national downloadable file. Centers for Medicare & Medicaid Services. Updated June 4, 2021. Accessed August 3, 2021. https://data.cms.gov/provider-data/search?theme=Doctors%20and%20clinicians
3. State population by rank. Infoplease. Accessed August 3, 2021. https://www.infoplease.com/us/states/state-population-by-rank