Bundled payment program covers kidney stone care

Kate Dwyer, MD

In this interview, Kate Dwyer, MD, and Ruchika Talwar, MD, discuss their 2024 American Urological Association Annual Meeting abstract, “MyUrology Health: implementation of a novel episode based payment model for nephrolithiasis.” Dwyer is a urology resident at Vanderbilt University Medical Center and Talwar is associate medical director of population health and an assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee.

Could you please provide an overview of the MyUrology Health program and describe the background behind your AUA abstract evaluating its implementation?

Dwyer: The MyUrology Health program at Vanderbilt is a value-based payment model. In this case, it's 1 bundled payment from a self-insured employer that covers an entire episode of care for a kidney stone event. That means imaging, labs, surgical procedures if needed. It also includes all types of visits, [including] clinic visits and emergency department visits. Importantly, it includes a patient navigator, someone that's intended to help patients move through their clinical course. This is one of the first times we've seen a model that's tailored to kidney stone care. Our goal for the abstract was to look into, how is this working for patients? What services are they using? What are their costs? And how do they feel about receiving care in a different payment model?

Ruchika Talwar, MD

Talwar: This is the first bundled payment model for kidney stone care in the United States. It is through the the MyHealth bundles program that Vanderbilt University Medical Center offers. What this bundles program is, is that we sell a direct-to-employer value-based payment package essentially, at a predictable price for employers, and in turn, they would seek their care for kidney stones at Vanderbilt, and everything would be covered under 1 specific episode with no cost to the patient.

What were some of the notable findings of your AUA study, and were any of them surprising to either of you?

Dwyer: I think what's really exciting is we've been able to prospectively enroll patients. We started at 60 at the time that we submitted our abstract. We're now at well over 100, which is great. We're finding that plenty of them are getting surgery. The way that the program is designed, there are different tiers as to what types of care patients will receive, whether that's operative, or trial of passage, or potentially multiple surgeries for someone who has a high stone burden and might need something like percutaneous nephrolithotomy. We're seeing about 60% of patients are receiving surgery; we're seeing pretty good compliance with post-operative imaging and things like that. The other thing that's interesting is whether providing this care in a bundle and providing something like a patient navigator can help patients move through their course. We are still seeing a fair amount of ED visits; about 11 of the patients in the first cohort of 60 did have an emergency department visit that was included in their bundle as well.

What are the next steps for this program?

Dwyer: I think the first thing is to optimize the bundles themselves, so catching patients who are coming not just through clinic with an acute stone episode, but also through the emergency department, people who need more urgent interventions. We're starting to address patients who have different types of health plans; for example, those who have high out-of-pocket costs or high deductibles and how the plan may apply differently to them. We also have some initial general survey data that patients have appreciated the bundle; the satisfaction rates are quite high. But we're looking into getting more granular survey data as to their experience as they're moving through this. I think would also be exciting in the future—and maybe this is further off—to implement this at other institutions.

Talwar: Absolutely. I think this is really an example for other academic institutions who are interested in moving away from fee-for-service models, and incentivizing high-quality care. We show that we actually can do this for a complex disease state like nephrolithiasis despite the fact that patients often have an option between procedures and even forgoing a procedure. It's still possible to bundle this up under a single episode.

What would you say is the take-home message of the paper for the practicing urologist?

Dwyer: Value-based payment models are a wonderful innovation in general that have seen success in other areas of medicine, [such as] maternity care, orthopedic surgery. This is an example that it can be applied to urology; specifically, for kidney stone care. As mentioned, this is a model that was thoughtfully developed to address all of the things that a [patient with] kidney stones would need. This is a way to give patients both comprehensive care and something that's accessible and helpful for the patient on their end.

Is there anything else about the program or the AUA presentation that you'd like to go over that hasn't been talked about already?

Talwar: I just think that this is a really interesting way to show that urologists can spearhead value-based care payment models in our surgical subspecialty. This is one example of that. It was an endourologist who was our clinical lead and really drove home the clinical pathways that we adhere to here. I'm a urologic oncologist, and Dr. C.J. Stimson, who's also a urologic oncologist, we are the ones who are involved in running the MyHealth bundles program. It really is just a call to action for urologists who may be interested in dabbling in a lot of these new, innovative programs. Because one day, we're going to have to move away from fee for service, so we'd be wise to try to navigate those waters ahead of time, so we're not left dealing with the aftermath when someone else has implemented it for us.