PRACTICE RESOURCES > Regulation/AUA Positions, Letters, and Talking Points > HCFA Regarding Supplemental Specialty Survey

HCFA Regarding Supplemental Specialty Survey

July 3, 2000

Ms. Nancy-Ann Min DeParle
Health Care Financing Administration
Department of Health and Human Services
Attn: HCFA-1111-IFC
P.O. Box 8013
Baltimore, MD 21244-8013

Re: HCFA-1111-IFC - Medicare Program; Criteria for Submitting Supplemental Practice Expense Survey Data.

Dear Ms. DeParle:

On behalf of the American Urological Association (AUA), representing 9,200 American urologists, I am pleased to submit comments on the criteria for submitting supplemental practice expense survey data. Although we are not submitting data for consideration by HCFA in developing practice expense relative value units for the 2001 physician fee schedule, we appreciate the opportunity to review and comment on the appropriateness of the criteria laid out in the rule.

We support HCFA's rejection of Lewin's recommendations that specialties must use the same contractor as the socioeconomic monitoring system (SMS) and that only the American Medical Association's (AMA) SMS project team can edit and analyze the data, as there are other trustworthy, capable survey contractors who have experience collecting and analyzing this type of data. However, we believe that some of HCFA's proposed criteria are still too stringent, especially if specialties wish to submit data they collected before these criteria were established. Some specialties may already have reliable, valid data that does not exactly meet the criteria outlined by HCFA, but nevertheless could be a valuable data source for developing practice expense values.

Therefore, we believe HCFA should consider adjusting some of its overly-prescriptive criteria in order to assure that existing worthwhile data can be accepted and utilized in this process. Otherwise, specialties may have to devote a lot of time, energy and money to develop and implement new surveys-even if they already have good data. This would delay the process even further, which could be especially unfair to specialties that currently have deficient or inaccurate practice expense data.

AUA Surveys

As an example, consider the AUA Survey of Practicing Urologists. Since 1992, the AUA has contracted with The Gallup Organization, Inc. (Gallup) to conduct annual telephone surveys of 500 practicing urologists. Although the AUA survey does not specifically meet all of the criteria laid out by HCFA, physician practice expense figures collected from this survey have always closely matched AMA SMS data, demonstrating the data's reliability. This survey does not use the SMS survey instrument, and does not collect practice expense data based on the six practice expense categories. However, the practice expense data is valid, and total practice expense could be allocated among the six practice expense categories using existing ratios.

We believe the methodology, survey instrument and stability of results of our survey, as outlined below, are sufficiently vigorous for the purposes of developing practice expense values, and hope that HCFA would accept this data should we need to use it in the future.

  1. Methodology

    Using a list of physicians provided by the American Medical Association, Gallup conducts telephone interviews of a random sample of 500 physicians who have completed urological residencies. Physicians are screened initially, such that any physician who has not completed a urological residency or who does not work in urological patient care for more than 20 hours per week is excluded. If the physicians were not in practice the year prior to the survey, they are also excluded from the sample. When a physician meeting the qualifications is not available during the first telephone contact, additional callbacks are made in order to complete the interview. This callback procedure ensures a high rate of interview completion.

  2. Survey Instrument Development

    Survey items for these studies are mutually agreed upon by Gallup and the American Urological Association. The American Urological Association identifies question areas and information desired, while Gallup writes items which are technically correct and without bias. Questions are asked the same way each year to assure consistency.

  3. Stability Of Results

    From 1992 to 1999, sample sizes have ranged from 500 to 537, with the maximum statistical error range at the 95% level of confidence ranging from ±4.2% to ±4.4%. For example, in 1998, the sample size was 537, which means that if 100 different samples of 537 physicians each were randomly chosen from a given physician population, 95 times out of 100, the total results obtained would vary no more than ±4.2 percentage points from the results that would be obtained if the entire physician population were surveyed. The table below shows the survey sample sizes and error range from 1992 to 1999.

    Table I. Sample Sizes and Error Ranges for AUA Survey of Practicing Urologists



















    Error range









    In addition, the AUA, under contract with Gallup, performed our first annual mail survey of urology practice managers earlier this year. From now on, we plan to conduct a physician telephone survey and a urology practice managers mail survey in alternate years, and would prefer to maintain our current formats in order to assure consistency of data collection. Due to the first-class reputation of our contractor, the established reliability and validity of our data and our excellent response rates, we believe HCFA should, if necessary, accept this survey data in the future for the purposes of developing practice expense relative values.


The AUA plans to work with the AMA as it refines its SMS. However, in light of possible changes to the AMA's SMS, we could have an occasion in the future to present data from our physician or practice manager survey. The absence of the SMS survey in its current form also underscores the advisability of relying upon specialty data sources to update practice expense values. Also, if no new SMS practice expense data is gathered, the current SMS data, as it ages, will become less and less representative of the true costs of running a medical practice.

Therefore, it is important that HCFA continue to update the medical community regarding the status of the SMS and potential solutions or alternate plans if HCFA does decide to discontinue using the SMS to develop practice expense values. This is important, as specialties may have to anticipate extra spending or survey projects if HCFA does stop using the SMS.

Thank you for considering our comments. If you have any questions, feel free to contact Robin Hudson, Manager of Regulatory Affairs, at 410-689-3762 or


Irwin N. Frank, MD, FACS
American Urological Association


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