AACU 2017

10TH ANNUAL AACU STATE SOCIETY NETWORK

October 20-21, 2017

Rosemont, Illinois

Lecture Notes

John Phillips, MD

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Contents Leonard G Gomella, MD: “Genetics in your practice” ................................................................ 2

Gary Steinberg, MD: “Intravesical therapy: Beyond BCG” ........................................................... 3

Peter Knapp, MD: “Treatment Options for BPH” ......................................................................... 5

Thomas Lendvay, MD: “Crowdsourcing: A new modality to assess your laparoscopic and

robotic skills.” ................................................................................................................................. 6

Nelson Bennett, Jr, MD: “How to Practice cutting Edge Male Health” ........................................ 7

Peter Langenstroer, MD: “The case for surgery in advanced RCC” ............................................. 8

Kevin Loughlin, MD: “The Testosterone Kerfuffle and clinical Implications” ........................... 9

Chris Coogan, MD: “Medical Liability and Current Perspectives” ............................................ 10

Mark Austerfeld, MD: “Maintenance of Certification” ............................................................... 12

Richard Pelman, MD: “How to Effectively Accomplish Local Advocacy” ............................... 13

Jeff Kaufman, MD: “Single Payor Option, „Lessons from California‟” ..................................... 13

Jeff Frankel, MD: “How to Start/Strengthen you State Urology Society” .................................. 14

Gregory Adey, MD: “How to Get Compensated for Night and Weekend Coverage” ................ 16

Gary Kirsh, MD: “How to Incorporate Advanced Practice Providers into Your Practice” ........ 17

Gyan Pareek, MD: “Scribes: All You Need to Know” ................................................................ 17

Niranjan Sathianathen, MD: “Taking Care of the Caregiver: Exercise and Lifestyle Changes”

....................................................................................................................................................... 18

Stacey Childs, MD: “Burnout is Real: What can I do about it?” ................................................ 19

PANEL: “THE CHANGING LANDSCAPE OF UROLOGY PRACTICE” .............................. 19

Lori Lerner, MD: VA System ................................................................................................. 19

Brian Irwin, MD: Vermont System ......................................................................................... 20

Lindsey Kerr, MD, PhD: Center of Excellence ....................................................................... 20

Ian Thompson, III, MD, MBA Solo/Hybrid Practice .............................................................. 20

Jonathan Henderson, MD: LUGPA ......................................................................................... 20

Michael Ferragamo, MD: “How to Code in a Changing Healthcare Environment” .................... 22

Keynote Addresses........................................................................................................................ 23

Hon. Tom Coburn, MD (R) ...................................................................................................... 23

Congressman Peter J Roscam (R), ILL ..................................................................................... 24

Mark Edney, MD: “Reflections of a Gallagher Scholar” ........................................................... 25

William Catalona, MD: “Active Surveillance- The Ideal Candidate” ......................................... 26

Anthony Schaeffer, MD: “How Urologic Research Impacts your Daily Practice” ...................... 28

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NOTES

Friday 20 October, 2017

Leonard G Gomella, MD: “Genetics in your practice” Noted differences between increasing popularity of „Recreational

Genomics‟ (e.g.” 23 & Me”, ancestry.com) vs. a Personalized Health Care Initiative for “achieving gene-based medical care combined with health information technology” signed by GW Bush.

GINA (Genetic Information Nondiscrimination Act): 2008 federal law that protects individuals from genetic discrimination in health insurance and employment.

Genomic Testing: $3,000-5,000

Next Generation and „Deep‟ Sequencing is a method to check and recheck to look at errors which increases cost.

Types of Mutations

o Somatic Mutations: mutation status of tumor only

o Germline Mutations: mutation found in every cell of the subject (i.e. inherited or acquired as zygote)

11% of patients with metastatic Prostate Ca have

germline mutations versus 1% in localized disease

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Genetic Tests available now o Prolaris looks at somatic mutations, e.g. BRCA1, which is a

massive undertaking with computational biologists. o Confirm MDx: „the halo effect‟; prostate genetic panels o Invitae, GeneDx o Myriad & Ambry Genetics have downloadable forms for

assessing FHx

Therapy: PARP inhibitors are going to be approved for patients with germline mutations of DNA mismatch repair.

