Key takeaways from this episode

• The urology workforce shortage is arriving faster than the AUA projected, and APPs are the identified solution. Americans over 65 will grow 42% in the next 15 years, 25% of the population will be over 65 by 2030, and roughly half of practicing urologists will retire within five years; the AUA consensus statement on APPs (2015, one revision since) came out of that work.
• Blue Cross Blue Shield of Arkansas has barred APPs from administering Xiaflex (collagenase) for Peyronie's disease since July 2025, while still allowing APPs in orthopedics to inject it for Dupuytren's contracture. The policy targets urology APPs specifically, despite evidence that APPs administer Xiaflex as safely as physicians.
• A payer policy like this is legal because it is a contractual term, not a scope-of-practice ruling. The payer can acknowledge that APPs may perform a service under state law and still refuse to pay for it, so practices should expect other payers and states to try the same thing.
• Tennessee is the only state with a payer-parity law protecting APPs, and it covers only nurse practitioners and was passed 20 years ago. Ken's call-to-action handout asks practices to contact their state legislators to pass similar laws, protect the existing NP language, and add coverage for PAs.
• Neither the AUA nor the AACU appears to have an official position on payer restrictions of APP services yet. Both Ken and Mark committed to pushing the AUA, AACU and the Urological Association of Physician Assistants to unify a position and carry it to the state level.
• Cystoscopy and other procedures once treated as physician-only will have to be done by trained, competent APPs to keep the clinic moving while urologists spend more time in the OR. "Complex" versus "simple" procedures is now in the eye of the beholder.
• Only about 1,200 PAs (roughly 1% of all PAs) were clinically active in urology as of 2022, and NP and PA programs offer almost no urology training. Recruiting requires selling urology's clinical-surgical balance, and retention requires a standardized onboarding curriculum and keeping the APP in the role they were hired for; the top complaint Ken hears is "they have me doing something they never told me about."
• GUYnecology (learnguynecology.org) provides men's health training for APPs and is expanding into consumer education in early 2026. No medical, NP or PA accreditation standard requires men's health content, while women's health is mandatory.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 264, recorded October 2025, with Scott Painter and Mark Painter of PRS Network, and guest Ken Mitchell, PA-C.

Introducing Ken Mitchell and the AUA workforce consensus statement

[00:00] Scott Painter: On this episode: a discussion with Ken Mitchell, a PA with Poona MD in Nashville, Tennessee. Stay tuned. Welcome to episode 264 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter. On today's episode we want to welcome Ken Mitchell. Ken Mitchell is a nationally recognized expert in men's health and sexual dysfunction. With nearly 30 years of clinical experience, he has been a driving force in advancing the role of APPs in urology, co-authoring the AUA consensus statement on APPs, serving as past president of the Urological Association of Physician Assistants, and earning the 2023 AUA APP of the Year award. He is also the founder of GUYnecology, a nonprofit organization dedicated to men's health research, provider training and community education. Welcome, Ken. Thank you so much for joining us on the podcast today.

Ken Mitchell, PA-C: I appreciate you having me. Looking forward to the discussion.

Scott: All right, let's start off by talking about the urology workforce. I know you've been active in that. Tell us how you got started and what's going on with the workforce.

[02:00] Ken: It's interesting. As a member of the AUA, I was picked to be part of a group that was looking at this, primarily because at the time I was membership chair for the APPs. In all honesty, I didn't know that much about how the changes in the workforce were coming, what was happening, or how big of a problem it was going to be. I was enlightened to the fact that the AUA had already done some work on this to inform some committees, had investigated the problem at the time and had some projections. Over the years, as the AUA census was obtained, they discovered that the problem was not only fast approaching, but at a speed they hadn't accounted for. And the solutions, if you will: there was an opportunity, given the rate of the declining workforce, while the demand for urologic services was also growing at a rapid rate. The intersection and acceleration of the problem got to be great, and it was determined early on that APPs would probably play a great role in helping service the problem. But there was a lack of knowledge there. So I was part of that group, and we subsequently stayed on task to help enlighten not only the AUA but all urologists in practice, and certainly our APP colleagues.

Mark Painter: When did you first jump on that committee?

Ken: Goodness gracious. 2008 is when I first heard about the urology shortage, and I guess our paper came out in 2015, so 10 years ago.

Mark: And you've updated it, what, twice since then?

