Alan L. Kaplan, MD

	Yes, you read the headline right. I said “millennial urologists.” It’s a thing; let’s proceed.

	In an effort to understand “the other side,” I have spent my fellowship year immersed in health system operations and administration. During this cross-pollinating education, I have astutely ascertained that physicians and hospital administrators do not always see eye to eye. So when the American Medical Association (AMA) and American Hospital Association (AHA) both came out in opposition to the GOP’s proposed American Health Care Act (AHCA), it was thought provoking at the very least.

	I have no interest in partisan commentary here, and the merit of the AMA/AHA opposition is immaterial. What I did find noteworthy, however, was my millennial colleagues’ atypically vociferous response to the proposed health care bill. Since the AHCA was introduced, my online network of millennial urologists has been abuzz with commentary. Through email listservs, text messages, Twitter feeds, and Facebook pages (I don’t do Instagram), I have been inundated this past week with peers’ electronic health policy musings. 

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 of the AHCA’s expected economic impact by socioeconomic status. A health services research fellow in Los Angeles posted an 

 proposing a California-led individual mandate. A colleague in Michigan provided an 

 of the expected effect on the MACRA legislation of 2015. And a friend in residency posted a 

 of Rep. Joe Kennedy III’s (D-MA) floor speech aimed at House Speaker Paul Ryan (R-WI).

	One limitation of these observations is that my background in health services research may lead to sampling bias; another is that Mark Zuckerberg may be curating my Facebook page ad nauseam. So perhaps these social media posts are not representative of the entire millennial urologic community. However, the frequency of these posts in the wake of current uncertainty in health care is nonetheless hypothesis generating.

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	The millennial generation has been criticized for its self-centeredness, short attention spans, and need for immediate gratification. None of these qualities portend meaningful future engagement in health policy. But there is talk of a political awakening among the millennial generation and it may very well manifest in the urologic space. That awakening may be an important opportunity to engage young urologists in the health policy realm-traditionally favored by the proverbial gray-hairs.

	I would challenge senior partners and senior faculty to reach out to your younger colleagues, invite them to a local society meeting, or contact your elected officials as a group to ensure your collective voice is heard. Likewise, millennial urologists should understand that social media posts do not an activist make. Engaging as a physician in the political process happens offline, in representatives’ offices and in loco-regional societies. But don’t worry-you can still use your smartphone to call or email your representative.

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Millennial urologists appear to have developed strong opinions on health policy as reflected by their recent social media activity, observes urologist Alan L. Kaplan, MD.

Millennial urologists display a political awakening

	Although much has been written about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), its implications for the practicing urologist remain uncertain. Despite the Oct. 14, 2016 policy finalization of the law, many practitioners show a fundamental lack of understanding and awareness of it. A Deloitte survey of over 500 physicians conducted in April and early May 2016 indicated some pretty stark statistics about how unfamiliar many doctors are with MACRA. Half of the respondents had never heard of the law and 32% only recognized the legislation by name.

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Dr. KirshFollowing the 2010 passage of the Affordable Care Act (ACA), much was written about accountable care organizations (ACOs), but direct relevance to urologists was scarce. MACRA, on the other hand, more directly affects the urologic book of business. To gain a better appreciation of how that impact might play out in the coming years, I spoke with some leading urologists with expertise in payment reform and value-based care for their perspective.

	For outgoing LUGPA President Gary M. Kirsh, MD, the passage of MACRA is a welcome ushering out of fee-for-service medicine. “Fee for service is ultimately not in our interest; we can’t run any faster on the fee-for-service ‘hamster wheel,’ and it’s limiting our creativity and entrepreneurship,” Dr. Kirsh said.

	“We’ve been waiting for this with bated breath,” said urologist Deepak A. Kapoor, MD, CEO of Integrated Medical Professionals in New York. The ACA, Dr. Kapoor said, “mostly focused on process rather than outcome measures. The regulatory burden fueled hospital acquisition of physician practices, driving up health care costs by shifting care to the least efficient and most expensive site of service. Fast forward to MACRA and [the changes envisioned by ACA] are codified into statute for CMS to implement.”

	Neal Shore, MD, director of the Carolina Urologic Research Center in Myrtle Beach, is a proponent of urology groups “embracing the changes… as we shift from volume to value. I think those taking the reactive rather than proactive approach are making a mistake.”