Screening: ask for FHx of breast cancer; anyone with a Gleason 7 or greater

o BRCA2 has more aggressive features if patients develop

prostate cancer.

o HOXB13 is the only known inherited prostate cancer gene

o BRCA1,2; HOXB3, ATM, CHEK2 are the “big 4” of Prostate Cancer Genetics

Gary Steinberg, MD: “Intravesical therapy: Beyond BCG”

“There is an enemy and it is us urologists” because utilization of BCG is the same for low to high risk patients.

Types of failure

o Relapsing (recurrence > 6 months) o Intolerant (patient can‟t take it) o Refractory (< 6 months) o Resistant or unresponsive (highest risk)

Death from bladder cancer for patients with upstaging is 85% versus 50%

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“If you wait for upstaging, you‟ve waited too long.”

Gemcitabine 2 year complete response = 21% (SWOG S0353) Phase III trials are open label non randomized and goal is 40% complete response at 36 months.

Paclitaxel Hyaluronic acid, n=16 patients, 60% CR at 6 weeks via CD44 binding and intracellular release.

Local Microwave therapy (Italy) with MMC intravesical therapy from 2003. 84 vs 43% recurrence free. Hasn‟t been done anywhere else in the world. Supposedly coming as a phase III trial but “don‟t know what‟s going to really happen”. Labor intensive device.

GemRIS is a silicone catheter and you can put in any drug you want. Can instill gemcitabine, folds up into a pretzel and stays there, low dose delivery over 5-7 days. Depletes T-regulatory cells.

Instiladrin: adenovirus vector secreting IFN2b in Syn3 medium. Big difference is that patients have detectable IFN2a with 40% response. Phase III trial with n=133 with half already enrolled. Interim data is pending.

IFN2b is dead because the cell:cell basis isn‟t reproduced but…

Oportuzumab Monatox is a pseudomonas endotoxin mediated therapy with 15% durable response at 12 months.

CG0070 is a GM-CSF expressing oncolytic adenovirus with exploits the weaker ability of cancer cells to fight viruses. Works in RB-deficient cancer cells. The GM-CSF enhances the immune response. Phase I data shows that if you are RB deficient you have a better response. Six month CR response by stage of 25-58% for CIS.

“Future is looking incredibly bright”

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Peter Knapp, MD: “Treatment Options for BPH”

37% of men defer therapy

60% medical therapy

3% (n=310,000) with bladder outlet procedure

Rezum

o 30% reduction in volume at 6 months on MRI. o Rezum II Pivotal Study showed decline of symptom score

sustained over 2 years, increased peak flow is seen at 3 months and stable over 2 years. Adverse Events were reported in 40% with low bother of about 10%, without ED.

UroLift: L.I.F.T. STUDY was placebo controlled trial which showed sustained benefit of the implants with no incidence of ED or retrograde ejaculation

Rezum vs UroLift: both show comparable QOL improvement with 10-15% retreatment rate, 98% of UL patients can be done in office whereas 70% of Rezum. No catheter was used in UL group but 90% of Rezum group for 3-4 days. Retention was < 1% in UL and 4% in Rezum (Kaplan et al.).

Differences

o Rezum requires post op catheter o Rezum can treat median lobe o Onset of max QOL is 1-3 months versus immediate with

UroLift.

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Thomas Lendvay, MD: “Crowdsourcing: A new modality to assess your laparoscopic and robotic skills.”

Funded by DOD to research surgical warm up, performance, etc.

More and more transparency about our performance and analyses which may or may not be accurate.

There are no US credentialing practices. There is no evidence based cut points for credentialing. Usual community politics, friendships, and internal variances that influence how someone is credentialed.

Facebook has robotic surgery collaboration however it is not confidential or passing HIPPA muster. Also brings up legal problems. MUSIC offers collaborative opportunities.

There are 51,000,000 surgeries performed annually in the USA. How are we going to scale this…? Perhaps crowdsourcing (Crowdsourcing Assessment Tests, CSATs).

There are 6 million crowd workers who are willing to work for you. o Take media from operating room o Marry them to validated assessment tools o Provide that survey to crowd workers and quality experts o Global Evaluative Assessment Robotic Skills (GEAR) o Outputs and comments provided

Pilot study had surgeons perform simple tying technique. 1500 assessments were done in 3 hours by strangers versus 9 days by experts and the two assessments correlated.