[03:00] Ken: There's only been one revision of the consensus statement, and then the AUA Update Series is separate. We did that, and it took a lot of work. It was co-authored by Suzanne Quallich, a nurse practitioner at the University of Michigan, our upcoming president Eugene Rhee, and Tim Brand. On that one we dug deep, because we felt there was really critical and emerging information showing us how intense the problem was becoming.

An aging population and a retiring workforce that do not add up

Mark: I've seen you as I hop around the country, and you've been there as well, giving the workforce discussion to everyone. What's the highlight today that you're providing everybody before they need to run for a cocktail?

[04:00] Ken: Primarily, the message I've been trying to convey is that two things are happening at once, and they are not good for urology. One is that Americans are living longer and getting older, and because of that the number of individuals over the age of 65 is going to grow by 42% in the next 15 years. Add the fact that in less than five years, the urologists in that same age group are going to retire and leave the workforce, and they'll account for about half of the urology workforce disappearing. If you do the math, even trying to be conservative about it, by 2030, 25% of Americans are going to be over the age of 65. You don't have to be a mathematician to figure out that doesn't add up. If you took every American and every urologist, that's basically one urologist for every 30-something thousand people, something crazy like that. There are a couple of different growth models they look at, neither of which is really manageable, let's put it that way. We know there are not going to be enough urologists to meet the demand. What's unique about urology is that if you live long enough, you probably have to see a urologist. You can't really say that about a lot of other surgical subspecialties. It's a fact of aging. You may not have chronic disease issues or urologic disease, but at some point you're going to require their services, and there are not enough urologists to meet that demand.

Blue Cross Blue Shield of Arkansas restricts Xiaflex to physicians

[06:00] Mark: And the APP growth has been tremendous in urology as you've gotten into this and really promoted APPs. I've seen you over the years give a lot of talks on how to integrate APPs into the practice and the appropriate utilization of that workforce, which has been impressive, and virtually all practices have APPs or are looking to add them. I also know that in addition to the general workflow discussions, when you and I bumped into each other, you're running up against what I have to call pushback from the payers, starting to restrict what APPs can do beyond their licensing. Can you tell us what's going on in your latest battle?

[07:00] Ken: I'd like to start with one thing you just brought up that's really important: what are the threats? Changing the culture of urology and getting people to utilize their APPs to the top of their license is one way it's talked about, but another way of saying that is maximizing efficiencies and improving access to care. That's really what it's all about, and what it's always been about in the APP professions, both PA and NP. We've always had incident-to billing and things like that to help close the gap if there was no separate negotiation for reimbursement of APP services.

But the latest battle is that Blue Cross Blue Shield of Arkansas did something I never thought I would see in my lifetime. They now have a specific payer restriction that APPs are not allowed to administer Xiaflex, collagenase, for the treatment of Peyronie's disease. That policy was instituted in July of this year. What was interesting was that I thought, okay, they're just going after APPs. But look through the policy further and there's no restriction on an APP in ortho giving the same injection to somebody who has Dupuytren's contracture in the hand. So they've gone after APPs in urology, plain and simple. The repercussions are quite simple: with a diminishing workforce, we cannot withstand payer restrictions on top of that, denying access to care to these patients. And what's interesting is that it supersedes even scope of practice. It's well established not only that APPs can administer Xiaflex successfully, but some reports say they do it with fewer side effects and issues than, or at least comparable to, physicians doing it. So there's no risk involved, if you will. I have to believe it's financial. It's the only reason I can think of for limiting administration of the medication to patients who suffer from Peyronie's disease.

Payer contracts, the Tennessee parity law and a call to action

[09:00] Mark: It's crazy. We've definitely seen over the years the playbook of insurance companies as they try to level out utilization versus premiums. Everybody's getting pushback on premium hikes this year, which are all over the board, and we've seen the two favorite easy tools of the insurance companies. One is prior auths and an increase in denials and chart reviews, administrative bumps to getting paid. The second is restricting their networks. If you can't find somebody to treat you, then that treatment isn't paid for because it's not provided.