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Dr. KooAlec Koo, MD, managing partner of Skyline Urology in Southern California, shares Dr. Shore’s sense of opportunity. “Docs are fearing [MACRA] but really should be celebrating this as a tremendous opportunity. We all know there’s a lot of inefficiency in clinical care. When we start risk and gain sharing, then we have skin in the game to truly move the needle and improve,” Dr. Koo said.

Dr. EllimoottilUnder MACRA, two separate tracks are delineated for physicians and provider organizations to capitalize on their strengths and weaknesses: Alternative Payment Models (APMs) and the Merit-Based Incentive Payment System (MIPS). These disparate tracks will go into effect by 2019, although there is much disagreement among providers and policymakers about which course will be optimal. APM is a catchall term for non-fee-for-service payment structures and includes ACOs and bundled payment models. MIPS is a continuation of the current fee-for-service structure that’s driven by performance metrics. Although the Department of Health and Human Services has publicly supported APMs, Medicare’s qualifications for who can participate in APMs are subject to much debate.

	Urologist and policy researcher Chad Ellimoottil, MD, MS, studies episode-based bundled payments at the University of Michigan, Ann Arbor. “To understand the trends in APMs, it is important to study not only what is happening in Medicare but also what’s happening with large private payers and employers across the country. APMs are growing rapidly,” Dr. Ellimoottil pointed out.

	C.J. Stimson, MD, JD, a urologic oncology fellow at Johns Hopkins in Baltimore and an expert in value-based payment reform, notes that Medicare’s bent toward APMs is written on the wall. “New proposed rules… indicate that Medicare is committed to the concept of bundling, having just introduced bundles for acute myocardial infarction, coronary artery bypass grafting, and hip pinning. Although there are multiple routes to paying for value, bundled payment policy appears to have significant momentum,” Dr. Stimson said.

Dr. PensonDavid F. Penson, MD, MPH, chair of urologic surgery at Vanderbilt University in Nashville, TN and former AUA Public Policy Council chair, believes “both models will work… although APMs are how you win under MACRA. The government will push [APMs] since they directly help control the [health care] budget.”

	While the changing reimbursement paradigm may “not be a make-or-break for urology… it is important for urologists to get involved so that we can maximally benefit from the inevitable shift away from fee for service,” said Dr. Ellimoottil.

Dr. ThompsonAnd while “Medicare may think urology is too small to be involved in early APMs, the shift [in that direction] will surely hit urology in the future,” said Ian Thompson, III, MD, MBA, he isn’t completely convinced. “I believe this will be niche in urology,” said Dr. Thompson, associate chief medical officer at Christus Santa Rosa Health System in San Antonio and a solo practice urologist. “I say this based on the supply/demand curve of the urology work force as it relates to demographic trends. The demand for service will outstrip much of the need to develop complex bundled payments.”

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	Sanford J. Siegel, MD, CEO of Chesapeake Urology in the Mid-Atlantic region, carries a similar sentiment. Dr. Siegel relates that his group practices “in a fee-for-service world, and we’ll stay in that world until there is evidence that something else [has taken hold].”

Dr. ConcepcionLUGPA has begun aggressive preparations to facilitate success in the changing environment. Raoul Concepcion, MD, director of The Comprehensive Prostate Center and clinical assistant professor at Vanderbilt University, concedes that not all groups own an ambulatory surgery center, laboratory and pathology services, or radiation center, but those that are vertically integrated are situated very well. “They can control the costs [of the facilities] for the entire care continuum,” Dr. Concepcion said.

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	“LUGPA groups are ideally suited to deliver value-based care since our integrated groups are able to get all our docs swimming in parallel lanes,” Dr. Kirsh added. Speaking to the differences between academic and private practices’ preparation for MACRA changes, Dr. Penson said, “You will see similar changes in academic groups as you will in larger private groups. MACRA will make the old town-and-gown distinctions [between academia and private practice] a lot fuzzier.”

Dr. KapoorDr. Kapoor said his group has “stayed ahead of the curve and is actually waiting for the regulations to catch up. We [implemented] protocols and mandatory clinical pathways in 2008, and we audit thousands of charts each month,” he said. Although Dr. Kapoor’s group has a robust support staff, he stresses that the group relies on the commitment of its physicians to develop guidelines and ensure compliance. “Our physicians developed an internal report card system to track utilization and quality metrics. We created a system where we distribute bonuses for good citizenship [among our physicians],” Dr. Kapoor said.