29 surgeons submitted vide to 285 crowd-workers

o Provided assessment within 4 hours of anastomosis. o Correlation of adverse complications looking at highest versus

lowest crowd source scores.

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o Confidence intervals of experts were wider than those of crowds who were watching the same videos.

If the crowd says you‟re technically savvy, it costs the hospital less for you to do cases.

CSATS assessment. Even the process of submission alone is associated with improved outcomes.

CSATS validated in ureteroscopy, robotics, and other fields.

CSATS is extra-institutional, driving outcomes, scaleable, gets you CME credit

Nelson Bennett, Jr, MD: “How to Practice cutting Edge Male Health”

No shared waiting room.

Partitioned waiting room

Darker colors, uncluttered comfort, wireless access, men‟s health interest magazines

Offer integrated services

o Cardiology

o Cardiovascular Health: „testosterone causes blood clots‟ but further study T replacement may actually have protected effects of CV disease.

o Sexual psychology

Bone fractures in hypogonadal men versus control: 70 vs. 31%

iMORE

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o Innovation Early adoption of new technology

o Market: Brochures, Newspaper, Radio

o Outreach: Community health talks, Men‟s Health Fair

o Research

o Education

Peter Langenstroer, MD: “The case for surgery in advanced RCC”

“We now have drugs that have brought cytoreductive nephrectomy „back into our realm‟ ”. Flanagan 2001 NEJM: IFN-alpha cytoreduction is associated with a 3 month increased survival. Combined paper in 2004 in J Urology showed 6 month survival advantage. Cytoreductive nephrectomy increasing with availability of sunitinib Mortality has decreased from 5% to 2%. Mass reduction in neoadjuvant therapy reveals about 25% mass reduction Candidates: 1) Cytoreduction should decrease tumor burden by at least 75% 2) No sarcomatoid features 3) Good performance status 4) Low metastatic volume 5) Low risk disease 6) Would you have it done yourself? (Nope) CARMENA trial CN with or without sunitinib End point was OS.

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EORTC SURTIME CN sequencing, Upfront vs. neoadjuvant vs. both. Progression-free survival Metastastectomy: “Here to stay”

Very few candidates

Metachronous lesions do better versus synchronous mets

Thenappan et al Urol Oncol 2017 35:661

Lung lesions may yield 35% 5 year OS, even brain has a 12% 5 year OS

Lymph node disease is a biomarker of poor prognosis. Probably no additional survival benefit to an extended lymph node dissection.

Kevin Loughlin, MD: “The Testosterone Kerfuffle and clinical Implications”

Testosterone 1% decline/year

Morning T should be done if there is a low T in the afternoon

There is a T testosterone decrease calculator available but one should adjust for age and not always compare 70 year olds with 25 year olds.

Only about 75% of men who started on T replacement had a T level known in previous 12 months

There is overlap of true hypogonadism from normal aging.

There are equal studies showing low, no, and high risk of prostate cancer and T levels. There is a difference between serum T and intraprostatic T levels which points to differences of avidity of androgen receptors.

“What was really an „ah ha‟ moment for me was a paper from Germany which looked at men who did and who didn‟t develop prostate cancer.” It was the variability of T and largest single decline

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of T and median of maximum decline in T that was associated with cancer.

“For the first time, evidence that a single post-hoc testosterone level is probably pretty meaningless.”

Many men who are diagnosed with prostate cancer, probably had prostate cancer for years or decades earlier. Similarly, we would never use a single glucose to predict the severity of future diabetes.

Many of the studies showing no risk are underpowered and that saturation model is overly simplistic. Why is it that other diseases like depression or bone disease do better when the T is normal? -> suggesting that saturation is not too important.

Bottom Line: “Which I think is reasonable” Giving somebody exogenous T probably has some definable risk but appears to be fairly low and certainly does not preclude you from embarking upon T replacement therapy as long as you discuss theoretical risks, but “you have to be monitored with regular PSA, T, and DRE….although that interval is not uniformly agreed upon.”

AUA BP Statement: T therapy in absence of low T is inappropriate

Chris Coogan, MD: “Medical Liability and Current Perspectives”

NPDB data has shown that # of cases has gone down about 50%!

Still, significant costs.

In NY, 0.8% of hospital discharges involved urologic AE

8 negligent injuries per each claim so something other than negligence is driving claims.

