Introduction

The American Urological Association (AUA) officially endorses the use of advanced practice providers (APPs) “in the care of genitourinary disease through a formally defined, supervisory role with a board-certified urologist under the auspices of applicable state law” [1]. However, many urologic practices have not utilized APPs perhaps due to confusion about how to begin and how best to utilize these providers.

Significant changes in healthcare including lower reimbursement, decreasing numbers of trained urologists, increasing numbers of urologists reaching retirement age, and an increasing population requiring urologic care have resulted in an accelerating urology workforce shortage. Well-trained and integrated APPs can alleviate this threat to patient access to care by providing a wide range of urologic care and practice support. The concept of extending services provided by qualified non-physician providers to underserved areas of medicine is the very foundation by which the physician assistant and advanced practice nursing professions were created. In response to the growing interest regarding utilization of APPs in a urology practice, the AUA in 2013 formed a workgroup comprised of APPs and urologists to develop a consensus statement addressing the multiple questions surrounding APPs in urology. The consensus statement was born of the necessity to address the looming shortage and maldistribution of urologists. It represents one of the most comprehensive examinations of the education, training, regulatory and Medicare considerations, patient satisfaction, liability concerns, and practical clinical scenarios illustrating APP utilization. Since its recent completion, several articles have expressed the views and continued concerns of urologists regarding APP utilization in a urology practice. Included in the current discussion are continued concerns regarding competency and training as well as perceived threats of APPs infringing upon the practice of the urologist.

Workforce Shortage

According to the recently published AUA 2014 census, there is strong evidence of a looming crisis in patient access to urologic care. The average urologist is 52.5 years old, there are only 3.9 urologists/100,000 population [2•], and the number of patients is rapidly growing while training slots have been held flat since the 1990s. APPs have been employed in urology practices in a variety of roles which have provided greater patient access to evaluations, education, and treatment including procedures. Broader utilization of APPs can be an important means to offset the diminishing supply of urologists.

APP Qualifications and Training

The training for physician assistants (PA) is uniform throughout every PA program in the USA. In contrast, there exist some variations amongst nurse practitioner training programs that can be confusing to a hiring urologist. Nevertheless, the variations that may or may not exist have clearly demonstrated that the training provided is more than adequate. A PA will be a graduate of an accredited program usually providing a Master of Physician Assistant Science (MPAS) degree. The certification is national, and the license is state-based, but work is always in conjunction with a supervisory physician. PAs will typically complete 1000 to 2000 h of clinical practice during training. An advance practice registered nurse (APN)/nurse practitioner (NP) has a Bachelor of Science in Nursing (BSN) and a masters or doctorate degree in nursing. Licensing and credentialing is state-based, and some states allow completely independent primary care style practice. APRNs/PAs have less clinical hours for certification than PAs, but they have significant prior clinical experience. PAs and APNs are comparable in their abilities and skills once they are integrated into urology practices. The training and mentorship of the APP is similar to that of a resident, and the goal is that the APP will eventually be fully capable of remote supervision for most complex diagnoses and management plans.

The newly initiated APP, having recently graduated and being new to urology, may not be able to triage multiple complaints well and will require close supervision with the physician performing the exam and interviewing the patient side by side with the APP. Consequently, it is believed, a formal urology training curriculum can be beneficial. The AUA Education Council and the APN/PA Education Committee have identified six topic areas of training development to assist APP training and integration: They include (1) Overactive bladder/non-surgical, (2) Urologic oncology, (3) Male sexual dysfunction, (4) Surgical assistance, (5) Stone management, and (6) Female sexual dysfunction. These modules are available on “Education for APN/PA/Allied Health” portion of AUAnet.org. A more experienced APP, who is nevertheless new to urology, may require the urologist to verify, validate, and provide constructive feedback. Supervision can be predominantly remote as in over the phone. There can be coordination with the urologist and the APP to plan complex interactions. At this point, the diagnostic and therapeutic skill set may expand and more complex patients may be managed by the APP. In time, the APP will emerge as a highly skilled clinician with remote supervision being standard. This progression leads to the role of the urologist becoming more collaborative than supervisory, thus allowing the APP the opportunity to focus on more sophisticated contributions to the urology practice such as developing quality improvement initiatives and in depth educational sessions [3].

