Avi Baskin: Yeah, thanks so much for having me. I really appreciate it, Dan. Really excited to be here and share some of the stuff our team did together. Again, I'm at UC Irvine Medical Center, and one of the projects that I worked on actually during my fellowship, SUO Fellowship at Vanderbilt, was this project looking at basically the mismatch between where we see urology services are built and where we know urologists are. And just to go over just a brief presentation today, I'm going to talk a little bit about the rationale for this project, our methodology, key findings, and the take-home points. A lot of this project comes from really a lot of these text messages that most of us are used to getting as urologists, which is basically somehow a locums company gets our number and they say, "Hey, there's this opportunity X, Y, and Z," and you get many, many of these texts. And I started to wonder, it's like how many urologists are doing locums? How prevalent is this? Where are they traveling? What's going on? And there's a lot of great data that comes from the AUA census that's done every year, basically saying, "Where are urologists located?" And one of the findings is they basically map out the entire US and say, they have each urologist, there's about 50,000 urologists, and they say, "What is your primary zip code of practice?" And they find this basically from national NPI data.
And so for all of the urologists in the US, they have a primary zip code of practice. Most urologists are in basically cities. Less than 10% are in rural areas, and we need to better define where urologists live and work based on this data compared to where urologic care is delivered. And so to do this, we took two datasets. The first is from CMS. They basically published this inpatient, outpatient dataset on urologic procedure type. We went through all of these codes and found out which ones are related to urology and basically took this list of hospitals and said, "Okay, did urology happen here?" Were there urologic procedures or things that we would say that our group decided that would be done by a urologist or could be done by a urologist? And then we took the AUA census data and basically found for all of these about 15,000 urologists where their primary zip code of practice. We cross-referenced the two and we asked two questions, where is urologic care delivered without a local urologist, and how far is the nearest urologist to that particular hospital? Basically, what we found was that there are urologic services billed in about 1,400 US counties, and 24% of these counties had no resident urologist, meaning there was no urologist listed as this county as their primary place of practice. 909 hospitals delivered urologic care without a co-located urologist in that county, and the median distance for these hospitals to the nearest urologist was about 15 kilometers. This is a graph that breaks it down.
So again, 10% of hospitals were greater than 50 kilometers from the nearest urologist based on the AUA census data and the CMS data. And so there were a number of these hospitals, and in particular rural areas where urologists, or I should say people delivering urologic care and billing for CMS for urologic care were traveling quite a distance. Overall, the take-home message is that there are workforce gaps, and that may not always equal access to care. There's evidence of a very mobile workforce based on this data. In the setting of the new, there's $50 billion that the federal government's putting into rural health, data like this can help guide smarter allocation and then flexible collaborative care models maybe the future to ensure urologic care and access.
Daniel Joyce: Thanks so much, Avi. Really, really interesting work. I'm curious, so the urology care is happening, right? You have these codes because you know the actual care is being delivered in all these areas, so somebody's doing it. Who do you think is doing it in all these places?
Avi Baskin: It's a good question, and that's the major limitation of the study. We don't have provider, and I wish we did, we don't have provider-level data to say, "Okay, is a urologist actually doing it?" The way that you try to control for that is I looked through or we looked through all of the procedure codes. And to me, most likely, if someone's putting up a ureteral stent, for instance, it's going to be a urologist. If they're doing bladder repairs, it could be a trauma surgeon, could be a urologist, those sort of things. So there is potentially an overlap. But the way that I looked at it was that it's probably a urologist, but I can't say for sure based on that data, because all I know is the actual billing code or the procedure code. So it could be general surgeons, it could be an APP, of course, it could be a variety of people. But to have the actual billing, because initially I had called them locums, but then I realized, we realized it's not necessarily locums. It could be anyone just filling these urologic codes. So I would love, and that's the next step potentially, is if we can get hands on a dataset that would basically tell us exactly who are the providers, are they urologists, are they other folks that are delivering this care?
Daniel Joyce: Avi, I have noticed, and I'm sure you have too, that there has been a big change in practices, particularly academic institutions that are taking up the more smaller community practices, and then they exist under this umbrella of, let's say, Vanderbilt. A lot of academic urologists then are, I think, being pushed to go out into these communities and at least serve part-time in those settings. Do you think that is one way or the way to address this mismatch that you describe, or do you see that as maybe making things worse?
Avi Baskin: Yeah, in the era of what's happening, hospital consolidation, most physicians compared to 10 years ago are employed. It'll be interesting to see how we deliver care. Being in Orange County, for example, if you live in Orange County where I practice, you have a lot of options for care. You could go to UC Irvine, you could go to Hoag, which is a huge hospital system here. You could go to Kaiser, you can go to City of Hope. There are many, many options, go up to LA. It's different. It's different if you're in a different place, but if these hospitals are expanding, in my mind, they're now responsible for these lives and they're responsible for this care. One way is these academic urologists or anyone who practices will be asked to go out to these satellite sites. The other thing is you have to incentivize the physicians. We know that 90% of urologists live in metropolitan areas. By and large, people are choosing to live in cities, so what can you do to incentivize people to practice or live out in these rural communities and serve where a lot of people are needed?
