During 2017, the Large Urology Group Practice Association (LUGPA), Integra Connect, and an industry sponsor formed a collaboration to develop urology-specific Alternative Payment Models (APMs) since no APMs relevant to urologists exist. The first such project relates to localized prostate cancer.
APMs are payment approaches that reward doctors for delivering high-quality and cost-efficient care and are intended to be an alternative approach to the current fee-for-service (FFS) system, which reimburses doctors based on the volume of treatments and services administered.
While the pace of scientific advances, clinical best practices and standards of care have accelerated, the current Medicare FFS payment systems have not evolved synchronously. This has created a misalignment of incentives which results in decision-making that promotes Active Treatment (AT) for men with localized prostate cancer – when data suggests that some of these patients are instead appropriate candidates for active surveillance (AS), which entails closely monitoring with no detriment to their clinical outcomes. Specifically, analysis suggests that an “average” AT episode costs Medicare more than 2.5 times that of an AS episode for appropriate patients, which translates to a difference of more than $20,000 per episode.
The LUGPA/Integra Connect designed APM is 12 month episode-based payment that aligns incentives for physicians to recommend active surveillance in clinically appropriate patients following a positive biopsy for prostate cancer, allowing these patients to avoid unnecessary treatments.