The Present and Future of LUGPA

Neal D. Shore, MD, FACS, presented “The Present and Future of LUGPA” at the International Prostate Cancer Update on January 27, 2018 in Beaver Creek, Colorado.

How to cite: Shore, Neal D. “The Present and Future of LUGPA” January 27, 2018. Accessed [date today]. https://grandroundsinurology.com/The-Present-and-Future-of-LUGPA/

Summary:

Neal D. Shore, MD, FACS, summarizes how the Large Urology Group Practice Association (LUGPA) has and continues to preserve and advance the independent practice of urology by healthcare policy advocacy, business and administrative excellence, clinical and therapeutic education, and ensuring the success of future leaders through their Young LUGPA program.

The Present and Future of LUGPA – Transcript

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LUGPA 2018: The Present and Future

So I’m going to talk about LUGPA, first so many of you in the audience may be very familiar with who LUGPA is, the Large Urology Group Practice Association.

LUGPA 2018

We started literally 10 years ago, and some of the presentation is on the plenary, or the keynote, I gave at our annual meeting this year, but with some twists. So what are the challenges confronting the independent practice of urology? What will be LUGPA’s role? LUGPA now represents about 2,400 urologists, about 150 member practice in 46 states in the United States. I’m going to review for you today what we’ve accomplished, why we think we have value, in addition to so many other really important urologic associations, and what can we do to get better.

LUGPA 2018 Priorities

So our mission, what is LUGPA and why did we start? It’s to preserve and advance the independent practice of urology. And so we sort of have two essential tracks. The business and health policy—well, really three tracks, health policy and advocacy, and as everybody knows, if you are not at the table, then you’re on the menu when it comes to governmental legislation and regulatory affairs. And then, the other thing that has really changed for many of us, you know, whether you are comfortable with it or not, is the fact that we became physicians, clinicians to take care of patients and do the right thing, but the clerical burden, and the regulatory burden, and thus the ratio of business of healthcare to clinical healthcare, has changed dramatically, and so it would be imprudent not to recognize that and not to do things to optimize the ratio of business and clinical excellence.

Headwinds Abound

So, we have a lot of headwinds that abound, and so how do we work our best? You see the three people off on the right there. Sometimes, when you’re at the head of an organization, you can see yourself as being that person on the far left, if you’re not careful, to work well with your board.

Headwinds Abound

So what are some of these headwinds? Well, there’s increasing work volume, declining reimbursements. This clerical regulatory burden, there was just an op-ed piece on it in New England Journal this week. It’s creating a tremendous amount of burnout. So, how do we make sure we avoid this burnout? And we’ll talk a little bit about that. All of these health policy changes, clinical advances, how does one find the time to keep up with it? And I think the answer is- it’s a Herculean challenge.

You have to have collaboration. You have to have non-physician and physician resources in order to do it. So, this is the notion of teamwork and collaboration, and we all went to pre-med, med school, residency, and sort of this lone wolf mentality. That has to change. It’s not sustainable. Practice ownership, what is the price of independence? We’re going to have a presentation at this meeting on some of these things that are out there competitively competing, possibly threatening the independent practice of medicine, let alone urology, and that would be hospital-based institutional systems, and now private equity organizations, which are really making a strong play in healthcare.

So, we have to avoid these internecine conflicts with our fellow societies and specialties and get away from the circular firing squad, what payers like and government officials see as completely ineffective in us getting our message across, which is first and foremost, how do we do the best patient care we can do? And I think we have historically had problems with this, whether it’s how we interact with – in a multi-disciplinary way academic community, radiation oncologists, nuc med radiologists, med oncs, urologists, primary care. We have to do better.

And I’m going to talk later on today, and there’s going to be more on these federal barriers, which get promulgated without any sort of stakeholder involvement of the folks who are at the front lines, and that would be us.

So why is this important? There’s a perfect storm. We have a person/power shortage. We have a greying of the world, particularly the United States, what some have called the Silver Tsunami, generalists versus specialists, it’s not any way feasible, a sustainable option. And then there is this thing that we all talk about at dinner breaks and at coffee breaks, is how do we do this life balance, and avoid burnout, and this topic is ubiquitous in publications and on websites. It’s a real, real significant issue.

How can we trim our sails?

How do we trim our sails? How do we deal with these headwinds?

Health Policy Advocacy

Churchill

Here is Churchill. You know, I was always fond of giving Churchill quotes, but I don’t think we’re in our darkest hour. As he said, “You must put your head into the lion’s mouth if the performance is to be a success.” And we at LUGPA really feel strongly about that, especially on the health policy side, and we also on a personal level I’ve hoped to be able to champion to our colleagues the importance of recognizing that urologists can deal with systemic therapies, and that would be in all of GU oncology, not just prostate, but bladder and kidney as well.

“Success isn’t final, failure is not fatal; it is the courage to continue that counts.”