Being at Vanderbilt, we saw folks come in, drive five, six, seven, eight hours to come and get care. What can you do to have a hospital out closer to folks where people can go and get advanced care that they need to get rather than having to make these huge, huge commutes to get their standard of care? So I think that's, you look at pay, you look at loan forgiveness, you look at other factors that will incentivize people. And that's really important because at the end of the day, you're going to have to convince urologists, you're going to have to convince anyone delivering urologic care that it's worth their time. And that's what it comes down to. I think in the setting of this new $50 billion investment in rural health from the federal government's, things that we need to think about in the way that we are reimbursed to make sure that all the people who are out in these more rural areas and these areas or less access still have the same opportunities as those in a major city or metropolitan area.
Daniel Joyce: Let me turn that question a little bit then and ask, do you think what you're seeing in your study is because of the centralization of care that's happening, or do you think it's because there is truly a shortage of urologists who want to be there?
Avi Baskin: Maybe it's a little bit of both. I think it's probably a little bit of both. I mean, we know rural hospitals are closing, that's one thing, but we also know urologists by the census data by and large live in these major cities. So I think it is a little bit of both, and I don't think there's one factor that pushes it either way. Yeah.
Daniel Joyce: Do you think then, if it is both and there is a shortage of urologists that are not being incentivized to go to those rural areas, do you think we have the workforce to find those people who we can incentivize to do that? Or is there a bigger problem here that we just simply don't have enough urologists?
Avi Baskin: Well, I think we know we have a shortage of urologists, and I think we need to incentivize people to be in more rural areas in some way. I think in general, one of the things we talk about, especially I've heard about urologic oncology, is the concept of centers of excellence, which I think is great. If you're doing very complex procedures like a cystectomy, or a lot of times when that I think about penile cancer and lymph node dissections related to that, it's a complicated procedure with lots of complications, and you need to have a team that knows how to manage these patients, not just the urologists, but nurses and physical therapy and wound, ostomy, and all sorts of different things that you need to have in place. And while I think the centers of excellence are a great idea conceptually, I think it's also a problem if people are having to travel 12 hours to get to their nearest hospital that can actually take care of them. I think those models of the centers of excellence are great, but they need to be branched out a little bit to make it more realistic for someone who's living far away to actually come and get the care that they need.
Daniel Joyce: Yeah, that's a really good point, and probably some value in doing a better job of defining when a center of excellence is needed and for what care so that we can then coach and provide education for the more rural communities and empower them to deal with the things that they can deal with. Along those lines, I want to talk to you about telehealth and that being a potential solution here too. Obviously, you're looking at procedural things done within these local hospitals. However, a vast majority of follow-up and things like that could probably happen through telehealth. Is that something you see as an answer here, or does that complicate things even more because now we have somebody who's a remote physician managing that patient, and they still don't have that immediate access to that physician should they need to be admitted or need procedure done?
Avi Baskin: Yeah. I mean, I love the concept of telehealth and I offer it to a lot of patients. I think there is a lot of value in meeting someone in person maybe during the initial visit and you need to do the physical exam and those sort of things. And obviously, for any sort of surgery, you obviously need to be there in person, but I think the telehealth is great so far as a lot of times for follow-ups or maybe even for the first visit, you could do telehealth and say, "Hey." Learn more about them, get their medical records, get everything in line, and then bring them in for another visit where you're getting scans, you're getting lab tests, you're getting all that. It's much more efficient for the patient. I thought Vanderbilt did a great job of that, being in clinic where someone would come in, they'd see us in urology, see med-onc, maybe see rad-onc, get some CT scans, get some labs. And it was just a really efficient day visit where they're taking care and getting a ton of different opinions and a ton of the work done. And I think it's great for someone who lives far away. So I think we need to encourage telehealth in that sense because I think patients really like it. The data shows patients definitely really like it, and I think it definitely has a role.
Now, we have issues. During the pandemic, you could do across state lines, other things, now you can't. There's a lot of regulatory burden around it, but I think realistically, those potentially need to be relaxed, in my opinion. I know there's a lot of things to work through there, but when a urologist is board-certified, it's a national deal. It's not just state-by-state, I know how the medical licenses go. But I think for patient care, it's much better because especially in Tennessee, Tennessee touches nine states, you have folks coming from all over to Vanderbilt. Here, I see mostly folks in California, but people occasionally do come from Nevada and come from other areas. I think it's really helpful if we're putting patients first to think about those sorts of legislations and regulatory requirements around telehealth.
Daniel Joyce: Yeah, absolutely. All right, I'll get you out of here on this. If you have absolute power, you're in a position where you can make whatever policy decision you want and it will absolutely happen. What's the one intervention you would do from a policy standpoint that would help address this problem?
Avi Baskin: I mean, the quick and easy stroke of the pen would basically say you can do telehealth across state lines, and you don't have to be in California to see a doctor in California. And I don't think it really makes a lot of sense that you can't. There's obviously some licensing and other folks that may disagree with me, but if that patient could travel to my office and see me in my office, I'm not sure why we can't have a chat over the phone or via video visit.
Daniel Joyce: Great. Well, Avi, thanks so much for joining. Really, really exciting work, important work. I think there's a lot of work to be done in increasing the rural buy-in in general for all of our patients and getting them the care they need and access to care so I really, really appreciate your time and thanks for chatting.
Avi Baskin: Thanks so much for having me on. Really appreciate it.