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Off the fee-for-service hamster wheel


Alan L. Kaplan, MD
Dr. Kaplan


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.

Related: MACRA implementation emphasizes specialty collaboration

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.”

Also see - MACRA: How changes in final rule affect urology

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.


Next: APMs vs. MIPS



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.

Read - MedPAC talks cost cutting as IPAB looms

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.”

A make-or-break issue for urologists?

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.”

Also see: Researchers validate robotic cystectomy quality tool

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].”


Next: How are you preparing for MACRA?


How are you preparing for MACRA?

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.

Read - MOC: 84% of urologists dissatisfied with current process

“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.”

Engaging physicians in change

“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.”

More from Urology Times:

Look for MOC changes in 2017, American Board of Urology says

MOC: Members of the UT editorial board weigh in

Update: States limit the role of specialty certification

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