Urologists weigh value-based options

Broadly, value-based care means paying for value, rather than volume. That’s how David F. Penson, MD, MPH, professor and chair of urologic surgery at Vanderbilt University Medical Center in Nashville, TN, says he thinks of the concept.

Just how value-based care will replace fee for service and what that will mean to urologists and other providers isn’t so clear. But the urgency to act is real, according to Deepak Kapoor, MD, chairman of health policy at LUGPA and chairman and CEO of Integrated Medical Professionals in the New York metropolitan area, the largest urology group in the U.S.

Big health care-the system that existed before the Medicare Access and CHIP Reauthorization Act (MACRA)-is unsustainable, according to Dr. Kapoor.

“The question is not whether or not value-based care is going to happen; the question is what is it going to look like and who is going to initiate it. Are physician providers going to be involved in the change to craft something, where we wind up with a structure that values the individual physician and individual practice, and creates a proper balance between independent and employed physicians? Or is the system going to be imposed upon us because of economic necessity that fundamentally devalues the role of the face-to-face providers in health care?” Dr. Kapoor said.

Next:Value-based options and urologyValue-based options and urology

Among the models used in value-based care: the alternative payment model (APM), in which providers are reimbursed for taking care of patients with a certain disease, usually for a certain period of time or around a certain procedure, according to Dr. Penson.

Providers must provide a minimum standard of quality care, often at a reduced cost and at a bundled price. In some cases, providers earn bonuses for providing a higher quality of care. But if the care costs more than expected, the provider is at risk for the loss.

Medicare is leading the value push, according to Alec S. Koo, MD, of Skyline Urology in Torrance, CA.

“Medicare’s concept of value, as originally proposed in MACRA, was initially with MIPS [the Merit-based Incentive Payment System], which all along was meant to be an intermediary. Ultimately what CMS would like to do is to have most of the payments go through one of the APMs,” Dr. Koo said. “So, ultimately, what value means to Medicare, and other payers will adopt the same concept, is the advanced payment model.”

While Medicare is pushing for APMs, currently there are very few such models that are applicable to specialists. Most are primary care or hospital-based APMs, according to Dr. Koo.

“In urology, we’ve had some work in developing APMs. A number of different professional societies have worked in that direction. The AUA has worked with the American College of Surgeons to develop an APM for nephrectomy and prostatectomy. It’s really still a work in evolution,” Dr. Penson said.

Developing an APM through CMS is no easy endeavor, especially in urology. The process is laborious, bureaucratic, and detailed, according to some urologists who have been involved in it.

LUGPA is the furthest along in developing an APM for Medicare. The APM, which focuses on localized prostate cancer care and use of active surveillance, has the potential to save the Medicare program $254 million a year, according to Dr. Kapoor. But it hit roadblocks when presented for review to the Physician-Focused Payment Model Technical Advisory Committee (PTAC).

During the review process, PTAC issues a nonbinding report, which the secretary can accept or reject.

“They declined to recommend the proposal based on a fundamental philosophical difference,” Dr. Kapoor explained. “The philosophical difference is that they didn’t believe that physicians should be rewarded for modifying their behavior to adhere to evolving clinical guidelines. I fundamentally disagree with that. What’s the whole point of value-based care if it’s not to compensate doctors who are practicing value-based medicine?

“We’re going to continue to pursue the proposal. Basically, our team is going to be working to see what we’ve learned from the PTAC process. If there’s a tweak to the proposal we can make that advances it, we certainly will. But the core of the proposal, we believe, is very strong.”

Dr. Kapoor says there are options, including other types of value-based constructs, such as those created around episodes of care, accountable care organizations (ACOs), involvement in medical homes, and those that involve taking full or partial risks. There are capitated payment plans and even sub-capitated risk models, where a hospital or some other entity takes the risk contract and urologists carve out the urology services.

Medicare is not the only avenue for these models. “A third-party payer may be way more engaged in doing this,” Dr. Kapoor said.

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Urology represents 2.3% of the health care system, so Medicare and other payers have focused more on the primary care model and other bigger, costlier players in health care, Dr. Kapoor says.

“I’m not devaluing urology as a specialty, but nobody is paying attention to us,” he said. “The simple fact is that the least expensive site of service for health care is the independent physician office. And if we create constructs, which focus on outcomes over volume and focus on value-based care, there really isn’t anybody that can effectively compete against us. This is the paradigm shift that, in my mind, physicians need to get their arms around.”

There is research to back up the claim, including a study by McWilliams et al (JAMA Intern Med 2013; 173: 1447–56) showing that value-based care models run by independent physician practices not only were less expensive, but also scored better on quality metrics than value-based care models run by hospitals, according to Dr. Koo.

