Advanced Alternative Payment Model Research Articles

ACO Clinicians Have Higher Medicare Part B Medical Services Payments Than MIPS Clinicians Under the Quality Payment Program.

The Quality Payment Program (QPP) is a Medicare value-based payment program with 2 tracks: -Advanced Alternative Payment Models (A-APMs), including two-sided risk Accountable Care Organizations (ACOs), and Merit-based Incentive Payment System (MIPS). In 2020, A-APM eligible ACO clinicians received an additional 5% positive, and MIPS clinicians received up to 5% negative or 2% positive performance-based adjustments to their Medicare Part B medical services payments. It is unclear whether the different payment adjustments have differential impacts on total medical services payments for ACO and MIPS participants. We compare Medicare Part B medical services payments received by primary care clinicians participating in ACO and MIPS programs using Medicare Provider Utilization and Payment Public Use Files from 2014 to 2018 using difference-in-differences regressions. We have 254 395 observations from 50 879 unique clinicians (ACO = 37.86%; MIPS = 62.14%). Regression results suggest that ACO clinicians have significantly higher Medicare Part B medical services payments ($1003.88; 95% CI: [579.08, 1428.69]) when compared to MIPS clinicians. Our findings suggest that ACO clinicians had a greater increase in medical services payments when compared to MIPS clinicians following QPP participation. Increased payments for Medicare Part B medical services among ACO clinicians may be driven partly by higher payment adjustment rates for ACO clinicians for Part B medical services. However, increased Part B medical services payments could also reflect clinicians switching to increased outpatient services to prevent potentially costly inpatient services. Policymakers should examine both aspects when evaluating QPP effectiveness.

Impact of Radiation Oncology Advanced Alternative Payment Model on Black Americans

<h3>Purpose/Objective(s)</h3> In January 2023, the Centers for Medicare and Medicaid Services (CMS) will implement the Radiation Oncology (RO) Alternative Payment Model (APM) to reform how cancer patients receive radiotherapy (RT) and standardize payments for services. The CMS asserts that the purpose of this model is to "reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries." The RO Model requires mandatory participation for 16 cancer types and encompasses RT providers from "randomly" selected zip codes that includes approximately 30% of all eligible Medicare recipients for these RT claims, with a stated goal of saving $230 million over the initial 5 years the model is to be in place. The purpose of this study is to analyze the potential impact of this model on already existing demographic disparities in cancer care between APM-affected zip codes and unaffected zip codes. <h3>Materials/Methods</h3> Demographic data from the agency for Healthcare Research and Quality and data from Zip Code Tabulation Areas (ZCTAs) for affected zip codes were used to examine demographics within affected and unaffected zip codes. Specific social determinants of health (SDOH) variables such as education, food stamps, median household income, and Gini coefficient were also examined. Data collected from the Surveillance, Epidemiology, and End Results (SEER) Program was used to analyze the difference in 5-year cancer incidence based on race and gender. Each individual APM diagnosis code was analyzed according to race and gender in order to determine the number of people impacted for the 16 different cancer types included within the RO Model. <h3>Results</h3> In total, 20.2% more black persons (1.56 million) and 1.9% fewer (878,000) non-Hispanic white (NHW) persons are included in APM zip codes compared with a randomly-selected U.S. population. There was no significant difference in SDOH variables between affected and unaffected zip codes; however, there is a higher population density (1990 vs. 1273 per sq. mile) and average population (16,000 vs. 10,000 per ZCTA) in APM zip codes. When examining all cancer diagnoses, 7.9% more NHW persons (480.3 per 100,000) than black persons (445.2) were diagnosed with cancer; however, when looking at only APM cancers, 17% more black persons (391.5 per 100,000) than NHW persons (334.5 per 100,000) were diagnosed. A breakdown of race and gender disparities showed 17.4% more black men than NHW men were included in the APM diagnosis codes when compared with a randomly-selected U.S. population. Likewise, NHW women had 15.2% (456.6 per 100,000) more cancer diagnoses than black women (396.4), but when looking at only APM cancer diagnoses, that gap narrowed to 7.2% (319.2 NHW vs. 297.7 black). <h3>Conclusion</h3> These data indicate that the RO APM Model is heavily imbalanced in terms of the number of black persons mandated to participate and further optimization of this model is needed before widespread adoption.

