AUA developing Advanced APMs
Meanwhile, the AUA is developing Advanced APMs covering prostatectomy and nephrectomy, Dr. Gonzalez said, noting that the AUA worked closely with the American College of Surgeons and Brandeis University to develop the framework for creating Advanced APMs, which the AUA is now using in its work.
“These episode-based APMs can take 3 to 5 years to create,” Dr. Gonzalez pointed out. “New codes may need to be created, they have to be pilot tested, and the government provides no resources (for APM development)—and they’re expensive.”
The financial risk for physicians will come into play under these APMs if the cost for the procedure exceeds the target.
“The risk is that if the goal is to do a procedure for $100 and you overspend and it costs $108, you are going to lose some money,” Dr. Gonzalez explained. “CMS wants to drive down the cost and to force you to do that. It’ll be on us.”
But then, of course, those physicians who meet the targets established in the Advanced APM will be eligible for the 5% bonus and enhanced payments.
Two additional Advanced APMs will be created with LUGPA involvement, said Dr. Shore: Positive Biopsy/Localized Prostate Cancer and Prostate Cancer Biopsy Taking Risk on Sepsis.
Meanwhile, several more general Advanced APMs are already available at CMS, including the Medicare Shared Savings Program ACOs—tracks 2 and 3, the Next Generation ACO Model, and the Oncology Care Model.
“Urologists could participate in most of the Advanced APMs, assuming they are part of an ACO entity and meet the patient and payment thresholds to be considered a qualifying participant,” Miller-Jones said.
Some urology groups are participating in the Oncology Care Model, but it is now closed to new applications through 2021, she said.
According to CMS, for physicians to qualify for the Advanced APM track in 2017, they must derive 25% of Medicare payments from that APM or must have 20% of their Medicare patients in that APM. The percentages rise to 50%/35% in 2019 and 75%/50% in 2021.
All of this work by urology organizations to develop specific episode-based Advanced APMs for the specialty comes at risks inherent to the current political climate.
The Center for Medicare & Medicaid Innovation, created by the Affordable Care Act, operates the program. What would happen if the effort to repeal the ACA should succeed?
“If the ACA gets repealed, the CMS Innovation Center goes away. Who knows what’s going to happen?” said Dr. Gonzalez.
Then, there is the fact that the bonus payment program is only available through 2024, unless extended by Congress. So if it takes several years to develop and obtain approval for the urology-specific Advanced APMs, how much time will be left for physicians to actually take advantage?
“Who knows what the future will hold?” said Dr. Gonzalez. “When they are ready and the 6-year window on the 5% runs out, all of it could be lost. It’s mind-boggling. But we’ve got to keep advocating for things that are best for our members and go from there.”
“While it’s great that HHS has given the medical associations the opportunity to participate in development of payment models specific to their specialty, HHS needs to be more expeditious in approving some of these payment models once they’ve been submitted and approved by PTAC,” Miller-Jones said. “The secretary needs to give more consideration to the specialty specific episode-based Advanced APMs.”
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