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MEDICAL STUDENT COLUMN The Value of Business Education in Urology

By: Avani Desai, BS, University of North Carolina School of Medicine, Chapel Hill; Angela Smith, MD, MS, University of North Carolina School of Medicine, Chapel Hill | Posted on: 18 Mar 2024

The American health care system is notoriously fragmented and complex. National health expenditures grew to $4.3 trillion in 2021, accounting for 18.3% of gross domestic product and highlighting the system’s continued struggle with rising costs.1 Evolving regulations, innovation in medicine and surgery, expanding patient demands for services, and declining reimbursement rates further muddy the landscape.2-4 At the same time, the current shift towards value-based care compels physicians to embrace new care paradigms.5,6 It will be critical for physicians to adapt to these increased demands to reduce costs, improve the quality of care, and drive toward greater value. In order to adeptly navigate and thrive in this evolving landscape, physicians, trainees, and medical students need an understanding of the fundamentals of health care business.

Medical education has struggled with determining how and when to educate students about business. Unless medical students pursue additional degrees, we are often insulated from learning about medical economics in a meaningful and practical way.7-9 Instead, we tend to learn these fundamental concepts about costs, billing, and value on the fly during residency and practice, while already delivering patient care and facing other extensive responsibilities. This results in learning that may be suboptimal in breadth and accuracy compared to comprehensive, organized education. The absence of business training in medical school presents a missed opportunity for students to develop an early foundation in these concepts, which are critical to effective patient-provider communication and advocacy. This training also would equip us to maneuver the intersection of health care and business more effectively in our careers.

Understanding business is particularly valuable for trainees interested in urology (Figure). Urology encompasses a broad spectrum of open, minimally invasive, and endoscopic surgeries, as well as an array of medical care. This wide scope of practice renders urology particularly sensitive to changes in policy and reimbursement. Further, unlike specialties focused solely on medicine or surgery, urologists have more treatment options to offer patients. Consequently, urologists more frequently guide patients through comparisons of treatment choices. For example, patients treated with longer courses of radiotherapy rather than prostatectomy may face higher out-of-pocket burdens because they are billed for more appointments.10 Even within the same treatment, costs can significantly vary. Out-of-pocket costs for the prostate cancer treatment abiraterone can range from approximately $1300 to over $13,000, depending on insurance plan and pharmacy.11 Plus, as patient-centered tools that offer avenues for cost savings gain traction, such as the Mark Cuban Cost Plus Drug Company and GoodRx, a pressing need emerges for urologists to understand costs and options.11,12 Urologists equipped with this understanding and comfort in discussing expenses can better empower patients to navigate complex treatment decisions and better explore solutions that reduce costs without compromising care. This is especially valuable in urology, where many patients face financial toxicity.13-15


Figure. Examples of applications of business education in urology.

Having a foundation in business principles is also beneficial for medical students interested in urology, given that the field of urology is consistently a pioneer in embracing cutting-edge technologies. For example, the Food and Drug Administration approved the da Vinci–assisted prostate surgery in 2001. Since then, robotic prostatectomy has become the most commonly performed robotic oncologic procedure in the US, highlighting urology’s embrace and utilization of technological advancements.16 However, acquiring and using such innovations can be expensive. For example, a study found that the average cost per robotic prostatectomy across 197 hospitals was $11,878.17 Integrating these innovations into practice requires consideration of financial feasibility, implications for reimbursement, and navigating regulatory challenges. Plus, business knowledge can enable urologists to explore ways to make these innovations more accessible to patients.

The landscape of urologic practice is also changing, as the movement towards value-based care penetrates the field. Studies have found promising early results in applying value-based care to urology.18 Urology groups are starting to explore bundled payments, a type of alternative payment model.19 Additionally, explorations of Medicare’s merit-based incentive payment system have started to impact practice patterns among certain populations of urologists.20 Ultimately, changes driven by increasing interest in value-based care and by the Centers for Medicare & Medicaid Services will be particularly salient in urology, given that the Medicare population uses urological services 3 times more often than the general population.21 As such, it is valuable for aspiring urologists to comprehend these shifts as trends evolve. Understanding the why and how behind these changes will equip future professionals to navigate organizational shifts and changing priorities, drive change, and even understand our own earning potentials.

Simultaneously, the urology landscape is facing a rise in consolidation of practices, particularly by private equity acquisitions. The impact of this trend on the accessibility and delivery of urologic care is not yet well understood.22 As the landscape further develops, a grasp of business fundamentals will allow physicians to better understand potential impacts on clinical decision making, resource utilization, health care expenditures, and ultimately patient outcomes.