Transforming Clinical Practice Initiative Boosted Participation in Medicare Alternative Payment Models.

The Centers for Medicare & Medicaid Services' (CMS's) Transforming Clinical Practice Initiative (TCPi) was the largest national-scale practice transformation model. We analyzed the effect of TCPi on new enrollment into Medicare Alternative Payment Models (APMs) through January 2020 (3 months after program end), using 6958 physician practices enrolled in TCPi and a closely matched comparison group of 6958 practices. More TCPi practices enrolled in Medicare APMs and Medicare Advanced APMs relative to comparison practices overall and in subgroups, including rural, small, and specialty practices. Results suggest that large-scale technical assistance can boost participation in Medicare APMs for a diverse set of practices.

Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program

(Abstracted from JAMA Network Open 2021;4(8):e2118449) In an effort to deliver better patient outcomes at a lower cost, the Centers for Medicare &amp; Medicaid Services (CMS) mandates eligible clinicians to participate in either the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models. Physicians or physician groups being evaluated through MIPS can receive a maximum of 60 points for quality, composed of 6 measurement categories that they may select.

Economic Evaluation of the Merit-Based Incentive Payment System for Ophthalmologists

The Merit-Based Incentive Payment System (MIPS) is intended to promote high-value health care through quality-related Medicare payment adjustments. To assess the economic evaluation of MIPS scoring and reporting on ophthalmologists. In this retrospective, cross-sectional, multicenter economic evaluation conducted from October 10 to November 30, 2021, MIPS performance and related payment adjustments were evaluated using the US Centers for Medicare & Medicaid Service (CMS) public data files for ophthalmologists. Participants were stratified by reporting affiliation. Analysis of variance and summary statistics were used to characterize and compare total and subcategory MIPS scores and adjustments received by participants. Reported CMS methodology and performance year (PY) 2019 payment percentages were used to estimate payment adjustments for the following categories: positive MIPS adjustment plus potential additional adjustment for exceptional performance, positive MIPS adjustment, neutral payment adjustment, negative MIPS payment adjustment, and maximum negative MIPS payment adjustment. Study participants included ophthalmologists registered for Medicare Part B with participation in the Quality Payment Program (QPP) in PY 2019. Proportion of ophthalmologists qualifying for payment adjustments and payment adjustments. For PY 2019, 76.5% of ophthalmologists (13 621) who registered for Medicare participated in the MIPS pathway of the QPP. Ophthalmologists practiced in a predominantly large metropolitan area (12 302; 90.3%). Roughly 99% of participants (11 182) received nonnegative reimbursement adjustments, and 92.6% (10 367) received positive adjustments. Ophthalmologists filing as individuals were less likely to achieve exceptional performance scores compared with those who had a filing category of advanced alternative payment model (APM; odds ratio [OR], 0.0003; 95% CI, 0.00002-0.00481) or group (OR, 0.21013; 95% CI, 0.19020-0.23215). When analyzing participating ophthalmologists with available Medicare payment data (11 193), a total of 8777 (78.4%) achieved exceptional MIPS scores corresponding to mean (SD) adjustments per physician of $244.60 ($217.36) to $4864.78 ($4323.08), or 0.07% ($2 146 835.21 of $3 212 011 252.88) to 1.33% ($42 698 166.89 of $3 212 011 252.88), of the total nondrug Medicare payment. Results of this economic evaluation showed that although 78.4% of ophthalmologists received exceptional positive payment adjustments, roughly 84% (798916 of 954615) of all health care professionals nationally achieved this benchmark. Exceptional MIPS was associated with filing as group or APM, resulting in, on average, a relatively small additional payment per participant; this suggests that ophthalmologists who file as individuals should consider an alternative filing approach. Changes in MIPS methodology may disproportionately affect certain ophthalmologists, which warrants further study.

