Key takeaways from this episode

• Advocacy changes policy faster than research does. Dr. Bretan's experience is that a published paper can take five to 20 years to change anything, while educating a legislator on a life-and-death patient issue can produce change almost immediately.
• State-level advocacy cannot be ignored because states regulate commercial insurance, prior authorization and Medicaid. Medicare is foundational, but much of what affects a practice's day-to-day billing is decided in state legislatures, which is where the AACU and state medical associations do their work.
• Good and bad legislation both start locally, so monitor it and use local wins to build national ones. Dr. Bretan's Santa Cruz County soda tax campaign won with about $2,000 against $2 million from the beverage industry, and a local success gives you a track record to bring to Congress.
• If you practice in a small or rural area, the AACU will organize and amplify your voice. Share the obstacles you face taking care of patients, and the AACU will carry them to legislators and partner with the AMA and state medical associations, so you do not have to reinvent the wheel.
• Membership matters more than PAC money, and the AACU is broadening who can join. A membership count of 5,000 or 10,000 is what Congress pays attention to; the organization is renaming itself the American Association of Clinical Urology and opening membership to organizations, whole practices and ancillary staff such as medical assistants.
• Stay non-partisan and never be a one-issue doctor. Work both sides of the aisle, come at each obstacle from several directions, and join at every level (state societies, AUA sections, AUA, AACU and LUGPA) with time or money, because hoping things improve without action does not work.
• Low-cost prostate cancer screening is coming through an AACU partnership with ZERO and Tunnel to Towers. The program launches first in Baltimore and Atlanta and is intended to extend through the AACU network of urologists, with an emphasis on rural areas.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 250, recorded July 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network, and guest Dr. Peter Bretan, president of the American Association of Clinical Urologists (AACU).

Introducing Dr. Peter Bretan

[00:00] Scott Painter: On this episode, Dr. Peter Bretan joins us to discuss advocacy, policy and the future of urology, from his experience as a practicing urologist to leading the AACU. Welcome to episode 250 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter, and we want to welcome our special guest, Dr. Peter Bretan. Dr. Bretan is president of the AACU, the American Association of Clinical Urologists. He's the past president of the California Medical Association and a practicing urologist in Watsonville, California. He specializes in renal surgery, transplantation and female incontinence, and is also affiliated with Chicago Medical School, where he teaches and conducts research. Welcome, Dr. Bretan, and thank you for joining us.

Dr. Peter Bretan: Thank you, Scott. It's truly an honor and a pleasure to speak with you. As we were talking earlier, I've had an affiliation with you, your business and your family for many years, and I'm proud to have progressed to this closeness and cooperation for our specialty and all urologists throughout the country.

Scott: Thank you. We really appreciate you joining us. To start things off, can you tell our listeners a bit about your background and how you became involved in the AACU?

From academic transplant surgeon to advocate

Peter: I started out in academics, like many of the people in the AUA, as an academic transplant surgeon. First at the Cleveland Clinic. I was actually an AUA scholar, the first AUA scholar there, doing research, working with Andy Novick. Then I came to UCLA, and then I came full circle back to UCSF and did 20 years of academic urology, and published many papers in that area. Then around 1998 to 2000 I made a transition to private practice. I had a huge NIH grant and three research fellows, and that left a void. Private practice is much different than full-time academia. You have a mission as a researcher, as a scientist, but that changes.

When I got more involved, I became president of my county medical society and learned about advocacy. What I learned is that you can publish a paper for research, and it often takes five, 10, maybe 20 years, and maybe never, to effect the change. But I found out that if you go talk to congressmen and educate them about issues and patient relationships and life and death right here, right now, you can see changes, sometimes immediately. That changed my whole outlook. I became much more involved in local politics as well as California Medical Association politics, and rose there. You go from teaching medical students and arguing with other professors and progressing your academic career to doing something that is often foreign to many urologists and many physicians, and that is the political process in which we govern ourselves in the United States. Not just how we govern ourselves; it is how we interface with our legislators and teach them about medicine, for the California Medical Association, and now, in the last 20 years, educating on what is necessary for men's health and urology, things like prostate cancer. Often you have to struggle to keep funding for that year, and that's what you do. I think what you guys do with CPT coding and educating all our clinical urologists on what to do in that space, I do in advocacy, representing national organizations such as urology at the AMA, at the AUA and at the American Association of Clinical Urologists, representing our whole profession with the legislature.

