For years, we have been battling a workforce shortage in medicine. The Association of American Medical Colleges projects a national shortage of up to 124,000 physicians by 2033.¹ According to the AUA, 28.5% of urologists are over the age of 65, nearing retirement, and the median age is 55. One way to help address it is by leveraging advanced practice providers (APPs) into urology practices. An APP is a health care professional who is not a physician but has advanced education, training, and certification to provide medical and/or surgical care. APPs include nurse practitioners, physician assistants, and nurse anesthetists. According to the AUA Census 2022, 81.5% of urologists already utilize at least 1 APP in their practice, and patients demonstrate a growing acceptance of APPs in urology. Currently, APPs are utilized more in metropolitan areas and academic centers (96.4%) than private practice (64.7%). Overall, 75.9% of urologists feel APPs help improve wait times for patients.

Incorporating APPs into practice can decrease wait times for patients but can also increase the patient volume seen by the practice, thus increasing surgical cases and revenue. APPs can bill independently utilizing their own provider ID, or bill as “incident to” services, which are billed at 100% of the physician fee schedule. In the latter scenario, the patient is seen by the APP and the physician.

Regarding Centers for Medicare & Medicaid Services reimbursement, the APP who bills independently will bill 85% of the physician fee schedule. However, this is not the case with third-party payers. Third-party payer reimbursement depends on contract negotiations with those payers. Example of reimbursement is provided in the Table. This shows the average collections for APP vs MD at University of Texas Southwestern Medical Center in Dallas from September 1, 2021, to September 1, 2022, for the listed Current Procedural Terminology (CPT) codes. On average, the APP billed 90% of the MD for a new level 4 visit. In the case of cystoscopy (CPT code 52000), this was 100%. One potential explanation for this surprising finding is that APPs may have performed cystoscopies on more patients with third-party insurance and higher negotiated reimbursement rates for this CPT code compared to their MD colleagues.

At University of Texas Southwestern Medical Center, urology APPs bill independently and do not routinely bill “incident to.” For the 2022 fiscal year, collections were $4 million for 8.95 full-time equivalents.

One of the most frequently asked questions is how to find and train an APP in urology. One opportunity would be to reach out to a nurse practitioner or physician assistant program in your area and serve as a preceptor. This would give you an opportunity to educate APPs in urology and look for potential job applicants. Another option is hiring a urology fellowship trained APP. This may be harder to come by as there are only approximately 7 APP urology fellowships nationwide (at time of publishing). However, these fellowships provide a tremendous amount of education in all aspects of clinical urology, including procedure and operating room training.

There are several urology associations targeted for urological APPs as well. These include AUA with their APP track, the Society of Urologic Nurses and Associates, and the Urological Association of Physician Assistants. These organizations provide membership and annual conferences to advance urological knowledge and skill. By encouraging the APPs to actively participate with these organizations and attend conferences, their urological knowledge and expertise will continue to expand. Typically, these conferences will have hands-on training, such as workshops in cystoscopy, posterior tibial nerve stimulation, percutaneous nerve evaluation, and ultrasound. Additionally, AUA University provides an APP Core Curriculum, an online community, webcasts, and podcasts which are great resources for education and networking.

In conclusion, leveraging APPs provides one means of tackling the growing workforce shortages in urology. Many urologists work with at least 1 APP and feel that APPs are an asset to their practice by shortening wait times and increasing patient volumes. Finding an APP who is interested and trained in urology can be a challenging task. However, having an APP on the clinical team can help expand our reach to the urological patient population. As with any clinical practitioner, it is important to support continued learning through training opportunities, conference attendance, and workshops. This will help not only train but increase APPs’ urological fund of knowledge to better serve our patients.