[10:00] Ken: Right. Even from the practice side, I never thought I would see the forcing of a urology practice to make a business decision about utilizing their employees and their providers. The other thing that's interesting is that I was inspired to do some digging: can they do that legally? I like to jokingly say that every now and then in healthcare I'm reminded of what it felt like to find out there was no Santa Claus. Realizing that the policy is in fact just a contractual agreement between the practice, the providers and the patient, it doesn't necessarily have to be compliant with scope of practice laws. They can acknowledge that, yes, we know APPs can do this, but we're just not going to pay for it. You're in or you're out. I'm not going to use inflammatory rhetoric, which a lot of people like to do, but in any other circumstance that would not be legal. In this it's perfectly legal, because it's a contractual agreement. You either agree to the terms or you don't. That in and of itself is really concerning, because who's to say Arkansas is just the start of other places doing that.

What I was inspired to do was dig into whether any legal challenges have ever been brought on this. Interestingly enough, the state I reside in, Tennessee, is the only one that has legislation on the books that denies payer discrimination against an APP, basically payer parity. That's only for nurse practitioners in the state of Tennessee. That was interesting, and the second part that was really interesting to me was that it is the only state in the country that has something like that.

Mark: Wow.

Ken: And the third level of what was surprising to me was that that legislation was passed 20 years ago.

Scott: That is interesting.

Ken: So why would 49 other states, or our professional organizations, physician or APP, why have none of us ever really thought about that or looked at that? I'm still trying to find out more history about how that even came about in Tennessee, because I think it bears investigating. I try to write more and more as the years go by, and as I find out more I'll certainly try to get it published and talk about it more.

Mark: That'd be great. They always say healthcare is federal, but in the end it is local. Yes, we have to battle the federal rules and the influence of Medicare and Medicaid across the board, but all of the laws for licensure and for insurance companies and commercial payers are state-specific. So I'm going to ask the next obvious question. Now that we're facing some of these things, and contractually we know they can do it, what can practices do? What can APPs and physicians do as a group?

[13:00] Ken: As you mentioned, I go out and give as many talks as I can about the workforce, utilizing your APPs, leveraging training, et cetera. What I started doing as an advocacy strategy was to develop a call-to-action handout to tell your practice: this is happening somewhere else. Don't be naive and think you're not next; it could happen to you as well. It challenges them to talk to their local legislators about developing a law similar to what we have in Tennessee for nurse practitioners. I'm going to advocate for NPs, obviously, to continue that and make sure that legislation is never threatened or repealed, and then add language to cover PAs as well. I put a little QR code on the handout. It says contact your local legislators, talk to your practice if they aren't aware of it, and start building your coalition to fight this. Because, like I said, we can't have that in addition to the fact that we just don't have enough bodies to meet the demand. We can't have any other threats to access to care.

[14:00] Mark: Do the AUA or the AACU have official position papers, or is that something they're exploring?

Ken: I don't know. I honestly have not seen anything like that. I would like to think that if there were, I would know, but that's not necessarily true. Going to meetings, I've never really heard anybody talk about it. And in all fairness and transparency, I tell people don't be naive, but I certainly was naive, because I didn't think I would see this happen. So I'm certainly inspired now to say that if such things do not exist, I'm going to work real hard to champion them so they become reality.

Using APPs to the top of their license, cystoscopy included

[15:00] Mark: That's something I'll explore too, because I haven't heard of that. And certainly, as noted in your intro, that part of the workforce in urology is essential. For a long time we battled scope of practice issues and, I think, physician fear that APPs were going to run them out of business, which was of course older thinking. Now, to keep a urology practice up and running and keep your ability to service your patient population, we've been preaching for years that you need that second-level workforce to make both the financial and the clinical goals of the practice work. You would think that somewhere among all the connections and friends we have, we might be able to start something if it's not there.

[16:00] Ken: Sure, absolutely. You bring up another really good point, even in my discussion and my language around what that utilization looks like. When you've got a workforce that's diminishing by such a large amount, that's going to shift where the urologist has to be. The demands of the operating room are going to go up significantly. I often use the phrase: you need to make sure things don't grind to a halt in the clinic because you can't be in the clinic. Things have to keep moving. So what used to be considered a threat, like the hot button for years, cystoscopy: "Oh my gosh, if you put a cystoscopy in the hands of an APP, you're taking away my business." At the end of the day, there are too many people who need a cystoscopy. Cystoscopies have to happen; they're part of how we evaluate a number of different urologic conditions. So you have to say it's a fact, it has to happen, we need to train up to it, make sure our APPs are competent and able to do it, and get it done. There are other, more advanced procedures that are likely going to be forced to be done by APPs in order to continue to have reasonable access to care. In my last talk on this I said complex procedures and simple procedures are now going to be in the eye of the beholder.

