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Communication Key for Transition to Alternative Payment Models

When payers and providers move toward value-based care and alternative payment models, these stakeholders will need to open up a dialogue, said LUGPA's Dr. Neal Shore.

By Vera Gruessner

- Along with health insurers, more and more providers are expected to transition to alternative payment models (APMs) especially due to MACRA’s Quality Payment Program. For example, urology group practices are likely to adopt advanced alternative payment models under the Quality Payment Program in future years since the trade organization LUGPA began collaborating with cloud-based technology vendor Integra Connect to design alternative payment models, according to a press release.

Quality Payment Program

Dr. Neal Shore, President of LUGPA, spoke to to explain how MACRA legislation and the Quality Payment Program have pushed providers along with commercial payers to adopt alternative payment models.

“The MACRA legislation, which clearly delineates a movement to advanced alternative payment models over time [brought LUGPA to work with Integra Connect]. This is clearly the objective of the transition for CMS from volume to value-based care,” Shore explained.

The main goal of the Centers for Medicare & Medicaid Services (CMS) and MACRA regulations is to transition the healthcare industry toward alternative payment models over the next several years. With the move toward value-based care reimbursement, providers may begin the Quality Payment Program under the Merit-based Incentive Payment System (MIPS) but are likely to transition to advanced alternative payment models over time, said Shore.

“The overwhelming majority of physicians will start off within the MIPS reimbursement methodology but it’s clearly their intent to have advanced alternative payment models established for primary care physician groups, specialty groups, multi-disciplinary groups, integrated groups, independent practices as well as hospital-based practices and hospital-affiliated organizations,” Shore continued.

READ MORE: Payers Benefit from Aligning with MIPS, Value-Based Care

Currently, there are only a few advanced APMs being implemented via the Quality Payment Program and none among urology practices. However, LUGPA will be moving forward with assisting urology providers in establishing alternative payment models by working with stakeholders and government agencies.

“It’s been my understanding that there are very few numbers of advanced APMs, which have been accepted by CMMI - no more than three or four and none within the urology specialty,” pointed out Shore. “As President of LUGPA and when I was President-Elect, our board unanimously voted and recognized the need to provide service to our members to help them understand what, ultimately, advanced APMs would look like in the field of urology.”

“We are and continue to always be interested in various expert organizations that have not only the consulting expertise but also the resources and methodological expertise to assist us with navigating the development of advanced APMs,” said Shore. “This process is extremely time-consuming, resource-dependent, and evolving. As an organization such as LUGPA, a nonprofit organization, we’re very interested in collaborating with consultant expert groups as well as with industry and government stakeholders where we can ultimately achieve an advanced APM that would meet the validation and approval for CMMI review.”

The biggest challenge for urology practices in transitioning to value-based care payment structures and the Quality Payment Program is the sheer size of the transformation in moving away from fee-for-service reimbursement and volume-based care to a more pay-for-performance arrangement. Specifically, there is not a “well-defined road map” for providers looking to adopt alternative payment models, explained Shore.

“Urology practices, whether the size of a five to ten person group, 10 to 20, or greater than 20, are all uniformly concerned regarding this transition, which is rather dramatic in terms of the historical volume-based fee-for-service model,” explained Shore. “There is not a well-described or well-defined road map for the physician leaders of these practices and organizations to necessarily follow in a cookbook methodology. So, there are assuredly concerns.”

READ MORE: Why Value-Based Care Reimbursement, MACRA are Here to Stay

Some of the potential solutions for addressing the complexities of transitioning to value-based care include opening a dialogue between private payers, CMS, and the provider community. Shore advises providers and payers to be more proactive in engaging with each other regarding major payment transformations.

“I do believe that CMMI has very carefully listened to the comments that LUGPA and our government affairs committee has formally submitted into the federal registry,” continued Shore. “We have been very proactive in dialoguing with CMS regarding the evolution and development of APMs as well as the MIPS system.”

“My advice for all of our membership and, quite frankly, for all of healthcare practitioners would be to adopt a proactive philosophy towards engagement regarding the expectations over time that CMS has released for this very dramatic transition in healthcare reimbursement. I would not wait, if I were the physician or non-physician leadership, until the last minute to begin a proactive plan of next steps forward,” he stated.

While data supporting the gains from alternative payment models are not yet available for the urology space, orthopedic care using value-based care reimbursement such as bundled payment models was found to be successful, said Dr. Shore.

“We don’t have any contemporaneous data within the urology specialty [on alternative payment models],” he explained. “In orthopedics, there have been some joint-replacement advanced APMs that have been successful.”

READ MORE: Quality Metrics Pose Problems for Value-Based Care Reimbursement

For example, UnitedHealthcare adopted bundled payment models for its orthopedic care and exhibit positives from other value-based care programs such as reduced lengths of hospital stay, clinical quality improvement, and decreased readmission rates.

Shore advises health payers to create strong communication channels with their provider network and create a dialogue addressing any challenges they may experience. Better communication between payers and providers could bring about improved patient health outcomes. Providers, insurance leaders, and patient advocacy groups will need to move forward together in the transition toward value-based care reimbursement.

“For health insurance payers who have existing strong communication with their healthcare providers, they should open as early as possible a directed dialogue reviewing what they see as their initial biggest hurdles both from a health insurance viewpoint and a healthcare provider viewpoint and, ultimately, how it will impact patient care outcomes,” Shore advised.

“There is tremendous heterogeneity within disease states and specialties including throughout the country and often times within a county of an individual state. Having frank, direct communication early on with key leadership groups including providers, insurance, and patient advocacy stakeholders is a wonderful way to move forward,” Shore concluded.


Dig Deeper:

How Medicare, Medicaid, and CHIP Guide the Health Payer Industry

Time, Commitment Required for ACO, Value-Based Care Success


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