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In Colorado, only 3% of negative outcomes sued.

83%-93% practice defensive medicine and order additional tests.

Physicians Insurers Association of America (PIAA) most complete data for all of US.

o Mean payment almost doubled adjusted for inflation. o Costs of a case are percent paid to close at $300,000. o Only 20% yield settlement. o 65% are withdrawn. o Plaintiff verdict 1%. o You‟re more likely than not to be successful.

11% urologists caused 50% of complaints per Stimson et al. J Urol 2016.

Mean time defending: 21.8 days

20% felt patient deserved something

60% considered limiting their practice

Only 2-3% of negligent injuries sue; avg indemnity $275,000; overall 70% chance of winning

Communication decreases chance of being sued. 40% of patients reported never getting an apology.

Need to have „2nd generation consents‟ for different procedures. David Sobal has consents and videos. http://www.dialogmedical.com/partners/aua/

HR 1215 passed 218-210 on 060282017 first comprehensive medial liability reform to be passed, flexibility for states, applies to CMS, but “doubt it is going to go anywhere.”

ACESS, similar to MICRA, save tax payers $50 billion

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Mark Austerfeld, MD: “Maintenance of Certification”

Changes are happening quickly

ABU “serves to protect the public; the AUA serves the urologist”

Life-Long Learning (LLL)

Is the MOC era over? There was a huge MOC backlash. MOC likely abandoned for LLL this year

Town Hall meeting at AUA met with some diplomates o High risk exam caused anxiety o practice logs burdensome o Concluded that MOC should evolve into LLL that is valued to

the diplomates.

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Richard Pelman, MD: “How to Effectively Accomplish Local Advocacy”

Pro: o When you speak for your patients you represent potential votes and $$$ o No one is more expert or understanding of the issues

Con: o Insufficient time and energy o Lack of actual $$$

Go back to home office to follow up. o The absolute best place to meet with them, usually at a higher level than

you get on the Hill. It shows, you‟re committed, and you represent votes.

Lobbyists who had previously served on the Hill: 60%

Pool resources. Though other organizations may represent other interests, they may share a common goal.

Strong state society: o State society director keeps things moving o Goals, activities and coordination are facilitated o F/U and relationship development are strengthened and expedited o AACU has the resources to help us o State advocacy may be easier than national

Uropac also can assist you to host events which facilitate the introduction of membership to legislators and staff.

Jeff Kaufman, MD: “Single Payor Option, „Lessons from California‟”

“We spend 3.2 trillion dollars, 50% of that is government sponsored.

Half of that is for overhead”

“If we switched to Medicare tomorrow we‟d save half.”

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Canada Government paid private health care vs Britain which is government run health are

California o Wealthy state o Progressive state

SB562 o Single payor bill in California. o $368 billion paid in premiums which would no longer be paid.

This would offset $300-400 billion dollar cost of MediCal for all. 2.3% increase in sales tax.

o At end of day, costs less than what state is currently paying. o Expansion would go from 70 to 100% not 0 to 100%. o Hospitals would receive lower payments, insurance industry

(which would be abolished), medical societies, and patients. o Dead on Arrival in Assembly by Speaker Rendon who received

recall demands and death threats.

Options: o Mandatory coverage o Thinner public safety net with private option o Public option to buy Medicaid Medicare o Lower Medicare eligibility to 55 o Free Market, dog eat dog Republican Plan

Jeff Frankel, MD: “How to Start/Strengthen you State Urology Society”

State Legislatures have a total of 128,145 bills per year

23 times the number of bills introduced in US Congress

Many bills die in committee

New York introduced 4,688 bills in a year.

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Medical Practice Freedom Act: no MD will be required to take Medicaid or you can‟t practice here.

State society network: Rapid Response. An anti-IMRT bill in Florida was squashed by the state society pulling out the stops.

If you have the relationship with somebody in the legislator, that should be supported, let‟s you know of things early, let‟s you be introduced as a „champion‟

Consistent board meetings

Executive administrator

Frequent communication

Annual meeting or conference

UROPAC still advocating for o USPSTF transparency HR 539 has 20 cosponsors o IPAB bill in ACA 14 members who perform cross the board cut to

physicians. Committee not appointed. Slash and burn legislation doesn‟t make sense and we now have a number of sponsors.

o MACRA is not designed for urologists but we have to comply. Six of 100 questions are relevant to urology.

o MIPS and MACRA refer to small practices under 10 practitioners o HR 1215. Stark Law modernization. Doing a cystoscopy on a patient with

hematuria is a self-referral. There may be a method to do more self-referral that is budget favorable: $50 billion could be save as an offset which Republicans like.