Recruiting, training and retaining urology PAs

Scott: How many APPs are there in urology right now, roughly?

[17:00] Ken: Oh, goodness. I have just the PA data, so my apologies, but there are approximately 1,200 PAs clinically active in urology as of 2022. The problem with that number, to be honest with you, is that I don't think any of us get really good, accurate census data on this. You're talking about a large number of PAs, or even NPs, who may or may not be members of the AUA. My larger organization, the AAPA, does not necessarily have good numbers either. Needless to say, if that's true, then about 1% of all practicing PAs in the US are in urology.

Scott: So if a urology practice is looking for a PA, how would you recommend they go about finding one, and what's the best course right now?

[18:00] Ken: It's interesting. If I were to reshape that question a little bit: one, the pool of PAs and NPs is not very big. We just recently presented a poster at SMSNA, the Sexual Medicine Society of North America, and what we showed there was that, at least in NP programs, and we're currently looking at PA programs, there's very little training offered in urology at all. So even if you get one, it may be the first time they're even thinking about urology. That's problem one. Problem two, in terms of finding a urology PA, it's like trying to sell anything: here we've got great work, a beautiful balance of clinical and surgical. It's just like recruiting any provider, MD, PA, NP; it's very similar. It's just that there is a very steep learning curve that has to be overcome when you bring in a PA or an NP, because of the lack of training at the most basic level. That's one of the other things I preach all the time: the importance of having standardized training that you adhere to as part of onboarding your APPs when you bring them in. Some practices do it great; some, not so much.

I'm bragging on the practice I started in, in Minnesota. I can't say enough about how far ahead and progressive they were in thinking about having the APPs do more. Going back to the growth: when I joined that practice there were seven of us, that grew to nine, and now there are about 35 APPs who work in that practice. They're almost one-to-one there, which in reality, in that practice, is what works. There's no one-size-fits-all answer, but the fact that they've taken the time and thoughtful consideration to plan and strategize utilizing their APPs, train them up, and have them meet the needs of the practice is great. They get them, they retain them, they get them feeling valued. That's an easy recruiting message at that point.

Some of the pitfalls that come with that, and I talk about this as well, is that sometimes the practice just gets overwhelmed with volume. And again, you're hiring a medical professional who may not have a lot of training in that discipline. They're really good, they've got capacity to learn, but if you don't have a really good onboarding strategy within your practice, that person's not likely to stick around. They don't feel competent to do their job, or they might feel overwhelmed and asked to do too much too soon. Nobody's fault; it's the nature of the beast. But it's something that has to be taken into consideration moving forward. You have to sell urology, and then make sure that once you get somebody, you really put in the time and energy to make sure they feel confident in what they do, and keep them in the position you hired them for. I would say the number one email or phone call I get is, "I got hired to do this job in this urology practice, but now they've got me doing this, and they never told me I was going to have to do that. I want to quit." And I'm like, "No, don't quit. Hang in there. It's going to be okay." I'm saying one thing, but then I'm saying, "Look, we need you. Don't go anywhere. We'll make it better. We'll figure it out."

GUYnecology and community education in men's health

Scott: That's good advice. One thing I wanted to ask before we wrap up: tell us about your nonprofit, GUYnecology.

[22:00] Ken: You catch me at an interesting time. We started GUYnecology for all the reasons we just talked about. In urology there's a significant knowledge gap, but there's an even greater one in men's health. Almost all medical programs, nurse practitioner, PA and medical school, have as part of their accreditation a mandatory women's health requirement to keep their accreditation. Not one has men's health. It's not required. So we started GUYnecology primarily to help my colleagues, many of whom I've had the opportunity, honor and privilege to train over the years, and then others who were interested in the men's health space and might have gotten what I would consider inadequate training, and give them the opportunity to get some really good training. I have lots of people who mentored and trained me, so they partnered with me and provided the lectures, and we developed our own little network of APPs. That was part one.

