Shawn Dason: Yeah, absolutely. Thanks so much, Sam, for the invitation. And it's a sincere pleasure to discuss what I think is a really important study in our field, just to get more publicity of some of the greater and broader healthcare economic shifts that are certainly happening. So, this study was really the brainchild of one of our residents, Dr. Kyle Kopacek, who is really a budding and rising star in this kind of area, which I think is looking at the intersection between legislative work and fees. And he was recently a North Central scholar in this and went to the Hill and discuss some of these topics based on this study. So, just wanted to really give him credit for that. But what we did here is we looked at physician fee reimbursement for Medicare. Now, this isn't Medicare advantage. They have their own separate reimbursement rates. They tend to be tied to this and with up to half of patients having a Medicare Advantage plan, I think that's an important clarification just to state up front.
And this isn't, of course, commercial insurance, which can also be up to half or sometimes more depending on practice setting of physician fee payments. But what this did was look at traditional Medicare and key urologic oncology procedures, and how the physician fee reimbursement has changed over the past few decades. And what we can see is that there has been a significant decline relative to inflation. And depending on the procedure, a lot of that is highlighted in the text of our study. But the key message is that we are seeing that an average inflation adjusted percentage change of 41% has happened between 2002 and 2024 across 20 uro-oncology procedures. There aren't that many uro-oncology procedures, so I think this covers the key procedures that a lot of us are performing. And that really hasn't been that heterogeneous in terms of what the declines are across the different procedure types.
Certainly, prostatectomy it seems like has gotten, whether it's a fair shake or an unfair shake, but a significant decline over time. But that kind of occurs throughout the entire spectrum of the type of procedures that as a uro-oncologist we would perform. And there pretty much has not been a real procedure that has not declined. Additionally, our paper goes into some details surrounding regionality of the declines, and we can see that the decline has perhaps hit different regions slightly harder than others, and there is a bit of a heterogeneity in terms of how the declines are occurring across the country.
A lot of that is kind of normalized to an index that Medicare uses to describe the perhaps costs associated with practice in different regions. But we don't find a clear and consistent trend as to whether that decline has been more significant or severe in urban areas or in regions like the West coast or the East coast. It seems to be kind of normalized to this GPCI index, which may or may not reflect necessarily the exact economic and market conditions with healthcare in different settings. So, I think the main message that I would have for the viewership is just that when we look specifically at physician fee reimbursement over the past couple of decades, we see a significant decline relative to inflation for your oncology procedures.
Sam Chang: That's a disturbing trend for me personally, because you've outlined basically, all right, ever since Sam's been in practice, his reimbursement has gone down around 40% during my time in practice. So, it begs a lot of questions. So, within oncology, a common procedure is obviously a prostatectomy is a common procedure and there might be variation within the different oncologic procedures. What about treating for stones? What about pelvic slings or those types of things? You may not have looked into that, but do you have an idea within other subspecialties of urology, has there been a similar decline in the fee reimbursement for physicians?
Shawn Dason: I mean, Sam, that's really an excellent question and the message is that, yes, that has occurred I think throughout the field of urology, and frankly has occurred throughout surgical specialties. We are following up actually with another study that is looking more broadly across the entire spectrum of urology at all of the key index procedures being performed as a country, whether that's in the private practice setting or the academic setting. And generally speaking, I think you can use this as a bit of a, as a marker of what's happened throughout these remaining procedures.
It's been a large, broader shift away from Medicare and commercial payers reimbursing for physician fees, and certain other macro trends which are more focused on facility fees, and certainly there could be some discussion about the efficiencies that are occurring within the practice to make up for these declines to keep overall physician reimbursement on a kind of hopefully par level. But we are definitely seeing that throughout the entire field of urology, and in fact probably the entire field of all surgical specialties.
Sam Chang: So, it is, Shawn, we know there's an overall bucket of relative value units, of RVUs throughout all the medicine, and that if you take away from, say, the RVU total goes down for a certain procedure, it can go up for another, but there can't be a continued increase, etc. So, is it that the RVUs for urologic oncology procedures have gone down and/or is it the reimbursement per RVU has gone down? Because I'm trying to figure out, all right, if we still think that our work is similar and we're getting reimbursed less, that's a painful pill to swallow. But if it's a combination of, oh yeah, it's really not that difficult, so the amount of your RVU has gone down and your reimbursement, that's a double whammy. Do you have an idea regarding what has impacted more the overall trend?
Shawn Dason: Yeah. So, we don't have that data in our study and it's certainly something that would be very interesting to look at. I think a lot of that depends on the type of procedure, like we talk a little bit about this in the paper and of course you know in your own experience probably, prostatectomy RVU values have shifted quite a bit recently relative to our UC surveys and relative possibly to just efficiencies that have been optimized over time. So, 10 years ago, the value was quite a bit higher, then it dropped to a value quite a bit lower and then settled out somewhere in the middle.