Reimbursement for genetic variant reinterpretation: five questions payers should ask.

Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced alternative payment models (APMs). Many of these models will continue to be voluntary because they either are in early stages or have not yet proven their effectiveness. The models that have proven their effectiveness should become permanent, comprising the new way that providers are paid in the Medicare program. Either way, getting today's high performers into those programs and keeping them engaged to continue to innovate and set new benchmarks is as important as attracting and improving the performance of poorer performers. That will require a shift in Medicare's policy on pricing and evaluating APMs.

Medicare APMs at a crossroads.

Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced alternative payment models (APMs). Many of these models will continue to be voluntary because they either are in early stages or have not yet proven their effectiveness. The models that have proven their effectiveness should become permanent, comprising the new way that providers are paid in the Medicare program. Either way, getting today's high performers into those programs and keeping them engaged to continue to innovate and set new benchmarks is as important as attracting and improving the performance of poorer performers. That will require a shift in Medicare's policy on pricing and evaluating APMs.

Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence.

Historically, our health care system has been based on a fee-for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a paradigm in which health care providers are incentivized to provide cost-effective, coordinated, value-based care in an effort to control costs and ensure high-quality care for all patients. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was created and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development.

Merit-Based Incentive Payment System (MIPS) Participation in Radiation Oncology Practices — A Simple Survey

Our purpose was to survey nationwide radiation oncology practices on their participation in, burden of, and satisfaction with the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) payment programs. All radiation oncology practices accredited by a national specialty organization were invited to participate in a voluntary online survey from December 2018 to January 2019. Questions focused on participation in the Merit-based Incentive Payment System (MIPS) in 2017 and 2018, as by the time of this survey, radiation oncology did not yet have a specialty-specific advanced Alternative Payment Model. Of n = 705 solicited practices, n = 199 completed the survey for an overall response rate of 28.2%. Practices varied significantly in their duration of participation in MACRA programs, means of data submission, and reported improvement activities under MIPS. Forty-nine percent of respondents described being either somewhat or extremely dissatisfied with the ease of submitting measures and data in 2018. The estimated cost to the practices of compliance with MACRA was queried in bins; of users able to estimate the cost of compliance for 2018, the median reported bin was $10,001 to $20,000 (range, less than $1000-100,000 or more). The participation style in MACRA among radiation oncology practices varied substantially in the years 2017 and 2018. The Center for Medicare & Medicaid Services gave no precise estimates on the cost of compliance for MIPS, but estimated a $3019.47 cost of compliance with the mandated Radiation Oncology Alternative Payment Model in the 2020 Final Rule for selected practices. In this survey, respondents commonly reported the cost of compliance with MACRA significantly exceeded this estimate.

Utilization and Cost of Radiation Therapy in the Oncology Care Model: Final Results from Performance Period 1

