When Congress passed and President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) and ended the sustainable growth rate (SGR) payment formula, cheers from urologists and other Medicare providers could be heard throughout the land.
But now confusion and consternation may have replaced that sense of euphoria. While the SGR’s replacement, the Quality Payment Program, promises ultimate financial rewards to providers who can improve quality of care while reducing cost, it is filled with such complexities that practical maximum realization of these benefits may be difficult to achieve.
As Lisa Miller-Jones, manager of regulation policy at the AUA explains, the Quality Payment Program includes two paths that physicians may choose for reimbursement: the Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs)—of which there are two types: Advanced and non-Advanced.
A push to Advanced APMs
For most urologists, it’s the Advanced APMs where the gold can be found.
“We are trying to push urologists to Advanced APMs,” said AUA Public Policy Council Chair Christopher M. Gonzalez, MD, MBA. “But it is extremely difficult.”
That’s because right now there are no approved episode-based Advanced APMs for urology, although the AUA is working on two and LUGPA has submitted one for approval by CMS.
Under MIPS, payment adjustments for the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and the Medicare and Medicaid Electronic Health Record Incentive Program will end on Dec. 31, 2018, while other key components of these programs will be consolidated and continued as a single streamlined program.
Also by Bob Gatty: Urology-specific quality measures are coming
An AUA memo explains that in 2019, the MIPS program will make positive or negative adjustments to a physician’s payment based on a composite score of their performance in 2017 across these four categories: Quality Reporting (will replace PQRS), Improvement Activities, Advancing Care Information (replaces Meaningful Use), and Cost (replaces Resource Use).
Meanwhile, physicians who qualified to participate in an Advanced APM are exempt from MIPS and are eligible for a 5% lump-sum bonus payment on Medicare Part B services from 2019 through 2024, and will receive higher annual increases in their payments starting in 2026 and onward, the AUA memo explained.
But, participants in an Advanced APM must assume more than nominal financial risk (or be part of a medical home), report quality measures comparable to those adopted under MIPS, and use certified EHR technology. Only risk-bearing accountable care organizations, patient-centered medical homes, and certain bundled payment models qualify as Advanced APMs. Physicians participating in non-Advanced APMs are subject to MIPS and are not eligible for the 5% lump-sum bonus payment.
LUGPA President Neal D. Shore, MD, said the first Advanced APM developed by LUGPA covers newly diagnosed prostate cancer and the effective use of active surveillance.
“It is clear that there has been over-treatment of many patients who have low-risk disease because there has been a lack of understanding that many such patients can be very safely monitored. Not everybody with diagnosed prostate cancer needs to have active or interventional treatment,” he said.
The problem has been that active surveillance “has been under appreciated from a cost-of-care standpoint,” Dr. Shore explained. The new APM has been submitted to the Physician-Focused Payment Model Technical Advisory Committee, which makes approval recommendations to CMS. It was 18 months in development, provides a way for physicians to demonstrate savings to CMS, and includes a care management fee for physicians “who are following a pathway of active surveillance.”
The physician’s risk comes into play if he or she fails to meet the outcome quality parameters and costs to Medicare increase.
“If costs and outcomes do not meet the goal, then the physician could potentially lose money,” Dr. Shore said.
Once approved, he said, the active surveillance Advanced APM will be available for use by all urologists.