Alternative Payment Models in Prostate Cancer: Nomenclature Impact "Presentation" - CJ Stimpson
July 24, 2024
At the CAncer or Not Cancer: Evaluating and Reconsidering GG1 prostate cancer (CANCER-GG1?) Symposium, CJ Stimpson discusses the potential impact of changing nomenclature on alternative payment models (APMs) for prostate cancer. He asserts that such changes would not cause significant problems in developing or executing APMs, as these models are rare for prostate cancer and must already adapt to frequent ICD-10 code changes.
Biographies:
Cary (CJ) Stimpson, MD, JD, Assistant Professor of Urology, Vanderbilt University, Nashville, TN
Biographies:
Cary (CJ) Stimpson, MD, JD, Assistant Professor of Urology, Vanderbilt University, Nashville, TN
Read the Full Video Transcript
CJ Stimpson: So I was asked to talk about the impact of alternative payment models. Would this nomenclature change cause problems or potentially solve some problems? My answer is that changing this nomenclature would not cause any material problems for developing alternative payment models or executing them.
The reason for that is, number one, alternative payment models for prostate cancer are rare. We don't see those very much. And then ICD-10 diagnosis codes, I heard someone refer to C61, change all the time. Alternative payment models have to adapt to changes in diagnosis codes. APM development is an actuarial art informed by clinical expertise, and actuaries know how to carve up populations and make risk-based payment models as long as there's a code in the claims data to do it. There could be some friction for these alternative payment models, particularly if you're trying to benchmark and your benchmark is different than your performance period and you don't have similar coding.
But again, that happens, and I personally have experience dealing with this with our own payment models at Vanderbilt. We just have to make adjustments to try to accommodate that. It is not infrequent that we're making those adjustments. Then there's a question of whether it could solve problems for APM development and execution. I think potentially, yes, it could. Now, this is a reason to do it, but just for everyone's awareness, if we had this reclassification, we would need a new diagnosis code. So we'd have a new, more granular ICD-10 diagnosis code for prostate cancer that would allow us to distinguish in claims data between grade group one and grade group one.
And so that could allow us to have more precise stratification when we're doing, at least in my world, alternative payment model development and implementation. So my question for future research, which I mentioned in a talk I gave this morning for bladder, is that alternative payment models are here to drive out waste. They are here to drive out low-value care. The question is, what is the low-value care that we're trying to drive out, and what would be these two new populations that we have access to? Matt, thanks for letting me go a little early, and I'm happy to take any questions.
CJ Stimpson: So I was asked to talk about the impact of alternative payment models. Would this nomenclature change cause problems or potentially solve some problems? My answer is that changing this nomenclature would not cause any material problems for developing alternative payment models or executing them.
The reason for that is, number one, alternative payment models for prostate cancer are rare. We don't see those very much. And then ICD-10 diagnosis codes, I heard someone refer to C61, change all the time. Alternative payment models have to adapt to changes in diagnosis codes. APM development is an actuarial art informed by clinical expertise, and actuaries know how to carve up populations and make risk-based payment models as long as there's a code in the claims data to do it. There could be some friction for these alternative payment models, particularly if you're trying to benchmark and your benchmark is different than your performance period and you don't have similar coding.
But again, that happens, and I personally have experience dealing with this with our own payment models at Vanderbilt. We just have to make adjustments to try to accommodate that. It is not infrequent that we're making those adjustments. Then there's a question of whether it could solve problems for APM development and execution. I think potentially, yes, it could. Now, this is a reason to do it, but just for everyone's awareness, if we had this reclassification, we would need a new diagnosis code. So we'd have a new, more granular ICD-10 diagnosis code for prostate cancer that would allow us to distinguish in claims data between grade group one and grade group one.
And so that could allow us to have more precise stratification when we're doing, at least in my world, alternative payment model development and implementation. So my question for future research, which I mentioned in a talk I gave this morning for bladder, is that alternative payment models are here to drive out waste. They are here to drive out low-value care. The question is, what is the low-value care that we're trying to drive out, and what would be these two new populations that we have access to? Matt, thanks for letting me go a little early, and I'm happy to take any questions.