	Dr. Koo’s group applied for, and was awarded, a Centers for Medicare & Medicaid Innovation pilot site for the Oncology Care Model (OCM). Designed to improve effectiveness and efficiency, OCM is a risk-based financial arrangement with payers surrounding episodes of care for chemotherapy. “We did this to really have a seat at the table on a [national] level,” said Dr. Koo, adding that it’s the first step to showing CMS that “urologists are able to best population manage stones, overactive bladder, benign prostatic hyperplasia, and men’s health.”

	“Changing physician behavior is difficult and will depend on organizations’ ability to engage [doctors],” said Dr. Ellimoottil. Dr. Concepcion believes in the importance of starting to define quality and outcome metrics. “It doesn’t have to be perfect the first time through, but start somewhere,” Dr. Concepcion said. “You can build a robust data-management platform on the back end.”

Dr. ShoreDr. Shore promotes group cohesion and the breakdown of silos. “It is important to have collaboration and cohesion within the group as well as appropriate subspecialization within both the clinical and business strategies for a successful integrated, independent group practice,” he said. Dr. Shore points out the unique opportunity to involve industry, government organizations, and specialized consultants. He concedes, however, that both the ACA and MACRA “will further amplify a burgeoning consultancy industry… which may foster resentment among physicians who are now asked to be coders, compliance officers, and regulators.”

	“We need to understand that these new payment policies demand that we rethink what it means to take care of a patient,” Dr. Stimson said. “Surgeons in particular think of patient care in discrete, acute episodes. I do a prostatectomy, the patient is discharged appropriately, and the pathology report is reassuring-that’s the 20th century approach to patient care driven by fee for service and volume-driven payment policies.

	“The next iteration of payment policies require that I expand my focus from the organ or pathology of interest to the entire patient,” he said. “Instead of considering the urologic outcomes during an episode, I need to consider all health outcomes during the episode as part of my responsibility and figure out how to restructure my practice to accommodate that reality.”

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Off the fee-for-service hamster wheel

	The Theory of Diffusion of Innovation states that, for a given population, adoption of new ideas and technologies comes in waves. There are early adapters, the early majority, late majority, and finally, the laggards. While early adapters and early majority may accrue higher risk, they frequently reap rewards while the others get left behind.

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	Medicareâs Comprehensive Care for Joint Replacement (CJR) model is a smoke signal for urologistsâa low-risk opportunity for us to get ahead of the curve. As a field, we will be well served to think critically about this changing reimbursement paradigm and adapt our practice to stay relevant. The orthopedic community is being thrust into this headlong and we have the terrific advantage of observing how that collision plays out. This blog provides a summary of CJR for the urologist.

	The Affordable Care Act reserved $10 billion for the Center for Medicare & Medicaid Innovation (CMMI) to test novel payment and delivery system models. These include accountable care organizations (ACOs), primary care transformation, and Bundled Payments for Care Improvement (BPCI). The common theme is a systematic shift in financial incentives and a move away from traditional fee-for-service payment models. CJR is the first mandatory bundle testing BPCI for hip and knee replacements. There are 67 geographic areasâroughly 800 hospitalsâthat are required to participate.

	Hip and knee replacements are the most common inpatient surgeries performed in the Medicare population. There is wide variation in outcomes (ie, joint infections, revisions), cost of care, and utilization. CJR financially incentivizes care coordination among hospitals, physicians, and post-acute providers to improve the quality of joint replacement care throughout the surgical and recovery period.

	The episode begins with an admission for elective joint replacement, includes the surgery and hospitalization, and ends at 90 days post-dischargeâincluding nursing facility and/or home health costs. With certain exceptions, the episode includes all services paid under Medicare Parts A and B. During the 5-year trial run, hospitals are given a target price for the episodeâdetermined by Medicareâbut payments are made in the usual fashion. At the end of each year actual hospital expenditures are compared to the target price.

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	A hospitalâs spending and quality metrics will dictate whether it receives a bonus payment at the end of the year or a bill from Medicare for the excess cost. Patient risk is stratified based on whether there is a concomitant hip fracture. Early in the model, which went into effect April 1, 2016, price targets will be based on hospital-specific historical figures, but this will change to regionally benchmarked price points by year four.

Next: Questions about CJR in the coming years

	Whether CJR will be successful in improving value for joint replacement care and whether any urology-specific bundles are in the pipeline remains to be seen. Nevertheless, bundled payments are the reform mechanisms for specialists. Many urologic procedures are ideally suited to bundling and, most importantly, they construct a platform for urologists to realize the benefits of the value they create.

Why urology residents should care about health policy

	Some important questions about CJR in the coming years are:

		What is an ideal episode for a urologic bundle?

		How will the transition to regional price points affect savings?

