AUA Addresses Integration of Advanced Practice Providers in Urology Practices

The skillful integration of advanced practice providers (APPs) into urology practices can help address issues related to the dwindling urologist workforce shortage and the aging of practicing urologists, according to a consensus statement from the American Urological Association (AUA), which was discussed during a plenary session at the 2015 AUA annual meeting.

“Most of the centers report that APPs function as resident substitutes up to [fourth-year residents],” said Aaron Spitz, MD, Urologist, University of California, Irvine, Orange County Urology Associates, Laguna Hills.

A review of patients who were managed by advanced practice nurses (APNs) versus physicians showed “no significant difference in patient satisfaction, functional status, glucose control, blood pressure control, emergency department or urgent care visits, hospitalization rates, length of stay, or mortality,” Dr Spitz added.

The potential of implementing APPs in urology practices has come into focus because of several factors. An evolving workforce shortage is expected to result in a shortfall of 65,000 physicians by 2025. Urology is among the specialties that will be the most affected, according to Dr Spitz. As of 2009, the United States only had 3 practicing urologists for every 100,000 patients, and the number continues to shrink.

Finally, urologists are among the oldest group of physicians in the United States, with a median age of 52.5 years.

“Advanced practice providers may help reduce the shortfall,” said Dr Spitz. “Currently, over 60% of urologists employ advanced practice providers. The consensus statement can provide guidance for integrating advanced practice providers into urology practice.”

The term “advanced practice provider” encompasses physician assistants (PAs) and advanced practice registered nurses (APRNs). An APRN has a bachelor’s degree in nursing, and may have a graduate degree. APRNs may have a licensure for independent practice, which is subject to individual state regulations. APRNs also have previous clinical experience.

Most practice arrangements conform to a supervisory and collaborative model. The APP provides quality care while allowing the physician to attend to more complex cases. The APP works with 1 or more physicians who provide direction and supervision according to jointly developed guidelines.

Roles of Advanced Practice Providers

The responsibilities of APPs can increase with their experience. The model is based on interaction, communication, trust, and alignment, noted Dr Spitz.

The role of the APP encompasses many clinical activities, including surgical assistance, postoperative rounds, emergency department and hospital consultations, difficult catheterizations in the hospital, overflow of office patients, work in outreach clinics, and preoperative and postoperative education.

Depending on the APP’s training and experience and the supervisory physician’s comfort level, procedural activities of APPs can include uro­dynamics, testosterone (Testopel) insertion, vasectomy, prostate ultrasound, and cystoscopy.

“The training and mentorship of an APP are similar to a resident,” said Dr Spitz. “The goal is that the APP will be fully capable of remote supervision for most complex diagnoses and management plans.”

The consensus statement recognizes 3 APP levels. A level 3 APP may be a recent graduate or someone who is new to urology. The level 3 APP may not yet be able to triage multiple complaints, may require close supervision, and may not be ready to prescribe medications except after consultation with the supervising physician.

A urology training curriculum is worth considering for level 3 APPs. With proper mentoring and training, a level 3 APP should be ready to move to level 2 status in a matter of weeks to months, said Dr Spitz.

A level 2 APP may be new to urology, and the physician role in the relationship may be to verify, validate, and provide constructive feedback. Supervision by telephone might be feasible, but a level 2 APP should have some regular in-person supervision.

Level 2 APPs learn and benefit from opportunities to enhance their diagnostic and therapeutic skills for complex patients, said Dr Spitz. The APP should work with a supervising physician to plan more complex interventions. Level 2 providers mature to level 1 status over time.

A level 1 APP is a “highly skilled clinician,” said Dr Spitz. Distanced communication with the physician is routine. These experienced practitioners work collaboratively with physicians, engage in quality improvement initiatives and educational sessions, and should have the trust of patients and families—they are similar to a physician.

6 Core Competencies

The AUA Education Council and the APN/PA Education Committee have identified 6 core competencies to guide and assist APP training and integration into urology practice, including:

  1. Nonsurgical management of overactive bladder
  2. Urologic oncology
  3. Sexual dysfunction in men
  4. Surgical assistance
  5. Kidney stone management
  6. Sexual dysfunction in women.

The details about these competencies are available on the AUA website (

Reimbursement for Advanced Practice Providing

The Centers for Medicare & Medicaid Services has developed billing guidelines to account for the use of APPs. The circumstances that meet Medicare’s “incident to” requirements can be billed at 100% of the usual rate. The requirements stipulate that the services are billable to a physician, but are performed by a nonphysician.

The APP provides the service in the office and is an employee of the billing practice. The initial service for a new patient or a new condition must be provided by a physician, and a physician must be physically present on the premises when an APP provides the billed service.

APP-provided services that do not meet the requirements are billed at 85% of the Medicare rate. More information about “incident to” supervisory requirements are available in the American Medical Association (AMA)’s Current Procedural Terminology codebook (CPT), CPT Professional Edition, said Dr Spitz.

The AUA and AMA support the concept of physician-led clinical teams, said Dr Spitz. The American Association of Nurse Practitioners is seeking complete coverage for the full provision of primary care in all settings.

Federal legislation has been introduced to expand and liberalize the definition of “site of service.” Currently, 20 states permit independent practice by nurse practitioners, 12 states require direct or indirect physician supervision, and 19 states require collaborative agreements. Private payers’ payment policies for APP-provided services vary widely, including not at all, said Dr Spitz.

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