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October 22nd, 2017

Gregory Adey, MD: “How to Get Compensated for Night and Weekend Coverage”

MD Ranger: urologist 4th most likely to be paid for providing coverage

Do you have a Professional Services Agreement (PSA)?

o More difficult if you‟re an employed physician but not impossible. o Money isn‟t the only thing: “Money doesn‟t necessarily make things better

(and can sometimes make things worse) but may help accomplish your work better”

Choose physician liaison for your group, not necessarily someone in your group.

Track your data:

o ER consults o urgent visits o intra-operative consults

Partner with strong consultant o Determine Fair Market Value o Use local and national benchmarks)

Make the meeting with hospital administration. Do NOT ask to be paid for taking call rather for the services that you provide

Explain exactly what you do (most people in hospital have no idea what we do) and how important you are to, e.g., orthopedics, neurosurgery

Document your strengths

Negotiate and secure, assign directorships, quality review, efficiency, productivity.

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Gary Kirsh, MD: “How to Incorporate Advanced Practice Providers into Your Practice” Physician Extenders

Less expensive than physicians but perform many of the physician‟s services

Help lessen burden off of your shoulders o Can make rounds o Can supplement the EMR work o Can triage calls after hours o Can accommodate add-ons and post op patients o Natural average is about $100,000 plus benefits which is about break

even if they see 7 to 8 patients a day. o Surgeons generate about $500/hour operating and extenders cost

$75/hour and they are profitable to see consults and make rounds o “In our practice, NPs/PAs are a profit center and they enhance physician

QOL”

Gyan Pareek, MD: “Scribes: All You Need to Know”

54% of doctors say they are stressed out

59% of doctors say they would not recommend field for their children

Factors Influencing Stress: Opinion polls o EHRs dominate docs‟ time o Direct clinical face to face 26% o EHR and desk work 48% (Physicians spend more time entering data

into EHRs than on any other activity)

o Face time with staff 6% o Administrative tasks 1% o Scribes: Personal Productivity Assistant

With Scribes vs Status Quo: o With dictation, physicians see 40 patients and then document in

sequence o With scribes, document is conducted parallel to care

Without scribes: o See Fewer patients o Documenting longer o Decreasing face to face contact

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Scribes may not only decrease cost but increased QOL, decrease burnout

Data provided by Scribe Companies: o Amount of money per minute saved transferring work to a scribe:

$2.15 o Amount that could be saved by scribe per year: $210,223

Data @ Brown Urology: o Q1 2015 vs. Q1 2016 in n=9 physicians o 636 increased to 788 patients seen o Revenue per MD $88K to 99K or about $9K per MD (Increase in

revenue 19%) and net revenue over year +$39K o Increased QOL surveys including 5.9 hours saved per week

Question from the floor (Marty Dineen, Florida). There may have been cost savings but what was the income before the EHR and did the cost savings reach a net zero gain or better?

Niranjan Sathianathen, MD: “Taking Care of the Caregiver: Exercise and Lifestyle Changes”

150 minutes a week of moderate intensity activity or 75 minutes a week of more intense activity meets AHA guidelines

Only 9.6% of Americans are compliant with guidelines

FitBit: Higher in surgical residents 7,938 vs 6,724 (medicine)

0% of family medicine residents met guidelines

Exercise decreases stress response to other stressors to which the subject was not exposed (e.g. public speaking, arithmetic task)

Exercise now shown to increase serotonin, cortisol -> cortisone, endocannabinoids which in turn induce release of the famous endorphins

Residents who achieved DHHS guidelines were less likely to experience burnout [OR 0.38] but lack of time and lack of energy predicted NOT reaching the guidelines.

Chris Weight study: 29% of residents experienced depersonalization and/or emotional exhaustion at least once per week.