		What should be risk stratified in a urologic bundle?

		To what degree are quality metrics incorporated versus simple cost cutting?

	Hospitals and physician groups considering these questions, initiating their own bundles, and working with payers to implement them are the face of the early adapters in this changing health care landscape.

	Some concrete examples from my institution, UCLA, include lower-extremity joint replacement (Los Angeles County is one of the geographic areas for the CJR model), a surgical home project run by the anesthesiologists, an accountable care organization (ACO), a Back Pain Quality Initiative, surgical care of BPH, among others.

	By most measures, the orthopedic surgeons as a field were not ready for disease-specific bundled payments. Urologists should be.

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	The judging and measuring started on my first day as a urology sub-intern and hasn’t let up since. Two hours into a radical cystectomy, nervous about my suturing skills, and tired from feverishly reading the night before, the attending finally directed a question my way: “Alan, who performed the lead in this 1977 Broadway classic playing on the radio?”

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	The notion of being measured and judged is as familiar to urology residents as coffee. Although that process continues beyond training where patients and colleagues form and spread opinions of a doctor’s aptitude, the world of physician measurement is rapidly evolving and residents need to understand the changing landscape.

	Recently, a friend right out of training told me how devastated he was over his first negative Yelp review. The patient’s insurance didn’t cover the visit, and that brought down the doctor’s composite score to three of five stars. While online reviews of physician performance are not always that base and crude, they are becoming ubiquitous.

	Last summer, ProPublica, a non-profit producer of investigative journalism, published its version of individual surgeon quality metrics using publicly available Medicare claims data. The “Surgeon Scorecard” incorporated case volume and complications to determine which surgeons were “best” at eight common procedures, including radical prostatectomy. ProPublica has come under scrutiny for its limited data scope (most prostatectomies are non-Medicare and thus not included), its non-validated method for risk-adjustment, and the inability to capture “clinically relevant” outcome metrics (such as functional status and quality of life).

	Despite the criticism, the Surgeon Scorecard publication attracted national attention on performance measurement and transparency, and the issue isn’t going away; ProPublica is currently working on version 2.0 of the Surgeon Scorecard. While ProPublica uses publicly available data, California-based tech startups are capitalizing on robust private claims data to refine those analyses further.

	The major criticism of these approaches, of course, is the 

 of the quality data. Insurance claims are a) only as good as the coders/billers and b) limited in their ability to give us information about key components of the patient’s clinical outcomes. To focus performance data around “how do we improve” rather than “who is better,” the Michigan Urological Surgery Improvement Collaborative (MUSIC) links measurement with improvement initiatives. MUSIC, which is supported by Blue Cross Blue Shield of Michigan, is a physician-led consortium of over 40 urology practices designed to improve value in urologic care. The goal of participating practices is to identify actionable targets to improving care, and they have been successful in reducing post-prostate biopsy sepsis, among other endeavors.

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	This type of high-level performance measurement strategy is an encouraging step in the right direction but is still geographically and topically limited. As trainees, it is essential that we prepare for a world in which our performance will come under intense scrutiny but perhaps without our input into the nuances of that inquiry.

	First, we must become informed about the metrics currently in use. Even our most technologically unsavvy faculty can understand Yelp, but what about the Pro Publica score? Being able to address questions like how data are acquired, how risk-adjustment is done, who does it and why, and what metrics are included into a scoring methodology allows us to better communicate with patients and colleagues that may ask about these tools.

	Second, we need to get engaged in the measurement discussion. Join a quality improvement collaborative if one exists in your area, join the AUA Quality Registry (AQUA), or work with local and regional colleagues and payers to promote value that is driven by high-quality data.

	Finally, advocate. Payers and policymakers are already driving health policy decisions based on quality and value data. As specialists, urologists have faced challenges getting the Centers for Medicare & Medicaid Services and others to adopt relevant metrics that make sense in our realm. Ensuring that policy decisions are based on metrics that represent relevant outcomes and are improvement oriented is of utmost concern to the young urologist.

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	Someone recently told me, “The good old days of simply doing right by your patient and being good to your referring docs are gone.” While that may be true, I believe the horizon is bright. Novel data acquisition methods and analytics, information technology, and physician collaboratives based on improving quality open the potential for doing even more “right” by our patients and being even better to our referring docs.

	So how do residents prepare for the inevitable changes in physician measurement? Embrace them.

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"The world of physician measurement is rapidly evolving and residents need to understand the changing landscape," writes urology resident Alan L. Kaplan, MD.