Health Care Policy

So health policy, there’s the in-office ancillary services exemption, which gives us the ability to have various services, whether it’s diagnostic imaging, in-house pathology, radiation oncology services. We’ll talk more in this program about Stark reform and how it’s quite antiquated and preventing us from doing the – and moving forward in the world of MACRA. And we’ll get into that in a lot more detail.

The USPSTF, again, a lecture prep coming up on that, and really fascinating insight into how things occur in the United States oftentimes, which we are completely obtuse regarding our awareness, but yet, how they really affect what we do and how we manage patient care. This has now been repealed, the Independent Physician Advisory Board, which had unbelievable absurd authority. Fortunately, that’s now been repealed. All of these things are policies that LUGPA spends a lot of time, energy, and resources on our consultants on the hill and that we’ve been working on.

Promoting site neutrality for physician reimbursement, so that you’re not penalized because you’re in a clinic and doing the same thing that could be done on a campus of a hospital-based system and getting half the reimbursement for that. And then, looking at various reimbursement policies and CMS constant changes, and final rules that get promoted or get stipulated every year.

And in-office dispensing services, much like our medical oncology colleagues, having the ability to have flexibility to provide beyond just using a specialty pharmacy, and we’ve been working aggressively on coming up with new clinical quality measures, which is an arcane data dictionary to make sure that we have the ability to meet MIPS criteria.

“Physicians have critically important perspectives…but I don’t hear our voices enough”

Here’s Harold Varmus, known to many of you, Nobel prize winner, and former head of NCI and NIH, who spoke at Baylor College. And he said, “Physicians have critically important perspectives, but I don’t hear our voices enough.” And this is really what lead to LUGPA getting started. We had to recognize that the independent practice of medicine, certainly urology needed a voice on the Hill.

LUGPA Resources Promoting Integrative Care

LUGPA APM: A collaborative effort

We’re promoting integrative care. It’s an ongoing collaborative effort. We have an APM that was organically developed. You’re going to hear more about this, so I’ll go through this very quickly, but it was three of our important groups in New York, North Carolina, and Louisiana, and then basically LUGPA got more involved, and you’ll hear a lot more about this, and how we’re moving forward with the first urology specific advanced alternative payment model, which will give universally urologists across the entire country potentially the flexibility to better participate, not just in the MIPS side of the MACRA, but the APM side of it.

LUGPA APM Projects

Why is this important? Because this goes right to pocketbook and goes right to your ability to sustain your models, whether you’re in academic medicine, community, etc. Here’s some of the other APM projects that we’re looking at.

LUGPA: Evolution of Priorities

So the evolution of our priorities over time, again, we’re only in our tenth year. We’re a young organization. We’re finishing our first decade, expanding our membership, which we have done year on year of the 9,000 roughly or so urologists, maybe 10 that are practicing, a quarter are within LUGPA. We think we basically are from a prescription standpoint closer to 30 to 40% of actual utilization of services. We want to ensure that there’s stability and fiduciary oversight at our organization level, and we have accomplished that, thanks very much to the support of industry, as well as our membership dues. We’ve increased our full-time capacity from one FTE to now four.

Expanding Membership Involvement

When we began in 2008, we were three committees with 11 unique individuals serving. Ten years later now, we have 17 committees and 43 unique individuals serving, and we hope to continue to expand that.

Providing Resources for Effective Management of Healthcare

So resources for effective management of healthcare.

Balance: Medicine vs. Business Healthcare

As I alluded to this earlier, I grew up and my dad was a solo practitioner of family medicine, and pretty much all he ever talked about was patient care. And he was trying to retire, but he died prematurely in 1989, and his biggest complaint to me was the bureaucracy is killing me. Like in 1989 he was saying that, but as we are all aware, this is where the seesawing effect is, and if you are not paying attention to the business of healthcare, then you are really the proverbial ostrich with the head in the sand.

Practice Management for Urology Groups: LUGPA’s Guidebook

So one of the things we did was thanks to Evan Goldfischer, he put together, he’ll be giving a presentation here at this meeting, a LUGPA guidebook, which is available to all of our members and can be purchased.

LUGPA Guidebook Table of Contents

Here are just a review of the different topics and the contents, and if you look through this and you thought to yourself five, six years ago, how many of these topics would you even be thinking about at the time? But, these are all things that are incredibly important today, and continually evolving.

Practice Management Benchmarking

Benchmarking—if you don’t know the data, if you can’t measure it, then you don’t know what you’re doing, and you can’t responsively negotiate with your payers.

Practice Management Benchmarking

It’s a big part of our initiative at LUGPA, benchmarking and level setting so that our different member practices can look across within their region, across the United States and see what they’re doing well or not doing well.

Clinical and Therapeutic Education to Optimize Care Delivery

So clinical and therapeutic education to optimize care delivery, which is really my passion.

