Figure 1. The proportion of urological procedural claims submitted by advanced practice providers to MarketScan (2010-2020).

Figure 2. The proportion of urological procedural claims submitted by advanced practice providers to Medicare (2010-2020).

The number of practicing urologists in the U.S. has steadily increased between 2015 and 2021, yet approximately 60% of U.S. counties are without a practicing urologist.¹ In an effort to offset the increasing demand placed on the urologist workforce, the AUA formally endorsed partnerships in 2014 between physicians and advanced practice providers (APPs), including physician assistants and nurse practitioners.¹ As of 2020, the average urologist-to-APP ratio was 2:1 within a medical care team.¹

The compositional changes to the urological care team are important to consider in the context of men’s health because the increasing involvement of APPs may be a unique mechanism to further bridge men’s urology to their general health. The global average life expectancy for men is approximately 5 years less than for women, with men engaging in more risky lifestyle choices and lower health care seeking behavior.^2,3 As male urological health conditions frequently intersect with other underlying issues, including those related to endocrine, sexual, and reproductive health, the growing roles of APPs in urology may be utilized to further expand men’s health.^2,4

To better understand the roles of APPs in male-specific disease conditions and how urological care delivery in the U.S. continues to evolve to meet patient needs within both publicly and privately insured patient groups, Medicare and commercial insurance claims from the Physician/Supplier Procedure Summary and the IBM MarketScan Commercial Database were queried for procedures submitted by APPs between 2010 and 2020. Common urological conditions were identified using Current Procedural Terminology codes and grouped into 6 categories: overactive bladder, testicular hypofunction, erectile dysfunction and Peyronie’s disease, benign prostatic hyperplasia, genital warts, and scrotal pain. The proportion of procedures submitted by APPs was calculated for each year and category.

Our analysis demonstrates that between 2010 and 2020 the role of APPs in men’s urological health has increased in each condition within both the MarketScan and Medicare groups—particularly in the treatment of genital warts (6-fold growth) and erectile dysfunction/Peyronie’s disease (13-fold growth; Figures 1 and 2). This is consistent with the trends of urology APP growth reported in the existing literature. Hyman and Modi demonstrated the growing proportion of urological procedural claims submitted by APPs between 2010 and 2020, with the greatest proportion of APP claims in procedures such as percutaneous tibial nerve stimulation (24% and 10%) and bladder instillations (16% and 8%) in both privately and publicly insured populations in 2020.⁵ We are currently unable to determine if our data are reflecting the effects of a growing scope of practice for APPs, an increase in the total number of practicing APPs, or a combination of the two.

To our knowledge, previous studies have only studied the growth of specific procedures performed by APPs.^6-8 In addition, most studies have not examined recent growth trends past 2017.⁵ We examined the growth of APP roles in various men’s health conditions through 2020, allowing a unique perspective on the care provided to a subset of the urological patient population.

We believe that our observed rates of growth may underestimate the roles of APPs in men’s health. “Incident to,” “split/shared,” and “direct” billing are the methods by which an APP may bill for rendered services. However, billing requirements vary by site of service and insurance company.⁹ In particular, “incident to” billing involves independent evaluation and treatment of a patient, but bill submission by the supervising physician.¹⁰ This billing practice is a challenge in quantifying the extent of APP care within the medical field.¹⁰ The insurance claims in our data were billed by APPs, which does not capture the count of shared cases that may ultimately have been billed by the physician, thereby underestimating the APPs’ true caseload and clinical involvement.

The increasing role of APPs in urological practice can help relieve the growing burden of the urology workforce shortage. While our data do not provide an assessment of patient outcomes and satisfaction, Hollenbeck et al assessed the effects of adding APPs to single specialty surgical practices and found that 1 year after adding the first APP to a practice, the odds of post-procedure complications, length of stay, and episode spending were reduced.¹¹ Further, general surgical, orthopedic, and urological practices had increases of 49 to 205 in-office visits per surgeon, demonstrating increased access to care. Similarly, Lai et al found that multispecialty group practices with higher rates of APP integration had lower rates of patient mortality, major complications, and readmission following major surgery.¹² Within urology specifically, studies have found that scheduling an initial visit with an APP could reduce wait time by 10-15 days.^13,14

Understanding the growing role of APPs can be utilized to guide the development of targeted training curricula and certification criteria, potentially improve clinical care and costs for patients, and relieve the worsening physician workforce shortage in urology. Further research on implementation of APPs in men’s health clinics, as well as the health outcomes of these workforce modifications, is warranted.