The Oncology Care Model (OCM) is a US Centers for Medicare & Medicaid Services Innovation Center (CMMI)-initiated episode-based advanced alternative payment model (APM). Herein, we detail the utilization and cost of radiation therapy among the Medicare patient population treated in OCM versus comparison practices. We analyzed the evaluation reports of the OCM from Performance Period 1. Performance Period 1 measured outcomes during the intervention period (starting in July 2016 to January 2017) and the baseline period (starting in January 2014 to July 2015). We specifically looked at the number of episodes of radiation therapy delivered per 6-month episode and the cost of radiation therapy as a percentage of the total cost of care (TCOC) per 6-month episode in OCM versus comparison practices. Additionally, we compared total drug costs (Part B Chemo Drug Costs, Part B Non-chemo drug costs, Part B chemo administration costs, Part D chemo drug costs, Part D other drug costs) with total radiation costs (Part B radiation therapy costs). From the baseline period to the invention period, the average number of radiation therapy services per 6-month episode of care decreased from 4.928 to 4.215 (14.5% decrease) among OCM practices versus 5.294 to 4.555 (14.0%) among comparison practices. The table displays the total cost of care (TCOC), drug costs, and radiation therapy costs both in OCM practices and in-comparison practices. Overall, the absolute dollar amount and proportion of the cost spent on radiation therapy decreased in both groups, whereas the absolute amount and proportion of spending spent on drugs increased in both OCM and comparison groups. The results from the OCM Performance Period 1 demonstrate that radiation therapy represents a small proportion of overall health care spending among cancer patients. Overall, radiation spending represented between 2.5% and 3.2% of the spending in the episodes studied, and decreased over the study period, versus drug spending which represented 55.9%-61.3% of overall health spending and increased over the study period. While the publicly available data are limited in scope, these hypothesis-generating findings suggest that the OCM modestly reduced radiation utilization and costs, while the total cost of care and drug costs continue to rise. Further work is urgently needed to study how advanced APMs, such as the Oncology Care First and mandatory radiation oncology APM, impact the appropriate use of and access to radiation therapy services.Abstract 201; TableDrug and Radiation Therapy Costs in the OCM per 6-month episodeOCM BaselineOCM InterventionDiffComparison BaselineComparison InterventionDiffTotal Cost of Care$28,202$30,995$2,793$26,494$29,893$3399Drug Costs$15,965 (56.6%)$18,992 (61.3%)$3,027$14,812 (55.9%)$18,077 (60.5%)$3265Radiation Therapy Costs$832 (3.0%)$783 (2.5%)-$49$836 (3.2%)$834 (2.8%)-$2All other care$11,405 (40.4%)$11,220 (36.2%)-$185$10,846 (40.9%)$10,982 (36.7%)$136 Open table in a new tab

Ophthalmologists in the First Year of the Merit-based Incentive Payment System

In 2017, the Medicare Access and Children’s Health Insurance Program Reauthorization Act began requiring clinicians providing services to Medicare Part B beneficiaries to participate in the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Model.1,2 MIPS was created by Medicare Access and Children’s Health Insurance Program Reauthorization Act to consolidate previous quality reporting systems, including the Physician Quality Reporting System (PQRS). This new program bases payment adjustments on quality performance, completion of improvement activities, and the use of electronic health records (EHRs).

Quality Payment Program Year 4 final rule

The Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) was passed by a bipartisan vote of Congress in 2015. MACRA repealed the sustainable growth rate that threatened to reduce Medicare physician payments by >20% yearly. At the same time, MACRA created the Quality Payment Program (QPP), which requires that most physicians who submit claims to the Centers for Medicare and Medicaid Services (CMS) participate in one of two programs: the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM).

Four years into MACRA: What has changed?

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), a policy intended to transition Medicare away from pure fee-for-service care to value-based care. MACRA does this by evaluating the cost and quality of providers, resulting in financial bonuses and penalties in Medicare reimbursement. MACRA offers two tracks for participation, the Merit-based Incentive Payment System and the Advanced Alternative Payment Models. Although the payment rules are different for each of the tracks, common to both is an emphasis on holding providers accountable for high-quality, cost-efficient care. Early data suggest that the End-stage renal disease Seamless Care Organizations, an Advanced Alternative Payment Model, resulted in cost-savings concurrent with improved care quality. Additionally, on July 10th 2019, the President signed an executive order that further attempts to improve kidney disease care by shifting its focus away from in-center hemodialysis toward chronic kidney disease care, home-based dialysis, kidney transplantation, and innovating new therapies for kidney disease. These changes to nephrology reimbursement present a unique opportunity to improve patient outcomes in a cost-effective way. A multidisciplinary effort among policy makers, nephrology providers, and patient advocacy groups is critical to ensure these changes in care delivery safeguard and improve patient health.