Supervisory/Collaborative Model

Physician-led healthcare teams are becoming more prevalent as a model of delivery of healthcare. Defining roles within the healthcare team and expanding on these roles enhances the quality of care provided. The concern that the APP is positioning themselves to replace the practicing urologist is inaccurate. The agenda for APPs is to simply be an integral part of a physician-led healthcare team providing quality medical care. In an article from Urology Times, entitled Collaborators, Not Competitors, Richard Kerr writes, “…the urologist functions as a CEO who uses APPs and telemedicine to direct patient care” [4•]. This philosophy is the embodiment of the APP professions. He goes on to point out that over time, there will be challenges regarding acceptable training for all parts of the healthcare team to ensure that the increasing practice needs are addressed. In general, the APN and PA relationships with the collaborating or supervising physician are evolving relationships that when done properly fosters greater autonomy of the APP and allows the urologist to handle more complex matters that are more reserved for the higher level of physician training. As the relationship evolves, the skills of the APP become more advanced through “on the job” or structured training, resulting in the APP becoming more vital to the healthcare team. This concept is addressed within the consensus statement, “The biggest challenge will lie with how we revamp our training for all members of the healthcare team a generation ahead of their arrival to the marketplace” [4•]. More complex procedures delegated to an APP are typically being performed out of individual practice necessities. The consensus statement addresses this by stating, “vasectomies, cystoscopies, prostate ultrasound guided biopsies, and urodynamics…may be delegated to highly skilled, well-trained APPs with the benefit of televideopresence when desired, as with prostate ultrasound or cystoscopy” [4•]. Acceptance by urologists to provide training and ensure competencies of APPs performing more complex procedures where applicable will be a significant challenge in the future [5•].

Scope of Practice Concerns

Scope of practice of APPs in urology is another area that often raises questions. Many urologists are unfamiliar with the laws governing scope of practice. Reports indicate that many APPs are already performing some in-office procedures traditionally performed only by urologists. Intense debate on how to properly train APNs and PAs in certain urologic procedures, in particular cystoscopy, remains a sticking point. One physician reported that he has trained his APPs to perform emergency cystoscopies for catheterization with a difficult urethra if a physician is not immediately available. However, diagnostic cystoscopy is not delegated to the APPs in this practice. It is recognized that in more remote areas where an APP may be the principal or sole healthcare provider and/or where personnel and resources are limited, more complex care can be delivered by a well-trained APP, thus improving access to care. In either case, some urologists are reluctant to embrace the concept of greater utilization of APPs to perform procedures typically reserved for urologists. The current healthcare climate requires that urologists be more flexible with utilization and ensure that levels of competency are achieved that are appropriate for the tasks performed. Concerns amongst urologists have been voiced regarding the differences between PA and APN practice laws. The ability of NPs to practice more independently is worrisome to many urologists. This growing concern has clearly at times become a barrier to acceptance. The perceived threat of physician displacement by an APP either within the practice or in the community is of great concern.

Urologists are challenged with garnering a clear understanding of the practice legislation that describes supervisory and collaborative agreements and how much authority the physician has in these relationships. Twenty states allow NP independent practice, 12 states require supervision directly or indirectly, and 19 states require collaborative agreements [6•]. Urologists will find that the practice laws clearly state that they have full delegatory authority regarding the scope of practice of APPs in urologic care. State laws to date do not allow for APNs or PAs to practice independent urology. PAs by law are required to be under the supervision of an MD, and APN require a collaborative agreement to practice within a urology practice. In reality, these laws allow the urologist to be more flexible in expanding the role of the APP. Proposed legislation to expand the role of an APP should be designed to increase the ability of the physician to delegate more complex care that is well within the capabilities of the APP with the premise of expanding access to care for the urologic patient.