LUGPA: Clinical Education Advancements

In addition to the health policy and the business tracks, we’ve been doing education, and we feel that we’ve been at the forefront. Oftentimes, when the community folks were giving somewhat of an afterthought to it, but let me also preface by saying it all works best if we work in harmony, academia, with industry, with government, and with community. So we began our CME programs in 2010. We have regional programming, which we try to get out to all parts of the country so our members who don’t come to our annual meeting, which is held every year in Chicago, we have worked with Reviews in Urology, our official journal, E Pub, since 2012.

We began Prostate Cancer Academy two years ago, and Bladder Cancer Academy as an offer to not just our members, but also to residents, and fellows, to specifically keep them up to date and up to speed of what’s going on with all of the changes that David showed in a really remarkable way with his introduction. And now we have the IPCU-LUGPA co-sponsorship this year. A lot of folks really enjoyed getting the opportunity to come out to a winter meeting, and then we have LUGPA Onsite, which is a new initiative for this year, where we’ll actually be bringing a full day of programming on establishing an advanced prostate cancer clinic, bladder cancer clinic, kidney cancer clinic, as well as the integrated business issues. We’ll be bringing this to our LUGPA member practices so we’re really excited about that.

2018 LUGPA Regional Meetings

Here’s just a list of the meetings. Jonathan Henderson, who will be speaking at this meeting, is chair of our programming committee and these are some of the regional meetings that will be happening this year. We change the cities. We change the venues. We’re always trying to make it as accessible as possible, and by the way so these have really been wonderfully supported by industry.

LUGPA CME Program History

This is just a list of our CME programming that we’ve done, some of the topics, and you can see where we’ve been going over the last seven years.

2017 LUGPA CME Program

This year we had a program on optimizing your GU oncology cancer clinic of excellence, and this is really where I think a lot of the sizzle is in terms of therapeutic and research development.

Prostate Cancer Academy (PCA)

Prostate Cancer Academy—we co-sponsored this with Reviews in Urology and Herb Lepor, and this has been really quite remarkable. We’ve had 50 LUGPA members come. They’re nominated to attend, and 50 urology residents and fellows. And many of the faculty who have participated in that are here today, and that has really been very rewarding, and it’s a really great opportunity to try to get the newer generation to deal with the older generation and see what’s going on in all of the advances of prostate cancer.

Bladder Cancer Academy (BCA)

We had Bladder Cancer Academy last year. We did it literally right after ASCO. We had incredible attendance. We have another program March 1-3 in St. Louis, and again, what we are trying to do is get LUGPA members, and in this one in particular we actually have medical oncology fellows come to this as well. I’ve co-chaired this with Argen Balard, NYU, so these are the types of things where we combine all of the different aspects of healthcare that we can really be transformative.

LUGPA Onsite

And so in the transformative mode- here’s the LUGPA Onsite.

LUGPA Onsite: GU Oncology (Bladder-Kidney-Prostate) Clinics of Excellence

This was really bringing, you know, the mountain to Mohammed, so to speak. But a lot of our members are so busy they can’t get out, so we’re actually bringing a full day of programming on optimizing these GU oncology cancer clinics of excellence, integrating your APPs, and also understanding other key areas of interest such as the business integration and health policy, and it’s not just on the national level, but it’s also local regional as well.

Live on Demand Educational Program

We also have additional programs that LUGPA has worked with with UroCare Live TV. Here’s just three of the first ones we did in 2017. These are live programs. We do them during lunch hour. They are archived for our members, but we actually do them live sort of in the spirit of ESPN or Crossfire or something, so that it’s unscripted, not a lot of slides, but really you know back and forth, three to five members on the panel. We did developing an APCC. We did hospital ownership, and we also did establishing a bladder cancer clinic. We just did that one a couple of months ago. I did that with Ashish Kamat and Noah Hahn.

UroCare Live

LUGPA Co-Sponsoring 2018 IPCU

So here it is, we’re sponsoring IPCU with David Crawford. It doesn’t get any better than that. We’re excited about it.

LUGPA Co-Sponsoring ICPU

Here are some of the talks you’re going to hear at this meeting that David was kind enough to let us change the agenda. We developed this partnership really in late September.

Developing Future Leaders

Future leaders- I’ll skip that for purposes of time.

You become invaluable by doing things that are not in your description

Young LUGPA –Independent Urology’s Future

This is extremely important is developing future leaders in young LUGPA. We have 400 of our membership now who have signed on to be part of young LUGPA. We’re very pleased about that, really improving not just age but all sorts of diversity, and that is essential to the growth of urology.

LUGPA: Teamwork and Dedication

None of this gets done without the teamwork and dedication of a really great board that I have the privilege of leading for now, a lot of the different management. We love to work collaboratively with AUA, AACU, and SUO, as well as all the GPOs, and none of this occurs at the LUGPA level without our industry supporters.