Considering that California is only one of the 50 states, it's always impressive how well we are represented in advocacy efforts at the national level.  At this year's Joint Advocacy Conference sponsored by the AACU and AUA held in Washington, D.C. March 25-27, more than 10% of the record turn out was from our golden state.  Before an intensive coordinated lobbying effort with Senate and House members, attendees heard updates on a wide range of health policy issues beginning with a briefing on options being considered to revise the Sustained Growth Rate formula used to update Medicare fees from year to year.  Ron Castellanos, M.D., the first urologist to be named to MedPAC (Congress' think tank responsible for recommendations regarding Medicare), gave us an insider's view on the program's budget challenges that will cause Medicare rates to fall 10% this coming January if nothing is done in the current Congress.  Learning how updates are determined and what alternatives are being considered gave us greater understanding and better prepared us to argue our case with Congressional staffers.  As legislation comes forward, each of you will need to contact your Congressman this Fall to demand a fair update and let them know how deep cuts in reimbursement are affecting your practice.  Unless the formula is altered, we face cuts up to 40% over the next 8 years at a time when inflation is predicted to increase your overhead over 20%.  Clearly, this is an unacceptable and unsustainable scenario.  

As if this wasn't motivation enough, our invited keynote speaker was California's own Bill Plested, M.D., president of the AMA.  This staunch advocate for physician independence challenged us to vigorously negotiate with private payers over their contract terms and accept nothing less than we deserve for the high quality care we provide.  We realize that's easier said than done but until we get tough and begin to refuse bad contracts, payments will continue to fall and restrictive regulations will continue to grow.  At some point, physicians have to stand up and say "enough!". 

California's Dave Penson, M.D. presented the latest on Urology's efforts to take charge and participate with federal Pay for Performance programs that go into effect this July 1.  Congress feels so strongly that this initiative will improve quality and cut health care costs that they are willing to pay up to an additional 1.5% of all your Medicare allowable charges to you as a bonus for participation.  If you haven't already, you should be making preparations to choose criteria appropriate to your practice and start learning how to report in order to take advantage of this.  Whether or not we agree with the intent of P4P or believe it will actually have an impact on quality, since it appears to be here to stay, we cannot afford to allow others to establish the criteria by which we are judged.  By October, Dave will have more for us on 2008 P4P proposals in his talk to the Socioeconomic session in Scottsdale.

In addition to updates on several other chronic concerns, we considered the serious challenges that have been raised to urologists performing (and being fairly reimbursed for) imaging studies which have become such an integral part of our practices.  The American College of Radiology has taken an aggressive position to keep other physicians off their turf by lobbying public and private payers to deny payment for a number of different studies.  At the same time, the Deficit Reduction Act of 2005 cut back Medicare reimbursement for a range of studies that has cost Urology $9 million this year out of prostate ultrasound exams alone.  A select task force was created during the JAC to meet with the offices of the Senate Finance committee and House Ways and Means Health subcommittee (the two groups primarily responsible for Medicare legislation) to craft a bill that would exempt prostate ultrasound from the DRA cutbacks.  Our initial efforts were very well received and as a consequence, language is being crafted that hopefully will be passed returning fair payment to us.  At the same time, we made a very strong case that ultrasound in our offices is an extension of our clinical exam and should remain in the hands of practicing urologists.  Reviewing these issues and our options, Pat Fulgham, M.D., chair of the AUA's imaging task force, discussed strategies including the potential for special certification qualifying urologists as imaging experts.  Pat will give further updates on this during the Socioeconomic Forum at this year's Western section meeting.  I strongly urge you to attend.

With the joint support of the AACU and AUA as well as broad participation by numerous state urologic societies, the annual Washington update has become a major focal point for legislative advocacy.  I hope to see many more of you at next year's conference.

Less than a month later, we were able to put more of that advocacy training to use by joining with other California physicians in Sacramento at the annual CMA legislative conference.  At least 500 doctors (including at least 6 urologists by my count) were addressed by Governor Schwarzenegger, our CMA lobbyists and various other political speakers before heading to the capitol to discuss the multiple health care proposals now being debated.  2007 has been termed the year that a major overhaul of California's health care system is expected. Although the smart money says that little will come out of the current legislature (and that change when we see it will be incremental rather than revolutionary), some of these initiatives contain threats that could greatly impact our practice.  In an effort to "share the pain" and increase funding to cover the un-insured, several bills include a proposal for a 2% physician tax.  Although referred to in euphemisms, this "fee" is in fact a tax that would apply across the board on gross receipts.  For a specialty like urology with many expensive drugs administered at little or no mark up, such a tax would cause great hardship.  I cannot see continuing to carry the overhead for LHRH agonists or bladder cancer drugs if their purchase and reimbursement was subjected to another 2% tax.  However, organized medicine does support some of the other initiatives being considered.  We do support extending some type of insurance coverage to all and we insist on greater regulation of the insurance industry which has become a monopoly in California where 5 or 6 large companies control virtually all covered lives.  We demanded legislation that would increase penalties for delayed payment by health insurers.  We asked that more of the premium dollar be left in the system to pay for health care and that less be diverted to administration and profit-a reasonable regulation that the state can implement.  And we demanded stronger laws to prevent retroactive denial payment for pre-authorized care.  It's unclear which of the many legislative packages will finally pass into law but we should take advantage of the current atmosphere in Sacramento to demand greater oversight of the private payers to create a more equitable system dedicated more to providing for the health of Californians and less for the economic health of the insurance companies.

For those of you too busy to join us in Washington or Sacramento, take advantage of your Congressman's or state legislator's local office.  Drop in and have a chat. Let him know how you're doing, what your patients' concerns are and what he can do for you to improve your ability to properly care for your patients.  Advocacy is not limited to one or two meetings per year.  In order to protect our practice environment, we must maintain steady pressure on the system.