Will Advanced APM Affect Urology Physicians reimbursement?

There was a certain cheer in the air from Urologists and other Medicare providers when the Medicare Access and CHIP Reauthorization Act (MACRA) was passed and signed. This ended the terrain of the sustainable growth rate (SGR) payment formula. However, what persists today in the world of healthcare is confusion and uncertainty. The Quality Payment Program (QPP) introduced to replace SGR; is a promise of ultimate financial reward to practitioners who improve the quality of the care they provide at a reduced cost. In reality, though, QPP is a bundle of complexities that makes the derivation of the promised benefits difficult to achieve. The Quality Payment Program offering physicians reimbursement in two ways, which are listed below:

Physicians reimbursement choices are further segregated into -Advanced and Non-Advanced kinds. Experts are of the opinion that for urologists, it’s the Advanced APMs where the benefit lies. However, the difficulty is that right now there are no approved episode-based Advanced APMs for urology. AUA is working on two and LUGPA has submitted one for approval by CMS.

  • The Merit-based Incentive Payment System (MIPS)
  • Alternative payment models (APMs)

Under the MIPS Quality Payment Program, the Physicians reimbursement payment for the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and the Medicare and Medicaid Electronic Health Record Incentive Program will come to a halt on Dec. 31, 2018

The other key components of all these programs will be contained in a single streamlined program in 2019. Through a memo, AUA had attempted to explain that in 2019, the MIPS program will make positive or negative adjustments to a Physicians reimbursement payment. These adjustments would be based on a composite score of their performance in 2017 across four categories:

  • Quality Reporting (will replace PQRS), Improvement Activities
  • Advancing Care Information (replaces Meaningful Use)
  • Cost (replaces Resource Use). Physicians qualified to participate in an Advanced APM are exempt from MIPS. They are also eligible for a 5% lump-sum bonus payment on Medicare Part-B services from 2019 through 2024. They will end up receiving higher annual increases in their payments starting in 2026 and onward. However, the urology practitioners that are participants in an Advanced APM must estimate more than nominal financial risk, they need to report quality measures comparable to those adopted under MIPS, and use certified EHR technology. One must also note that only risk-bearing accountable care organizations, patient-centered medical homes, and certain bundled payment models qualify as Advanced APMs. On the other hand, urologists participating in non-advanced APMs are subject to MIPS. They are not even eligible for the 5% lump-sum bonus payment.In the past, many patients have been over-treated. They mostly had the low-risk disease. The excessive over-treatment was prescribed because there has been a lack of understanding that many such patients can be very safely monitored. The over-treatment was also due to a lack of active surveillance to cut out the cost of care.

The new APM has been submitted to the Physician-Focused Payment Model Technical Advisory Committee. It provides a way for physicians to demonstrate savings to CMS, and includes a care management fee for physicians who follow active surveillance. Urologists face risk only in the case they fail to meet the outcome quality parameters and costs to Medicare increase. This means if costs and outcomes do not meet the goal, then the physician could end up losing on money.