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Stacey Childs, MD: “Burnout is Real: What can I do about it?” “I have officially been burned out twice….I put too much on my plate (with administrative work)…Then I took a position in Steamboat Springs, Colorado, (became a ski racer and wrote 3 novels), stopped doing surgery, and became disenchanted with urology (“I liked to ski and write more than practice urology”). Broke spine, ribs, 3 concussions, ACL and that ended my ski racing. Was employed by Rural American Physicians, 8 days a month, fly to various locations, work hard, go someplace else. Think about going to the Heartland. It‟s wonderful. 24 bed hospitals don‟t have a robot, can‟t do a nephrectomy but bread and butter urology, and you make a difference.” Question from the Floor (Middleton: what characterized the 45% who were

not complaining of burn out? One audience responder said that “it may

be more efficient to work at 110% with more full breaks rather than 75%

which fewer breaks…Analogous to athletics, banking.”

PANEL: “THE CHANGING LANDSCAPE OF UROLOGY PRACTICE”

Lori Lerner, MD: VA System Working in Veterans Affairs, employ a lot of women/veterans

2nd largest funded cabinet behind the DOD.

Benefits: work/life balance, 49 days off, pension, health insurance, cost of living increase, licensure valid in all 50 states, research encouraged and rewarded.

Can‟t be sued. If a patient brings a suit, it is against the United States.

CONS: capitated budget, administration, documentation of things to track

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Brian Irwin, MD: Vermont System

Hospital network, crosses into New York, incorporating an entire region. Now a huge economic component of all of Vermont and part of upstate New York.

Entire state was moving away from private practice and all of Burlington.

All physicians in Vermont will be a part of an advanced APM.

Lindsey Kerr, MD, PhD: Center of Excellence Loved writing/teaching in academic center, having earned degrees in

chemistry and immunology

“If you make more money than anyone else you have a seat at the table…but it may not come with any utensils.”

Wanted to be full professor and reach “the glass ceiling”, switched to locum tenens.

“Fabulous way to figure out” where she wanted to practice. Started her own program. Looking into being a COE.

Ian Thompson, III, MD, MBA Solo/Hybrid Practice Out of training for about 5 years, initially on faculty, 60%.

Did locum in Texas to pay for executive MBA program. Offered CMO job at the hospital. Did not jive with politics and continued as urologist.

Left job. Now in private practice but at VA as 1/8 employee, with health insurance, CMO job, started solo practice.

With the changing landscape, you need to diversify as physicians your sources of income.

Jonathan Henderson, MD: LUGPA Regional Urology

So busy that was leaving house at 5 AM and getting home at 10 PM. One weekend, had 23 cases. Looked for easier way.

Went back to a group of 20 urologists with everything internal. Not affiliated with a hospital.

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“We share everything to take the financial incentive out of it…Everyone makes the same amount of money.”

300-400 robotic prostatectomy cases a year.

Group offered first APM and looks like it will be first approved APM looking at early diagnosis of prostate cancer.

“If we do things in our group better, faster, and cheaper we should

share that experience with the system. Active surveillance, for example, is poorly advocated in the SE, around 15%, whereas it is

used, per CMS, in up to 50% in the NE.”

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Michael Ferragamo, MD: “How to Code in a Changing Healthcare Environment” “If you‟re going to do urology as a hobby, you really don‟t have to worry about billing. But if you do it to pay for your mortgage…you have to be interested.”

Email him at liqgold2@aol.com for a copy of his power point presentation.

Phone: 516 741 0118

A new system of E & M coding may in place by 2019. Your coding may be judged on time spent as most important factor, placing more emphasis on how sick the patient is and the intensity of the services.

There will be changes in 1. Providing postoperative care only 2. Non-Physician Providers‟ services 3. Shared E/M visits 4. Prior Authorization work Vignette:

If a urologist splits post-operative care, one must use modifier 54, to have a reduced fee so that another physician will be providing the remainder of the care: “I relinquish post operative care on date of discharge from hospital.”…

The other urologist must use the same operative CPT code with modifier 55 (gets 9% of the global fee) “assumed post operative care on discharge date” not the date he saw the patient in the office.

When no modifiers are used and the surgeon bills for total care, the patient may be surprised to be billed for a co-pay.

In those cases, the community urologist often does not charge for the co-pay but bills for customary E & M.

Incident to Billing (involving PA coverage):

In this scenario, the physician has o established a plan of care o subsequent visits by a non-physician can be billed at 100% of

the global fee by the PA

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physician must be in the office physician must be providing supervision (not by telephone

or in another building).