“I actually view this as an opportunity,” Dr. Koo said. “There are different types of APMs. One of the better concepts is probably bundled pricing.”

An example, Dr. Koo says, is that the current rate for a robotic prostatectomy charged by major medical centers is around $60,000.

“My group collaborated with a community hospital, and we can offer a robotic prostatectomy pricing bundle at $25,000. But what about our quality? From Medicare data, we have lower average blood loss than other programs, and we have shorter length of stay,” Dr. Koo said.

Urologists need to be driving value propositions, Dr. Koo says.

“In Medicare’s eyes, ultimately, any of these could qualify as an APM,” he said. “It doesn’t have to be a Medicare APM; it could be a local APM.”

Patient-centered medical homes are another solution-one that’s immediate, Dr. Koo says.

“A urology group can get certified as a patient-centered specialty practice, or PCSP. The National Committee for Quality Assurance currently has that certification available,” Dr. Koo said. “And if a urology practice becomes certified as a PCSP, then it could potentially qualify as an advanced APM. That’s one of the very few places right now for Medicare that a urology group could participate with a specialty or urology-centric APM.”

The benefit for the urology practice that is in an APM and qualifies as an advanced APM is that practice no longer needs to participate in MIPS, according to Dr. Koo.

“You automatically will earn the 5% annual bonus. You either have to play the MIPS game, or if you can, qualify as an advanced APM. And right now, the opportunity is with a PCSP,” he said.

Next:Grappling with unknownsGrappling with unknowns

There are issues that make value-based care expensive, exhaustive, and uncertain territory for physicians.

Researchers reported in 2016 that U.S. physician practices spend, on average, $40,069 to report quality measures. The current system for reporting is unnecessarily costly and standardization is needed, according to a paper in Health Affairs (2016; 35:401-6).

“My sense is that urologists are very familiar with the current transition toward the value-based program being implemented by the MACRA legislation,” said Franklin Gaylis, MD, chief scientific officer at Genesis Healthcare Partners in San Diego. “I don’t think many of us have a good grasp as to how this program will actually improve value, [meaning] better quality at lower cost. I believe this is a source of major frustration for physicians.”

Dr. Gaylis says that another major issue that remains unclear is how CMS will hold physicians accountable for the cost of the care they deliver.

“The whole issue of attribution, meaning which cost will be attributed to which physician, remains unclear but is of great importance. How will CMS risk adjust for patients with differences in comorbidities remains to be seen,” Dr. Gaylis said. “There are many important issues that need more clarity so that the system is fair.”

Sanford J. Siegel, MD, CEO of Chesapeake Urology Associates and United Urology Group, a newly formed large group with practices in Maryland and Tennessee, says value-based medicine isn’t yet a reality in daily urology practice.

“As the leader of United Urology Group, I’m running my company based on how we’re living today, which is still fee for service. We continue to focus on quality care. We continue to focus on driving down costs by doing things in our ambulatory surgery center. But we live in a fee-for-service world, and I just don’t know when and how this new paradigm in payment will be part of it,” Dr. Siegel said.

Next:Logical steps to take nowLogical steps to take now

Taking a wait-and-see approach could put the future of urology care at the mercy of payers.

“Physicians need to take more of a leadership role in defining what is value-based care and how it should be implemented,” Dr. Gaylis said.

Urologists need to take long, hard looks at their current practice patterns.

“They need to start thinking about how they can deliver effective and cost-effective care,” Dr. Penson said. “We want to do what’s best for the patient, and, currently, it often turns out that when we do more, it’s more lucrative for us. The payment structure might change, where it’s going to be to our financial benefit to do less. At the same time, we want to maximize patient outcomes.”

Urology groups and practices should have committees responsible for helping to transition practices from fee-for-service to value-based care. Genesis Healthcare Partners has a MACRA committee that includes the executive team, information technology, quality, and billing departments, which meets regularly to address MACRA-related issues and roles out programs that help Genesis remain compliant, according to Dr. Gaylis.

“In addition, we need to become more involved and suggest to CMS what needs to be improved in order to make value-based care meaningful and practical,” Dr. Gaylis said. “There is no getting away from the fact that the value-based paradigm shift will only continue and that private payers will adopt similar, if not identical, measures.”

Dr. Kapoor says the take-home for urologists is that engagement in the process from the independent physician is absolutely critical.

“As physicians, we could not only survive but thrive under [the value-based] model,” Dr. Kapoor said. “The question is whether or not this happens with us or to us.”