Black swan events were first introduced by Nassim Nicholas Taleb in his 2001 book Fooled By Randomness,¹ describing unpredictable financial events with severe consequences and our tendency to inappropriately rationalize them with simplistic explanations after the fact. His 2007 book, The Black Swan,² popularized this metaphor to events outside of finance. These black swan events are disproportionate, high profile, hard to predict and rare. Taleb derived the name for these events from the accounts of Dutch explorers in 1697, who were surprised to find black swans in Western Australia, insisting on the Old World presumptions that all swans were white.

The rise of the Internet, the fall of the Soviet Union and the September 11, 2001 attacks are examples from Taleb of black swan events. Last year brought us global pandemic, impeachments, riots, murder hornets, earthquakes, hurricanes, fires, huge unemployment, a contested election and, yes, whales swallowing kayakers.

The practicality of Taleb’s book is not to attempt to predict events which are unpredictable, but to build a robustness against negative events while still exploiting positive events. You ask a common question: “What does it all mean?” The black swan urges us to ask instead: “What am I going to make it all mean?”

In 2020, AUA Public Policy & Advocacy, surrounded by its corps of dedicated physician volunteers, AUA staff and patient advocates, have been making sense of what we are going to make it all mean for our future. We’ve continued the advocacy, the legislative and the regulatory work despite the challenges, understanding that resiliency is built from our central core desire to protect our patients, our practices and our nation.

These are key highlights:

• Medicare Part A trust fund begins to run out of money in 2026, a key fact with advocacy efforts.
• The AUA commits $2.5 million to public policy efforts annually.
• Policy initiatives cannot succeed without urologists.
  • We advocated at the Insurance Roundtable with CMS as well as virtual AUA strike force meetings attacking prior authorization on behalf of burden reduction. CMS published a rule addressing some of these issues in February, but the rule awaits finalization.
  • Budget neutrality, which requires CMS to cut payment in one area of the fee schedule if it improves payment in another, was counteracted for calendar year 2021.
    • Effort reduction for surgeon-scientist researchers at National Cancer Institute is being discussed through a Request for Information specifically for urology.
    • Legislation was introduced in Congress on improving prostate cancer treatment for our veterans and addressing the workforce shortage in rural areas by establishing a loan repayment program.
    • A major multi-pronged telehealth AUA strategy involving every Public Policy Council committee, task force, and workgroup has been set in place with targets to maintain audio-only visits for reimbursement and eliminate the originating site requirements, among others.

One day soon we will get back to the daily routine of life with sending the kids to school, celebrating birthdays in restaurants and running to the airport with excitement for well-deserved vacations or professional meetings to meet friends and colleagues.

What are you going to make it all mean? This is a time to reevaluate priorities, to ask what’s important, what are you working towards and how can we turn all of this into an opportunity? Public Policy is a course of action created in response to public, real-world problems.³ My hope is you support AUA Public Policy through your civicism and volunteerism, knowing Black Swans do indeed exist in advocacy.