If the urologist has NOT seen the patient, and the PA is seeing the patient at the same time, the patient must be billed in the PA‟s name.

Prior-Authorization:

22% of physicians spend > 20 hours per week on prior authorizations.

Cost of prior authorization per full time MD is from $2,161 to $3,430 per year.

75% of MDs classify prior authorization as a heavy burden.

25% of MDs are charging patient about $20 to the patient for prior authorization.

Outpatient Coding

Laparoscopic partial nephrectomy and prostatectomy may have to be authorized as an outpatient service….then hospital has to put patient in observation or admitted.

Others: o TURP o Fowler-Stephens o abdominal orchiopexy o laparoscopic pyeloplasty

Keynote Addresses

Hon. Tom Coburn, MD (R)

Author of the “Debt Bomb” and “Breach of Trust” Survivor of stage 4 melanoma, colon cancer, and prostate cancer.

$1.4 of $3.2 trillion dollars on health care is wasted

Unfunded liability and debt is $30 trillion more than what the country is worth.

“Is it right to steal from our grandchildren? If it‟s not, can‟t you so something about it.”

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$120 billion/year in fraud alone because the system is totally designed to be defrauded.

Our major problems aren‟t going to get solved in Washington

Washington will never fix health care “EHR takes away from eye contact and focuses on documentation required by some idiot in the government (applause)”

“4 ways of spending money o your money on yourself o your money on somebody else o somebody‟s else‟s money on yourself o somebody else‟s money on somebody else (i.e. the Medicare

model)””

Price Discovery (and transparency) o way of mandated transparency of costs o hope is to influence market economics in health care.

Two best economic models: o concierge medicine (75% fewer tests ordered per patient) o physician-owned hospitals.

Newer approaches o Direct Primary Care o Medify.eu: used to find cheapest outpatient facility o healthengine.com: used to find facility with the cheapest

surgery and incentivizes cost reduction

Congressman Peter J Roscam (R), ILL

Culture of the US Senate is cascading in on itself.

CMS: 12.7% of charges are either fraud or erroneous payments but CMS can‟t distinguish the two. Visa: Of $10 trillion, fraud rate is 0.6%.

Problem: “No matter what happens, the money always shows up because CMS is an entitlement program.”

If you reach an age, you get a particular benefit.

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o 2/3 of federal budget runs on automatic pilot and it is difficult to influence them.

o 1/3 of the budget is discretionary.

One of these two Senate plans is going to “break through and re-invigorate the House.”

o Alexander-Murray: o Graham-Cassidy:

Tax policy: “There is nobody defending the status quo. It is 70,000 pages, much of it is internally inconsistent... Nobody says „Oh, I love that thing.‟ “

“95% of American tax payers will fill out their taxes on a postcard.”

Advice: o “Don‟t vacate the public square. It will get filled quickly by

people who have no experience or knowledge with what you do.”

o Invite state legislators into your practice for an hour or two, talk to them about what‟s important to them.

Mark Edney, MD: “Reflections of a Gallagher Scholar”

Value Based Purchasing- slowing down (but not going away)

Bain US Line Front of Healthcare 2017 surveyed 900 doctors. “Better quality at lower costs” largely theoretical outside of integrated systems with established IT

CMS recognizing it is pushing too far too fast. o Proposed a moratorium on a cardiac rehab and a joint

replacement bundled payment system (08-15-17)

Predictive Analytics are going to start helping process data to provide good care.

Telemedicine: o 30% of telemedicine payments currently within the PFS. o AmericanWell is a telemedicine provider which allows you to

sign up and provide care through their platform

Corporatization of medicine- private equity ownership of practices

Professional Service Agreements (PSA) o Great way of establishing service line management

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o Quality metrics o Procurement of equipment o Pathways/protocols o Nice relationships to have with a hospital.

Artificial Intelligence (AI): “Watson for Oncology”. Helps to digest research data to direct point of care decision making. “Humans are not good probabilistic thinkers:” cognitive and last case bias.

o AI will continue to harness big data into predictive algorithms: predictive analytics.

o “AI will transform the science but cannot replace the art.”

“There are efficiencies from scale but those savings are not passed onto patients (prices haven‟t dropped).”