Liability Concerns

Liability risk is a leading concern amongst urologist considering utilizing APPs. In a survey conducted by Urology Times, 52 % of urologist felt that delegating tasks to an APP increased liability risk [7•]. Historically, there has been little evidence to support an increase in liability risk when utilizing an APP in urology. According to the National Practitioner Data bank from 1991 to 2007 of the 320,000 claims against physicians, there were only about 1500 claims against PAs and about 2700 claims against NPs. In total, there were 74 billion dollars paid out over this time with only 0.003 and 0.007 % of that total paid out to PAs and NPs respectively [8] As APP numbers and scope increases, liability may increase. The additional malpractice coverage required is typically a minimal increase in the premium. There is a shared limit. Many APPs carry their own insurance coverage policy to allow for job changes [6•]. The most litigious states are Florida, Washington, Alabama, New York, California, and Massachusetts. Eighty percent of claims are for “diagnosis and treatment” and 20 % for “medication” or “surgery.” Fifty percent of injuries ascribed to NPs were deaths [9].

Liability risk can be reduced through conscientious efforts at communication, guidelines, and documentation. There should be detailed protocols in place which are written or available for diagnosis, management, medication, tests, patient education, and consenting. Any limitations should be documented as well [10•]. Both the urologist and the APP should document all diagnosis, complaints, treatments, and follow-ups along with laboratory results within 24 h. The urologist must take care to exercise due diligence in the hiring of an APP for in rare circumstances a physician can be held liable for the actions of an APP whose pre-hire performance history was clearly problematic [10•].

Patient Satisfaction

Although formal studies of office based APPs in urology are lacking, primary care studies indicate that patients are generally as satisfied with APPs as they are with physicians [11]. A Kaiser study in 1995 for primary care, pediatrics, orthopedics, and obstetrics and gynecology found 89 to 96 % satisfaction with APPs [12]. Review of APRNs versus physician only managed patients demonstrated no significant difference in patient satisfaction, perceived health, functional status, glucose control, BP control, ED/urgent care visits, hospitalization rates, length of stay, and mortality [13].

Reimbursement for Services

Medicare billing for an APP is 85 % of the fee schedule for the urologist unless the services are billed as “incident to” the urologist. In order to bill as incident to, several requirements must be met. The APP must be encountering the patient in the physician’s office and he APP must be an employee of the billing practice. The initial service for a new patient or a patient with a new condition must be by a physician. Finally, a physician must physically be present on the premises. The vast majority of billings will be at 85 % of the Medicare fee schedule. It may be necessary to refer to the AMA CPT handbook for federal requirements of supervision per encounter/procedure [14, 15]. Private payers/institutions may or may not reimburse on par with urologist PPO or Medicare fee schedules.

Acceptance

Acceptance of utilization of APPs has become the focus in many areas of medicine. State governments are making concerted efforts to increase utilization of APP’s. In fact, all 50 states have made it a point of emphasis to increase utilization of APPs in all areas of medicine. The National Governors Association (NGA) in 2012 and 2014, issued briefs challenging governors and state legislators to review the laws governing PA and APN practice and make any and all necessary changes to remove any barriers that restrict the full scope of PA and NP practice [6•, 16•] Surveys conducted by Urology Times indicate that nearly two thirds of urology practices are using APPs and nearly half are expecting their use to increase [17].

Conclusion

The reality of the workforce shortage in urology dictates that scalable and affordable solutions to this critical problem be created and utilized. APNs and PAs historically have played a vital role in alleviating workforce shortages by delivering quality healthcare and improving access to care. Integrative urologist-led healthcare teams will be vital to the efforts of meeting the demands of urologic practices nationwide. Additional research will be needed in urology that will provide outcome measures indicating the impact an APP has on a urology practice. This data will be helpful in determining scope of practice laws, training needs, and more importantly, identify strengths and weaknesses of the delivery of urologic care by APPs. Furthermore, this information will allow all urology practices to use APPs in the most appropriate and efficient manner. The AUA Consensus Statement on Advanced Practice Providers is a document that can serve as a framework for a urology practice to successfully integrate an APP into a urologic practice. Further debate regarding scope of practice, training, liability, and overall utilization will continue in the years to come. AUA’s recognition that APPs are a critical component to solving the workforce issue will be at the forefront of recommending and assisting urologists with implementing a physician-led healthcare team that will include APPs. Dr. Howard M. Snyder, of the University of Pennsylvania, School of Medicine, Philadelphia, stated, “Only if we include non-physicians in urologic care will we be able to take care of the numbers of patients that will come to us for care” [4•].