Part two was an unintentional consequence. We have our logo and our t-shirts, and they say GUYnecology. I didn't realize people would find that catchy. That really wasn't the point; the t-shirts were made for the people who attended our meeting. But my wife and I in particular will be walking around with our t-shirts on when we travel, and invariably we'll be stopped by a number of people: "Hey, what's that all about?" We have a great conversation with somebody who may not have ever thought about their health, or we talk to a woman who's got a brother, a son, a husband who's not taking good care of their health. Sometimes we exchange information, and what we found is that the word is catchy enough to make people think about their health. We've gotten countless people who have gotten back to us and said, "I'm really glad I bumped into you guys. I went and got this checked out, I found this out, and now I'm taking care of it and I'm in a better place." Again, we didn't plan on that. So this year is actually the first year we did a man-on-the-street thing, and it's the first year we're actively making a plan to do more robust community and consumer education about men's health.

Scott: That's fantastic. Mark, any final questions from you?

Mark: First of all, we should probably tell everybody who can't see it that GUYnecology is spelled G-U-Y and then N-E-C-O-L-O-G-Y, which is why it starts conversations.

Scott: Very important, yes.

Mark: It isn't Ken out there running around with a GYN.

[24:00] Ken: Thank you for pointing that out. That is correct. That's generally what gets their attention, and then we have a very catchy little logo as well. I should give credit where credit is due, because I'd be remiss if I didn't. The whole reason it's called what it's called is my wife. We were dating at the time, and she asked me, "So exactly what is it that you do for a living?" I was telling her I've been doing this for a little over 30 years in practice, and she said, "Oh, GUYnecology." I looked at her: how did I not think of that? That is genius.

Scott: That is very clever. How can somebody get in touch with you or get involved in the GUYnecology movement?

[25:00] Ken: Right now our only website is learnguynecology.org, a big long word. But stay tuned. We're going to branch that out into something the consumer can look at. We have some really fun stuff. We like to laugh a lot, so we try to put some real humor around a lot of what we do, but also make sure it's really meaningful. We've got a whole host of things we're going to tap into, and we're smart enough to say that we're old people, so we're going to get some young minds in there to help us deploy it in a digestible manner and make it fun. We're working on that, and if things go as planned, in early 2026 you'll start seeing more of that come out.

Final thoughts, sponsors and the seminars

Scott: All right. We'll keep you posted when we hear some of that; we'll let everybody know. Let's wind this episode up here and go around and get some final thoughts. We'll get final thoughts from you first, Ken, then Mark's final thoughts, and then wind it up. Final thoughts?

Ken: First of all, thanks for having me. I hope those who hear this understand that we have a real workforce issue coming up. I strongly feel and believe, and always have, that APPs can be a solution to the problem. It's going to be rough for a while, but understand that we're here to help people, and we can do our best to do that. Also just be aware that there are a number of threats out there trying to stop that from happening. So be vigilant, keep your eyes and ears open, and communicate and connect with your colleagues. Together, I think we can fight those things off.

Scott: Very good. Mark, final thoughts?

[26:00] Mark: Bottom line, we've had several conversations on our podcast with different folks about the fact that we need people to be active. Unfortunately, when you're in healthcare, whether you're an APP or a physician, it's not just about treating your patients day to day. You've got to look at the future and where you can find allies to potentially block some of these roadblocks that are out there. Right now that includes political solutions, contractual solutions and solutions from our organizations: the AUA, the AACU, the Urological Association of Physician Assistants. All of those organizations need to help unify the voices of urology and help us move those messages down to the state level, where we can take active and actionable steps to protect the practice of urology so we can continue to provide clinical services at a financially viable level. It's unfortunately the game we're in. So find somebody in your practice, find somebody you know, and have these discussions. Don't be afraid to talk to your neighbors, your patients, your congresspeople. In the end, politics, even though it is done with money, still has a personal component. Have those conversations and get active. And yes, the money part's a big one, and that's where organizations like the AUA and the AACU can consolidate money and make it a bigger step. So play both. I think it's a requirement these days if we're going to keep this healthcare business a viable business.

[28:00] Scott: So true. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. We also want to let you know that our Urology Advanced Coding and Reimbursement Seminars are happening in Las Vegas in early December and New Orleans at the end of January. There's a lot changing in urology: a lot of new codes, a lot of new rules and regs, and the payers are doing a lot of new things. So we'd like to see you down there. Come join the conversation. You can go to prsnetwork.com, and right there on the homepage you can click seminar registration to get the information for the seminars. Thank you so much, Ken, for joining us. We really appreciate having you. It's been a great conversation, and we wish you the best of luck with GUYnecology and the rest of this. And thank you all for listening. Take us out, Mark.

Mark: Happy coding.

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