Clinical registries, part I

The Quality Payment Program, established by the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA), requires Medicare providers to participate in the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (AAPM). No AAPM is currently approved for vascular surgery, and most vascular surgeons will participate in MIPS. Failure to participate adequately in MIPS in 2019 will result in a 7% penalty in 2021 reimbursements. The Quality category will account for 45% of the final MIPS score in the 2019 reporting year.

Performance Measurement and the Kidney Quality Improvement Registry.

In the 2015 Medicare Access and CHIP Reauthorization Act, the Centers for Medicare and Medicaid Services (CMS) began the transition to a value-based payment system through implementation of the Quality Payment Program (QPP) ([1][1]). Representing a paradigm shift away from traditional volume-based

Accessing your Quality Payment Program feedback reports

The Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) established the Quality Payment Program (QPP), which shifts Medicare from a fee-for-service to a pay-for-performance program. The QPP requires that most Medicare providers participate in the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (APM). As there are no approved vascular APMs, most vascular surgeons will participate in MIPS. Providers who do not meet 2018 minimum participation requirements will receive a 5% penalty in 2020 reimbursements. The first performance year was 2017, and feedback reports for participating providers are available through the Centers for Medicare and Medicaid Services (CMS) website: https://qpp.cms.gov. QPP participants are required to obtain Enterprise Identity Management (EIDM) credentials to obtain their feedback reports. The EIDM credentials are used to submit and to review data for MIPS reporting. Clinicians submitting data as an individual already have EIDM credentials, whereas someone within small group submissions will also have EIDM credentials or know who in their practice does. Partcipation in QPP as part of a large health care organization or academic institution may present challenges in finding the proper department to help you provide access to your data/feedback reports. Institutions participating as an MIPS APM1White P.W. Sales C.M. Johnson B. Rathbun J. Woo K. What is an MIPS APM?.J Vasc Surg. 2018; 67: 353Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar (distinct from an Advanced APM) are responsible for distributing feedback data to clinicians; CMS will not directly provide feedback data to individuals.2Merit-based Incentive Payment System (MIPS) 2017 Performance Feedback Guide.https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2017-Performance-feedback-user-guide.pdfDate accessed: August 23, 2018Google Scholar If you do not have EIDM credentials, the first step in obtaining your QPP performance report is to create an account within the CMS Enterprise portal (https://portal.cms.gov). Select “PV: Physician Quality and Value Programs” from the application drop-down menu. Enter your demographic information, select a user name, and answer three challenge questions that can later be used to verify your identity. Submit the form, and you should receive an e-mail acknowledging successful account creation with your EIDM user ID. If you are in a large group and need to find out if your practice or organization is already registered in the EIDM, contact the Quality Payment Program by phone (1-866-288-8292/TTY 877-715-6222) or by e-mail ([email protected]). You will need to provide the group's Tax Identifier Number and the name of the group. Again, if your practice has submitted data to QPP, then someone in your group has EIDM credentials and should be able to provide your feedback report to you. With your EIDM credentials, you will be able to log into the CMS Quality Payment Program website, https://qpp.cms.gov. Select the “View Performance Feedback” button to obtain your report and to review all of the practice sites to which data were submitted under your National Provider Identifier and Tax Identifier Number. Based on your EIDM credentials, you may be able to review performance feedback for your entire group or be restricted to individual data. Detailed instructions on accessing performance feedback reports are available in the MIPS 2017 Performance Feedback Guide2Merit-based Incentive Payment System (MIPS) 2017 Performance Feedback Guide.https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2017-Performance-feedback-user-guide.pdfDate accessed: August 23, 2018Google Scholar with examples of reports and interpretations. According to CMS, 91% of MIPS-eligible clinicians successfully submitted data in 2017. High performers will receive up to a 4% bonus in their 2019 reimbursements. A final score of 70 or greater qualifies a provider for an additional bonus adjustment for exceptional performance from a $500 million incentive pool.