And I tell them I'm still a practicing urologist. I have come full circle from being a full-time renal transplant surgeon, and I take care of farm laborers now: prostate cancer, bladder cancer, diabetes. We all know that diabetes is the number one cause of kidney failure, so I've been dealing with that for years with transplants. The AMA is a different animal. It's the whole country, but it parallels Congress: going through that process, looking at what a bill is and how funds are allocated, and how we fight for funding for prostate cancer research. The AUA gets it. They have seen what's needed for research. Research is important, just what I was doing in full-time academics, but you need the money to help us screen for prostate cancer. I'll talk about that later. But it's the tools that keep us able to take care of our patients on a daily basis.

As a transplant surgeon, it's a life-or-death situation on a daily basis. But you don't realize that in urology, and in a lot of the highly specialized surgical specialties, it is also life and death, much more at the chronic level. People don't understand that until they have to see us. There's a great shortage, and I'll talk about that later; it's actually exacerbated in the rural areas. But that's what I do. I help fight to give the tools, like you do, to our fellow urologists so they can be in the trenches and take care of our patients.

The doctor-patient relationship and why politics are local

Peter: It was refreshing, because I had gone back to my medical-student understanding of the whole reason I went into medicine: that the doctor-patient relationship is the most precious part of our practice. It is the most rewarding. It's something we're all willing to fight for. And that is easy. That's easy when you're teaching medical students. It's even easy when you're teaching legislators. They get it. They get it when you speak with that type of passion to them and say, this is my patient. You could be my patient, your parents could be my patient, I can be a patient, but this is what we need to do as a democracy in the United States of America, and you need to understand that this is what's happening in the trenches. The other part is relationships. What I have with your whole family, and the associations, from the Western Section all the way through academia, it's all about relationships. You know what they say: all politics are local. They start off at a local level, and they are built on relationships. That's what I do at AACU, and it is much more hands-on, grassroots than the scientific process.

Scott: Mark, Ray, comments, questions?

Mark Painter: I'll just add in. As I travel around and give talks for various groups, and look at different states and the AUA sections, there is a lot of camaraderie among the individuals out there, but the actual feet on the ground are the discussions they have at the state level, because state health insurance is important. There's a lot that happens at the state level. I know that in a lot of our podcasts we focus on Medicare, because Medicare's a big player. It's definitely foundational in everything we do. But boy, when you look at the state level and what they regulate as far as commercial insurance, and what they do with prior authorizations, those types of things, as well as what they do with Medicaid, it's something that cannot be ignored. Peter, I've always been impressed at how you've played the local and state politics. You've been involved with an organization in the Western Section, as well as the CMA, that has really got its finger on the pulse. The West Coast, Washington, has a really active and important lobbying group, and it's really graduated a number of folks into the AACU who have taken what they've learned and pushed it up to the national level. That's an essential function, because, as you said, politics are local. That's where they start. But you can't ignore the national, and it's all got to work together. So I really appreciate all of what you've done, and all the extra time you put in above your patient care to do that. I know the AACU has been finding its place a little bit recently, let's just say, and I'm really excited to see you grabbing the wheel and seeing what you're going to do next with the AACU. That's one of the things we wanted to talk to you about: where the AACU is going right now, and what urologists can do to help on that state advocacy level.

Everything starts at the local level: the soda tax example

[11:00] Peter: That is the foundation of our whole talk today. Let me talk about the state and local issues. Everything starts at the local level. Whether you see it on the national level, it started somewhere, and sometimes it has a better chance of starting on a smaller level, the smallest state possible, Iowa or Idaho or whatever, because they could pass it.

Let me give you an example, which is relevant to medicine in general, because we all know that obesity and diabetes are among the worst comorbidities for our specialty as surgeons. Berkeley, where my daughter lives, and where I graduated from UC Berkeley many years ago, had the first soda tax. They're just so progressive. But I was able to campaign for Santa Cruz County, and all we needed was a majority of 1,500 votes, and we would be the second in the country, next to Berkeley, with a soda tax. Big soda put out $2 million. We put out $2,000, and we beat them. That is an example. When I talked in front of everybody, I said, this is life and death. I'm a transplant surgeon. The number one cause of death in my patients is comorbidities from diabetes, and I can't save them all, and you need to stop selling these sugar drinks. Did you know that one 12-ounce can of Coke or Pepsi has 17 teaspoons of sugar in it? You would never take two teaspoons of sugar; you would just be saturated, let alone forcing it down your gut with a can of liquid. You don't even know it's there. So you just gulp it down and you become diabetic, and it's the number one cause. It has to stop. Two-thirds of my patients have diabetes and they're obese. It's a problem. So that is an example.

