Bob GattyWhen 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.
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.
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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.
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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.
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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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