How one specialist's advanced alternative payment model can serve as a framework for value-based care

Advanced payment models are a pathway in MACRA that has been shepherding specialists into the realm of value-based care. And for many specialties, including cardiology, there exists a framework for doing so, with specialists joining APMs to facilitate the transition to value-based reimbursement.

However, some specialties, such as urology, can be left wanting when it comes to APM options. Urology represents only about 2 percent of the overall healthcare spend, and so the Centers for Medicare and Medicaid Services, which implements MACRA, hasn't prioritized it. It's a relatively small specialty, and within the confines of the specialty, the work can be very esoteric.

[Also: Healthcare groups urge CMS to count Medicare Advantage contracts as APMs in MACRA]

Recognizing this, Deepak Kapoor, MD, chairman and CEO of Integrated Medical Professionals and past president of the Large Urology Group Practice Association, decided the best way to speed urology's pivot to value-based care was to create an APM from scratch.

Kapoor said his model has received approval from the Centers for Medicare and Medicaid Services. 

"In 2017, there were six vehicles CMS identified as being qualified for advanced APMs," said Kapoor. "CMS tends to target whatever the highest-value expenditures for CMS are -- you have a comprehensive total joint model, a cardiovascular care model, and so forth. So Medicare is targeting their biggest expenditures, and that makes sense. APM development is very resource intensive and very time-consuming. They're going to focus on things that impact large populations."

As a specialty, urology is more, well, specialized. A surgical discipline, urologists are referred patients who have a symptom, not a diagnosis -- urinary symptoms, erectile dysfunction and the like fall under their purview. The urologist is then responsible not only for the cognitive evaluation of the patient, determining whether they need medication or surgery, but the operation itself, if needed. 

As such, it's a very self-contained discipline. When urologists interact with other specialists, it's very episode-based. But because urology is so self-contained, said Kapoor, it lends itself well to episode-based care models, because the urologist can integrate all of these different aspects of care.

Kapoor's urology-based APM, which serves one out of every eight adults in the New York area, was created for a simple reason: "Because nobody else is going to look at urology other than urologists," he said.

It was also created because out of the two tracks in MACRA -- APMs and MIPS -- MIPS, a modification of the old fee-for-service model, was causing some issues. One of the facets of MIPS is resource use, which Kapoor said can be dangerous for providers, because the derivation of the value-based modifier is not under the provider's control.

"The problem with resource use is you have absolutely no control over it," said Kapoor. "Resource use is determined by a two-step attribution process. CMS takes a look at any given beneficiary and determines whether that Medicare beneficiary saw any provider that was a primary care physician … during the course of the year. So if you're a beneficiary, at any point during the year, that patient is attributed to the primary care position.

"As it turns out, a lot of Medicare beneficiaries don't see a primary care physician," he said. "They have a whole cadre of people they see. If the Medicare beneficiary did not see a primary care doctor in the year, then the patient is attributed to the specialist who did a plurality of the visits that year. 

"That's important, because what are you charged under resource use? Are you charged for what you spend on the patient? No, no, no. Every inpatient charge, every part B drug, every imaging study, every doctor's visit is charged to you and you have utterly no control over how it's attributed to you, and you don't even find out who is attributed to you until after the visits have occurred."

Kapoor related the story of a woman who came into his office and was examined and treated twice, undergoing routine care, and was later admitted to the hospital. Because she wasn't seeing a primary care doctor, Medicare then charged Kapoor's practice $1.4 million for all of the inpatient charges, drugs, imaging and other costs.

The APM avoids those charges and puts the control back in the urologist's hands, he said. And it allows for the transition into a value-based model in a financially feasible way. Kapoor hopes that other specialities lacking a pre-made APM framework under MACRA will travel down the same path.

"Once you create the model where someone is the first to carry the torch, my hope is that other specialities will follow suit," he said. "I think you're going to be able to deliver types of episodic, value-based care that are complementary to the types of system-wide approaches that CMS, by its nature, wants to do and is committed to do."

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com