I think on a per procedure level, that certainly is impactful for certain surgeons that perform a lot of that procedure. We see shifts and they may not relate to the overall trend. They may relate to changes in efficiencies, changes in how that procedure is performed and the results of some of these RUC surveys.
When it comes to looking at the overall, I think field as a whole, a lot of it I believe is related to just a dollar per RVU that doesn't track inflation. Inflation, let's say target at about 2% a year, probably exceeds that in many years. And in certain periods like in 2022, 2021, can markedly exceed that. We don't see proportional increases, of course in government budgets, in Medicare payments. And so, that's where we start to see a lag over time, and just that 0.51% a year where the budget can miss the inflation number, you can see over time that compounds to quite a bit.
Sam Chang: So Shawn, what do you do about this? Is there anything that physicians can do? Is this advocacy on Capitol Hill? Do we alter or do we advocate more for more RVUs? Kind of what the next step is? Because I think physicians as a whole would at least want to stop the relative decline in comparison to inflation when, I mean, it is eye-opening when I think about, okay, I'm older and now the reimbursement as a bucket is 40% less. It's like... So, what would you say is a kind of a game plan for either urologists or for practices or for an organization like AUA? What can we do in terms of next steps?
Shawn Dason: Well, I guess the main, the first question is for us to decide whether this is a real problem or not. This is kind one piece I think of a broader puzzle, as I mentioned in the whole macro concern, which is that there's a big shift away from private practice. Sam, correct me if I'm wrong, but when you would've started practice, I feel like the proportion of urologists that would've gone into a pure private practice would've been quite significant. And as a shift from data that's been presented in a variety of different fields, we see that there's been a significant decline. Now, that's occurred for a variety of different reasons, but I think the message is that it's become a small minority of urologists today that are entering that practice setting. And this is a big factor. This might have led to that, this might be a by-product of that, but it probably directly impacts the private practice urologist the most compared to, let's say, urologist like you and myself who are employed within the context of a large organization.
Just because these physician fee declines are perhaps moderated by other shifts, including increases in facility fees, increases in efficiencies. And so, it only really tells one part of the whole picture. A lot of the picture, we're kind of in a black box of valid. So, I think as a field, it certainly makes sense that physician fees should not be declining by 40% inflation adjusted over the past couple of decades. But I guess we have to decide whether this is a big priority for us. And I think it is because it's really limiting the field in terms of practice setting and choice, in that it impacts the private practice kind of model so much. But I think on a broader level, that's where this just has to be really interpreted in context, that it's one piece of the puzzle. And how do we influence this? How do we influence this?
Well, I think a lot of it could be, as you said, direct legislative discussions and efforts. The physician fee reimbursement is still a critical component of what Medicare is paying, even if the facility fees have gotten a lot of the press, especially with commercial payers in their increase relative to the physician fees. Given that we want, I think as a great overall healthcare market to encourage different practice settings, including the private practice model, that we can't kind of box that out of the overall picture. And so, yes, I think that it does have to be taken in context that we're probably dealing with one, again at this point in time, at this moment, minority of practice setting models. It's a key aspect of that practice setting.
Sam Chang: Yeah, and I think it is, it's a component of obviously multi-component kind of payment structure and model that clearly is complex. Just as you point out, the regional differences within tight regions can be actually quite disparate. It does emphasize the complexity and multifocal kind of impact of different factors. But at the very least, I think that soundbite of, all right, over the past two decades, that 41%, those are hard numbers. And, oh yeah, no, this is inflation adjusted over this time period. Sure, a lot of factors have changed, but that, just in and of itself, hopefully we can get that word out in terms of, okay, let's at least figure out why this is going on, what's going on, what can we do to at least stabilize that? So, Shawn, thank you so much. We look forward to your future research. What are you guys looking at next?
Shawn Dason: Well, Sam, as you mentioned, I mean the key question is whether this is just a uro-oncology question or does this translate to the rest of the field as a broader concern? And I think that's really the impetus for the next project, which is to go from just uro-oncology towards the whole breadth of urologic subspecialties or general urology in kind of totality, to understand how this is impacting us across the field, whether it's impacting certain specialties more so than others? And I think that the message, just to give you a sneak preview of that is it's impacting everything. And so, as a field priority, it's pretty clear that at least this is happening. Now, the main question is, well, how important is it for us to preserve the private practice model as a viable model for the future? I personally believe it's very important and a key part of our field. And so then, yes, it's certainly across the entire field that this is happening, and that's the next project to really illustrate that.
Sam Chang: Well, once you have an idea regarding that, the work and the findings, we look forward to talking about all those key findings with you again. And thanks so much for spending some time with us and look forward to seeing that research as well.
Shawn Dason: Absolutely. Would love to.