Time-Driven Activity Based Costing (TDABC) is becoming a more analytical method of the future.

William Catalona, MD: “Active Surveillance- The Ideal Candidate”

During PSA era, 80% reduction in rate of men who present with metastatic disease and 50% reduction in rate of prostate cancer related death.

USPSTF 2012 recommended PSA screening against all men of all races of all ages.

There is a 35% reduction in screening nationally, biopsies, services, and surgery.

“All the gains we made in PSA era would be lost by 2025 if USPSTF recommendations were followed.”

Criticism could fall on rate of active surveillance but rate has gone from 10% to 30-90% of those with low risk disease.

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In May, 2017, USPSTF backed away from grade D for a „shared decision making‟ process and a very important reason was wide spread adoption of active surveillance.

Challenges of active surveillance implementation. Types of Risk

AUA: Very low risk, AS “the best option”; for low risk, AS “the preferred option” but definitive treatment of other select patients. Also for low volume, intermediate risk Prostate Cancer (Gleason 3 + 4) disease. PROTECT Trial

Patients treated with prostatectomy have similar long-term overall QOL at 5 years compared to monitoring.

50% of patients randomized to monitoring underwent definitive therapy and they had twice the rate of distant metastases (Though overall there was no difference in death rate)

Patient under AS had no better quality of life….

AS early results always look good. Most prostate cancer deaths occur 12-25 years after treatment.

20-40% moving to progression is still low risk yet 20-40% has biochemical failure.

Among men meeting criteria for surveillance but electing immediate surgery:

40% have Gleason upgrading

10% upstaged Active Surveillance Groups

Johns Hopkins, a long active surveillance program with conservative criteria

o Delayed Prostatectomy doubled LN positivity (from 1 to 2%) o PIRADS 1, 2, or 3 and PHI < 27, none had Gleason greater

than 3 + 4 = 7.

Toronto AS is most liberal AS cohort. o Patients who had to come off active surveillance, had poorer

PSA survival rate in half. o Median time to metastasis (in 14%): 8.9 years.

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o The presence of a Gleason 4 on biopsy conferred 3-4 fold increased risk of developing metastases.

Sweden: 90% of men are under AS. o “Low risk” had double the risk of progression compared to “very

low risk” disease. Rules of Thumbs

Biomarkers and mpMRI may be helpful

Gleason 4 pattern < 10%, liberal < 20%

Low PSAD < 0.15

African American men not excluded but acknowledge increased risk (risk is 3-4 fold higher, per CAPSURE database) and older men may harbor higher risk disease

Patients > 75 years of age comprise 53% of all prostate cancer deaths

Caveats

BRCA2 mutations should not be managed with AS

PROTECT trial:

PIVOT: Surgery was effective only in intermediate risk disease (HR 0.53) but low risk HR was 0.74 showing that prostate cancer death is still a reality for some.

mpMRI NPV is not perfect (85-90%); and PPV is only 40-50% (higher for PIRADS 4 and 5)

Anthony Schaeffer, MD: “How Urologic Research Impacts your Daily Practice”

Do African-American men get PCa at a younger age? Probably no but likely an increase in latent and progressive disease.

Isaac Powell: In 1000 autopsies, there was no difference in the rate of “indolent prostate cancer” in young Caucasian vs. African-American men. Still, „low risk African-American men‟ are similar to „intermediate risk‟ Caucasian male.

In PLCO, African-American men had fewer PSA tests and were less likely to follow up abnormal value.

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Are cancers in African-American more aggressive?

o Baltimore Study: Individuals who are destined to die of PCa had higher PSA velocity than those with low risk or no disease at all.

o Olmsted study, African-American men may have disease that starts at the same time, but becomes more aggressive.

Adjusting for PSA density, something appears to be going on in African-American men in the 40-60 year old age group that is different than Caucasian men.

Is there a genetic difference? African-American tumors may be enriched with low AR-A phenotype, as follows

o Anterior ERG positive tumors more prevalent in African-American men tumors were larger secrete less PSA per gram than posterior tumors lower androgen driven phenotype (via TMPRS-ERG

fusion). AR mutations may have LOWER AR activity and are

enriched in p53 o Low AR activity tumors are sensitive to PARP inhibitors o High AR activity tumors may be sensitive to hormone therapy,

Taxanes etc.