The other example is that both good and bad legislation start at the local level, and we have to monitor bad legislation. It could be toxic, and we could be trying to fight something that has good intentions, like presumed consent for transplantation. That never worked. You can't force people to donate their organs. There'll be a revolt. It's never worked that way. It's always been through altruism. You know these things because, as a physician, as a surgeon, you get to share within a family some really personal milestones in patients' lives, and a lot of those are life or death. You get to know how people think. We're a free country, a democratic country, but you have to be sensitive to the patient's needs. Then you have to go back around to Congress, or at the local level, and help legislate bills. Once bills get going at the local level, then you can say to a congressman, I've got experience with this, and they can implement it and see the success. Then you can take it to the national level, and then you can share that with your societies.

AACU has your back: organizing rural urologists and working both sides of the aisle

Peter: Now, what local urologists need to know is that if you are in a small area, and you have pockets of that in Colorado, and even in California, which you mentioned, the California Medical Association is second to the AMA as one of the largest associations in the whole country. It made me a better physician, taking care of the house of medicine straight across the board, two-thirds being primary care and the rest surgeons. It's easy for me to talk to urologists. So when I'm talking today for urologists: if you're in a small area, underrepresented, the American Association of Clinical Urologists has your back. We will organize you, we will let your voice be known, and I'll amplify the heck out of it, because together we're stronger. There is no need for you to be taking care of patients in a local area and have the basics of your practice be unknown. Share it with us. We will share it with the legislators, and we'll have your back. And we need your membership.

AACU wants to go around the country representing you at the rural level and organizing pockets, so that if you're not being represented at the AUA or Western Section or section meetings, we will represent you at the AACU. Then we'll come back around full circle, and we partner with the AMA and the state medical associations. If you see something that is not given to you to help you take care of your patients, or it's not funding a particular disease process, prostate cancer screening in your area, let us know. You aren't alone. There are probably 200 people doing the same thing you're doing throughout the whole United States. You don't have to reinvent the wheel for every clinical problem or obstacle you're having in taking care of your patients. That is what we're about. We know it at the local level, and I'm looking for those types of leaders. There are a lot of young urologists that have that experience, and they come from multiple different places. They come from private practice, or from Kaiser Permanente, young in that organization. But they have the same passion I had at their age, and they get excited when we can fix something, or help KP fix something as an institution. That's what we're all about.

And we have experience. I discussed with you Willie Underwood, a urologist who is now the president-elect of the AMA. We all have been working together for the past 20 years. I can't believe it: 20 years, that fast. Ray, you should have told me that 20 years was just going to go like that. I would never have predicted that life is so short. But those are the relationships. Before you know it, you've known your congressman 20 years now. So I can't give up all these relationships. I have to keep on fostering them, and I have to show the younger people how to continue to do this, because that's just the way our country works.

Now, one final thing. They just passed HR 1, that big, beautiful bill, and I've been studying it. We have to know how to work, as urologists, as physicians, on both sides of the aisle. We should be really non-partisan. We should just be the doctor-patient relationship foundation. We're all physicians, we're all altruistic. We all came through medical school to help take care of our patients. We work with organizations such as yours to accomplish that. We have to always stay cognizant that that is who we are, and it's not a partisan issue. So you should look at all things. There's good in everything that I see, and you have to be able to work. I think Willie Underwood and I know how to do that. When you're coming up, yeah, there are little things that tick you off, but you cannot be a one-issue doctor, and thus you can't be a one-issue person in politics trying to change the funding. You have to be able to come at every different thing and every different obstacle from five different ways. That's what the AUA is doing right now at a much more national level, and the AACU is doing at a smaller level. But nationally, we're herding all the small cattle herds that are running around the West and the countryside, and we're making them one big herd. That's what we do. Ray, your comments, thoughts?

Ray's reflections, and a word from our sponsor

Dr. Ray Painter: I had the privilege of working with Peter at the AUA, AMA and AACU for probably the first 10 or so years he's talking about, and he brought the passion you're hearing now to everything he did back then. He kept us older folks on our toes and kept us moving. Peter, I want to echo what Mark said. It's good to see you in this position at this time, and we're so lucky in urology to have someone like Peter heading up the AACU and working hard to re-energize and refocus what they started out doing. They were the first to really set up and work with states at a state level on legislative issues and keep track of what was going on at the state level. But I also remember the fun times at the annual meeting, where we all go up and enjoy the fellowship. Part of that is going to the legislature, meeting with the congressmen and bringing that local message to the national level. Peter, I'm anxious to see how this goes, and whatever we can do to help, we're happy to do. I might add, as another little comment on how lucky we are in urology: Willie is the right guy at the right time at the AMA, and it's really exciting to see him. He is a very practical voice, and he looks at things from the bottom up. He'll do a good job as our spokesman at the AMA as well.

