LUGPA Will Create Bundled Payment Models for Prostate Care

Gary Kirsh, MD

The Large Urology Group Practice Association (LUGPA) has announced the plan to create two alternative payment models (APMs) that involve bundled payments. Speaking at the group’s 2016 annual meeting in Chicago, President Gary Kirsh, MD, unveiled the proposed APMs and asked members to consider volunteering their practices to be part of the effort.

Flexibility shown by CMS in its final rule on Medicare Access and CHIP Reauthorization Act reforms has signaled that the public payer will allow broader physician led innovation in alternative payment models that promote greater value and better outcomes. In response, oncology groups like LUGPA and ASCO have stepped up their own initiatives to launch APMs. Roughly 200 oncology practices have volunteered for CMS’s Oncology Care Model (OCM), but ASCO and others have contended the OCM is too restrictive. “LUGPA is prepared to take the lead within urology in developing APMs,” Kirsh said. “We have concrete proposals for two APMS—this is real, not theoretical.”

Kirsh, who also chairs the LUGPA APM Task Force, described this effort as being of critical importance to independent urology. “As value-based care gradually penetrates the reimbursement landscape, it is imperative that urologists have alternative payment models that have been developed and validated by urologists, and not imposed upon urologists,” he said.

Kirsh shared what he referred to as the anatomy of a successful bundle/APM:

• The treatment cost for a set of services has to be meaningful for payer interest.
• There must be treatment variability in clinical practice for a given condition.
• There must be a cost savings if treatment variability is narrowed.
• Providers need integrated clinical and financial systems to monitor pathway adherence, patient outcomes, and practice costs.

Noting that bundled payments provide comprehensive reimbursement for a well-defined set of services over a specific time frame, Kirsh said that bundled payments are the most “approachable” form of APMs for urologists. “Bundled payments have potential financial upside for groups that can get their docs to ‘swim in lanes’ and follow well-designed and financially validated protocols which result in efficiency of care,” he said.

According to Kirsh, during the past 12 months, LUGPA leadership has explored several potential approaches to developing urology-specific APMs and is poised to collaborate with Integra Connect, a company that provides financial and clinical services to specialty practices.

Two bundled payment initiatives were described. The first involves bundle payments for prostate biopsy with risk of sepsis—an overwhelming immune reaction to infection. Kirsh said the APM initiative is hoped to reduce the incidence of sepsis. “This was a good choice for us because the cost of sepsis is high. Infection prevention regimens vary greatly, and sepsis rates vary,” Kirsh said. “And coordinated prophylaxis programs have been demonstrated to reduce costs.” Ten LUGPA practices will be selected for participation in this bundled care initiative. They will receive financial support from LUGPA and Integra.

Each practice will submit patient charts for a retrospective analysis of sepsis rates. Practices will then collaborate to develop a consensus biopsy prophylaxis pathway and draw up a projection of prospective sepsis rates under the new plan. “We will develop a viable financial model for a bundled payment for prostate biopsy that includes the professional and technical fees and covers the cost of sepsis events, and we will use outside experts to validate it,” Kirsh said. “And then we will seek reimbursement for the bundle from CMS and commercial payers.”

Kirsh cautioned that it remains unclear whether they will be able to save money on sepsis treatment. “Maybe there won’t be any reduction in sepsis rates, but if there is, our consultants can model it for us across the system,” he said. “We will share the savings and potentially make money by getting on the pathway.”

The other APM that LUGPA will develop is a localized prostate cancer bundle. Kirsh explained the decision by saying that the cost of localized prostate cancer treatment is high. “There may be overtreatment of some prostate cancers and there is great variability in the treatment of localized prostate cancer,” he said. “Bundled reimbursement regardless of the intervention chosen for localized prostate cancer will promote evidence and outcome-based quality care that is potentially more cost effective.”

Kirsh said that this APM will build on a current pilot project involving three LUGPA member groups and Integra. Several dozen LUGPA practices will be needed. They will be compensated for their participation and financially supported by LUGPA, Integra, and corporate sponsors that include Genomic Health and Myriad Genetics.

Participating practices will retrospectively assess their prostate cancer treatment patterns. “Together, we will develop a pathway that involves the use of biomarkers to help inform treatment decision-making and measure whether treatment patterns change as a result of biomarker use,” Kirsh said. “Then we will assess whether new practice patterns result in cost savings and/or more standardized care, develop a bundled payment for localized prostate cancer, and seek payer approval.”

Again, there are no guaranteed outcomes. “This pathway is about the appropriate insertion of biomarkers to drive care,” Kirsh said. “We won’t tell you which biomarker to use but we will measure whether treatment variability is less or the savings are greater. Our hope is that we can go to CMS and tell them we want one price to take care of a patient with localized prostate cancer because we’ll know the numbers will be solid.”

Individual practices need to be realistic about what participation in these APMs will mean, Kirsh said. “There will be lots of work and expenses, and you won’t be compensated for it all,” he said. “It’s also important to understand that participation won’t be optional for your docs once it’s implemented. Every member of your practice will need to commit to this experiment.”

Participation won’t be an automatic guarantee of success, but it will grant participating LUGPA members the right to call themselves pioneers. “To be honest, LUGPA is ahead of the American College of Surgeons and the American Urological Association on this,” Kirsh said. “But we are committed to developing specialty-specific bundles that will be groundbreaking in our specialty and beyond. We might fail but we want to try.”

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