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    Value-based pay in 2017: Where does urology fit?

    MACRA to drive participation in shared savings, capitation, episode-based payment programs

    Robert A. Dowling, MDDr. DowlingThe first performance year of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is underway, and most urologists are participating whether they know it or not. At the end of 2017, the Centers for Medicare & Medicaid Services will determine how a provider will be scored (Merit-Based Incentive Payment System [MIPS], MIPS alternative payment model [APM], or advanced alternative payment model) based on participation lists submitted by approved APMs to CMS.

    It is widely anticipated that almost all urologists will be subject to MIPS in 2017 and that most urologists are not participating in CMS-designated APMs in 2017. It is also widely predicted that MACRA and general trends in national health expenditures will drive more and more care into value-based payment models—commercial and public.

    Also by Dr. Dowling: MedPAC proposals seek to mitigate Part B spending

    Value-based payment models tend to fall into three general categories: shared savings programs, capitation models, and episode-of-care models. In this article, I review the current landscape of these payment models, including public and private-sector models that may serve as examples for urology.

    Shared savings programs

    Shared savings programs generally involve payment models that encourage coordination of care, best practices to achieve high quality, and management of the total cost of care for a defined group of patients. Typically, a target expenditure for a year is identified, and if costs are managed below that benchmark, the “savings” are shared according to a predetermined formula. If costs exceed the target amount, then the organization may share in that risk (owe money back to the payer) in “downside” models. Examples include commercial accountable care organizations (ACOs) and Medicare ACOs (Medicare Shared Savings Programs or MSSPs). MSSP tracks 2 and 3 include downside risk for the participating physicians and increasing opportunity for savings as well.

    According to a Leavitt Partners presentation at the 2017 Healthcare Information and Management Systems Society annual conference, as of January 2017 there were 928 ACOs in the US covering 32 million lives. (Also see related blog: bit.ly/ACOsin2016) ACO penetration varies widely across the country, with some service areas having over 20% of covered lives in ACOs and others having no ACOs at all. There are 480 MSSPs covering over 9 million lives, including 438 in track 1, 6 in track 2, and 36 in track 3 (bit.ly/CMSsharedsavings). Again, penetration varies widely even among metropolitan areas: from 25% in Boston to 6% in Seattle.

    Next: "ACOs generate savings by reducing spending, and this model has the potential to create 'winners' and 'losers' "

    Robert A. Dowling, MD
    Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality ...

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      Dr. Jaydeep Date,The Best Urologist in Pune has an experience of over 24 years as a Urologist. He specializes in all kinds of consultations related to Urology & Andrology.

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