Scott: All right, let's wrap this episode up here. We want to once again thank Peter for joining us on this episode. We also 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. Let's get some final thoughts. Mark, final thoughts?

Final thoughts: urology's voice at every level of government

[23:00] Mark: Yeah. We've had a few discussions recently about advocacy on our podcast, and certainly we believe in advocacy, and we've seen its effects across the board. We've got a few organizations out there that help support urology at the state level. You've got your state organizations, you've got your sectional levels, you've got the AUA, and you've got the AACU and LUGPA. We really need all of them working in coordination, working at all levels. That urology voice needs to be at the table at every level of government. I recently was listening to a podcast about the fact that we often separate economics and politics, and we really shouldn't. The government has a big footprint, whether you like it or not. It affects everything we do, and it is huge in its presence within healthcare. We are going to need all the advocacy we can get in the next few years to continue to support small and large practices around the country. We've got no shortage of patients; we've got no shortage of problems to address. What we really need is the support to allow urologists to function, to provide care, and that includes making sure their financial health is available as well. That's really where the focus needs to be. So I encourage you all to contribute how you can: time, money, all of those things. But if you sit there and hope that things will get better, it's not going to work. It's going to take action. I've heard it again and again, and certainly I've been pushed more and more in this direction. We adapt, yes, but we also need to advocate. I really appreciate all the work everybody's doing in that regard, and encourage you to join those organizations at whatever level you can to support the voice of urology.

Scott: Ray, final thoughts?

Ray: I've been a practicing urologist, and I echo the value of the patient-physician relationship. I also know that when you have a problem with a patient, that always comes first. The old adage is that when you're up to your rear end in alligators, it's tough to remember you're there to drain the swamp. But you have to keep up the advocacy, and you have to deal with the issues in addition to patient care. So regardless of the fact that you don't have time, you have to find the time. That's what keeps you in practice.

Scott: So true. All right, we'll give the final word to Peter, and then we'll end this.

Peter's final word: membership, a new name, and prostate cancer screening

Peter: The final word is you have to work together. No funding, no mission. These organizations help you foster a balance between those two. The advocacy helps us keep the funding going and prioritizes the need through the voices of our membership. If you want to do anything, and Willie Underwood will tell you the same thing, you need to contribute to your PAC. But the most important thing is membership. When they see that you're a member, when they see that we have 5,000, 10,000 members, that is hard for Congress not to pay attention to. So please join the AACU in that regard.

Let me tell you one thing. We're changing our bylaws, and we're changing our name a little. Instead of the American Association of Clinical Urologists, it will be the American Association of Clinical Urology. We're going to start increasing the umbrella for membership to all ancillary services that have an interest in urology, especially in the rural area. So we're going to open up our membership to you and to your organizations. You can join as an organization, you can join as a member, and you can have your whole practice join if you have medical assistants. So I look forward to working with you all.

And I'll give you two other things, in terms of the altruistic side. We are working with ZERO and Tunnel to Towers to do prostate cancer screening throughout our network of urologists in the United States, low-cost screening, because that's going to save lives, and we're going to help you in the rural areas. I think we have two states we're going to open it up with, partnering with ZERO and Tunnel to Towers: Baltimore first, and Atlanta. The second thing is our medical missions. I think Ray knew I was doing medical missions throughout the world, especially in the Philippines. I've done transplants there. I did the first laparoscopic kidney removals there more than 20 years ago, and I go back. It really is good for your soul, and it rejuvenates the reasons we all went into medicine to begin with. I'm not minimizing the funding aspects of our practice, but it also lets you become a better physician, because you can work with less when you start doing missions on a regular basis to developing countries. So I put that out there. Peace and love to all of you, and I look forward to building the practice of urology and helping all those who want to foster a relationship through advocacy and altruism. Thank you, Scott, Mark and Ray, for having me here today. It is truly an honor to be your friend and your professional associate, and I'd like to continue, for all of you, so that we can be one strong profession together in urology. God bless.

Scott: Thank you, Peter. Thank you so much for joining us. We really appreciate all the insights and the stories. That's all we've got for today. Take us out, Ray.

Ray: Happy coding.

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