Moving Beyond the Hospital.

Moving Beyond the Hospital.

Submission of MIPS Quality Metrics via Claims in a Radiation Oncology Practice

Participation in the Medicare Access and CHIP Reauthorization Act (MACRA) involves either Advanced Alternative Payment Models or the Merit-Based Incentive Payment System (MIPS). Most physicians will participate in MIPS, consisting of four performance categories to determine positive, neutral, or negative payment adjustments. The Quality performance category was preceded by the Physician Quality and Reporting System (PQRS) program and now affects physician reimbursement based upon performance rates. The Quality performance category has a high clerical burden on small practices that lack administrative support or access to a Qualified Clinical Data Registry (QCDR). We explored submission of quality data by claims, a method felt to require the least data entry for physicians. With the 4th quarter of the MIPS reporting period (starting 10/2/17 to 12/31/17), we selected seven measures from the CMS Quality Payment Program (QPP) website that could be submitted via claims. Measures were submitted with the appropriate current procedural terminology (CPT) code. Our billing sheet was configured to include these seven measures to be reported for each new patient consult (CPT 99201-5) and follow up visits (CPT 99212-5). Measure #156 was submitted with simulation (CPT 77295). Data on 148 patients was submitted. The measure reported on most frequently was #226 (tobacco use) with 100% of patients being screened for tobacco use and intervention offered for those were current smokers. Measure #130 (current medications) and #110 (influenza vaccination) were tied at 80%. Measure #111 (pneumococcal vaccination) was the next most frequent at 74%. The measures related to screening were the least frequently reported (#112 Breast Cancer Screening at 15% and #113 Colorectal Cancer Screening at 41%). Unlike the PQRS Program, which was a pay for reporting incentive program, the MIPS Quality Performance Category is a pay for performance program. When analyzing the performance rate for each measure, we achieved the following: #110 Influenza vaccination: 80% #111 Pneumococcal vaccination: 52% #112 Breast cancer screening age 50-74: 77% #113 Colorectal cancer screening age 50-75: 88% #130 Current medications 18 and older: 94% #156 Dose limits to normal tissues (for new starts only): 76% #226 Tobacco Use: Screening and Cessation: 97% Our online CMS MIPS Dashboard showed a score of 37.3 out of 60 possible points using this method. Measure #113 did not count towards the score. Participation in the MIPS Quality Performance Category can be successfully achieved via claims submission without the need for purchasing access to a QCDR or other commercially available web-based registry. Computer data entry by physicians was also minimized. Despite only five measures being accepted, our seven selected measures allow radiation oncologists to meet the minimum requirement of six quality measures to participate in the Quality Performance Category of the MIPS Program.

PCN191 - Value-Based Care In Oncology: Challenges And Barriers Amongst Community Oncologists

Reimbursement and payment models are rapidly shifting from volume to value where oncologists are increasingly being rewarded for reducing cost and improving quality. Barriers and challenges to the adoption of a value-based reimbursement model/ environment is not well-studied and is urgently needed for its success. During several live meetings conducted in 2017, US-based community oncologists from various geographic locations who represented various practice types were surveyed using an automated response system. Where appropriate, some questions allowed more than one answer. Questions centered on their understanding of various value-based care models, oncology care model (OCM), and payer/provider pathways. When asked to define value, most respondents equated value with better overall survival (75%) or improved quality of life (72%). When asked if they have already implemented value-based care initiatives in their practice, only 25% answered yes and 12% were not sure if any such initiatives have been implemented. Almost half of the surveyed physicians have not participated in a value-based care program; the top two programs among participants who have were the QOPI program sponsored by ASCO (31%) and the OCM (26%). While 58% of respondents strongly or somewhat agreed that implementing pathways can reduce the overall cost of cancer care, a large majority (41%) are not using pathway-directed treatments. Interestingly, practice-developed pathways were more often used than commercially developed ones. Despite 47% of physicians stating that their practices have the resources needed to implement advanced alternative payment models, only 8% are engaged with payers in these programs. Community oncologists define value as improvement in survival and/or quality of life. Despite value-based care being a major healthcare policy initiative, most oncologists lack the readiness and strategies necessary to properly implement value-based care initiatives and models. Additional resources are needed for successful implementation.