The AUA recognizes business education as being of significant value to urology professionals at all levels of their career.23 Until business education is more formally integrated into the curriculum, the medical student community, especially those interested in urology, would significantly benefit from proactive engagement with the business of health care. To start, students could explore the basics of insurance, current and expected trends in reimbursement, financial toxicity, and innovation in medical technology. Students do not need to become experts by any means; however, by building a foundation in these principles at an early career stage, we can equip ourselves to better adapt to intricacies of the health care system, maximize quality and reduce cost in eventual clinical practice, and enact change on both individual patient and system-wide levels.

If you want to learn more, check out the following organizations:

  1. NHE fact sheet. Centers for Medicare & Medicaid Services. 2023. Accessed November 15, 2023.
  2. Coffron M, Zlatos C. Medicare physician payment on the decline: it’s not your imagination. Bull Am Col Surg. Published online September 1, 2019. Accessed November 15, 2023.
  3. Medicare physician payments need overhaul STAT. American Medical Association. September 11, 2023. Accessed November 15, 2023.
  4. Landi H. Physician groups decry finalized Medicare payment cuts for 2024 as expenses rise. Fierce Healthcare. November 2, 2023. Accessed November 15, 2023.
  5. Kahn CN III, Rhodes K, Pal S, et al. CMS hospital value-based programs: refinements are needed to reduce health disparities and improve outcomes. Health Aff (Millwood). 2023;42(7):928-936.
  6. Abou-Atme Z, Alterman R, Khanna G, Levine E. Investing in the new era of value-based care. McKinsey & Company. December 16, 2022. Accessed November 15, 2023.
  7. Niccum BA, Sarker A, Wolf SJ, Trowbridge MJ. Innovation and entrepreneurship programs in US medical education: a landscape review and thematic analysis. Med Educ Online. 2017;22(1):1360722.
  8. Patel MS, Lypson ML, Davis MM. Medical student perceptions of education in health care systems. Acad Med. 2009;84(9):1301-1306.
  9. Pierce B, Roopnarinesingh U, Whiteman AS. The new normal: business education for medical students and practicing physicians. J Med Prac Manag. Published online December 8, 2021. Accessed November 15, 2023.
  10. Imber BS, Varghese M, Ehdaie B, Gorovets D. Financial toxicity associated with treatment of localized prostate cancer. Nat Rev Urol. 2020;17(1):28-40.
  11. Pockros B, Shabet C, Stensland K, Herrel L. Out-of-pocket costs for prostate cancer medications substantially vary by Medicare Part D plan: an online tool presents an opportunity to mitigate financial toxicity. Urol Pract. 2023;10(5):467-475.
  12. Cortese BD, Dusetzina SB, Luckenbaugh AN, et al. Projected savings for generic oncology drugs purchased via Mark Cuban cost plus drug company versus in Medicare. J Clin Oncol. 2023;41(29):4664-4668.
  13. Glazyrine V, Au D, Starkey J, Thompson J, Parker W. Evaluating financial toxicity in urologic practice. Urology. 2023;179:16-22.
  14. Green BW, Labagnara K, Feiertag N, et al. Financial toxicity of nephrolithiasis: the first assessment of the economic stresses of kidney stone treatment. Urology. 2022;170:46-52.
  15. Bhanvadia SK, Psutka SP, Burg ML, et al. Financial toxicity among patients with prostate, bladder, and kidney cancer: a systematic review and call to action. Eur Urol Oncol. 2021;4(3):396-404.
  16. Shah AA, Bandari J, Pelzman D, Davies BJ, Jacobs BL. Diffusion and adoption of the surgical robot in urology. Transl Androl Urol. 2021;10(5):2151-2157.
  17. Cole AP, Leow JJ, Chang SL, et al. Surgeon and hospital level variation in the costs of robot-assisted radical prostatectomy. J Urol. 2016;196(4):1090-1095.
  18. Reitblat C, Bain PA, Porter ME, et al. Value-based healthcare in urology: a collaborative review. Eur Urol. 2021;79(5):571-585.
  19. Stimson CJ. The role of bundled payments in urology. AUANews. 2022;27(1):28.
  20. Alam R, Clifton MM, Han M. Urologist scores in the era of the merit-based incentive payment system (MIPS). Urol Pract. 2022;9(2):119-125.
  21. Nam CS, Daignault-Newton S, Kraft KH, Herrel LA. Projected US urology workforce per capita, 2020-2060. JAMA Netw Open. 2021;4(11):e2133864.
  22. Nie J, Demkowicz PC, Hsiang W, et al. Urology practice acquisitions by private equity firms from 2011-2021. Urol Pract. 2022;9(1):17-24.
  23. Business education. American Urological Association. 2023. Accessed November 15, 2023.