MP76-08 THE IMPACT OF PRE-OPERATIVE PROSTATE IMAGING AND RESIDENT PARTICIPATION ON THE FINANCIAL MARGIN OF AN EPISODE-BASED PAYMENT MODEL FOR ROBOTIC PROSTATECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost & Outcomes Measures I1 Apr 2018MP76-08 THE IMPACT OF PRE-OPERATIVE PROSTATE IMAGING AND RESIDENT PARTICIPATION ON THE FINANCIAL MARGIN OF AN EPISODE-BASED PAYMENT MODEL FOR ROBOTIC PROSTATECTOMY David Johnson, Aaron Laviana, Jamal Nabhani, Reshma Gupta, Eric Kwok, Christine Ahn, Gerald Kominski, Karim Chamie, Mark Litwin, and Christopher Saigal David JohnsonDavid Johnson More articles by this author , Aaron LavianaAaron Laviana More articles by this author , Jamal NabhaniJamal Nabhani More articles by this author , Reshma GuptaReshma Gupta More articles by this author , Eric KwokEric Kwok More articles by this author , Christine AhnChristine Ahn More articles by this author , Gerald KominskiGerald Kominski More articles by this author , Karim ChamieKarim Chamie More articles by this author , Mark LitwinMark Litwin More articles by this author , and Christopher SaigalChristopher Saigal More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2576AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In response to evolving episode-based payment models, health systems must understand the financial margins under which specific service lines operate. Margins at teaching institutions may be particularly narrow due to the added responsibility of resident education and early adoption of advanced technologies whose value is unclear. We estimate the percent reduction in profit margin under an episode-based payment for robotic prostatectomy (RP) associated with varying utilization of pre-operative multiparametric prostate MRI (mpMRI) and resident participation in the operating room. METHODS Episode costs and reimbursements were calculated to determine the margin for all 160 RPs performed at a single teaching hospital in 2016. The episode spanned the initial urologic oncology consultation preceding surgery and continued 90 days post-operatively. Outpatient costs were calculated using previously described time-driven activity based costing (TDABC). Inpatient hospital costs were calculated using a combination of TDABC and hospital activity based costing. Total reimbursement was calculated using hospital-specific Medicare Diagnosis Related Group and Medicare Fee Schedule amounts for all billed codes within the episode. We determined the impact on financial margin for three combinations of mpMRI utilization (0%, 33%, 100%) and number of residents in the operating room (0, 1, 2) using previously calculated TDABC amounts. Direct Medical Education payments and the impact of resident participation on operative time were not included in these calculations. RESULTS Compared with the reference case of no mpMRI and no resident in the OR, the percent reduction in the margin ranged from 4.8 to 43.0% depending on the utilization of mpMRI and resident participation (Figure 1). CONCLUSIONS Varying degrees of utilization of modifiable cost drivers results in a substantial reduction of margin in a theoretical bundled payment model. Resident education is a core mission for academic centers and this mission may impact margin by 19-43%. Granular analysis of cost and reimbursement informs opportunities for value-based care redesign to help health systems succeed under advanced alternative payment models currently being tested by Medicare. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1021 Advertisement Copyright & Permissions© 2018MetricsAuthor Information David Johnson More articles by this author Aaron Laviana More articles by this author Jamal Nabhani More articles by this author Reshma Gupta More articles by this author Eric Kwok More articles by this author Christine Ahn More articles by this author Gerald Kominski More articles by this author Karim Chamie More articles by this author Mark Litwin More articles by this author Christopher Saigal More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...