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Ruchika Talwar: Hi everyone. Welcome to UroToday. Today I'll be highlighting some recent relevant articles in health policy to bring some of these important issues to the spotlight. Today, I'm really excited to have my good friend, Dr. Kamal Golla, who is part of the National Clinician Scholars Program at Duke University, and a urologist at the Durham VA. Kamal, thanks so much for spending some time to chat with us.

Vishnukamal Golla: Thanks, Ruchika. I really appreciate the chance to come out and talk to you guys today.

Ruchika Talwar: I wanted to take a deep dive into a recent publication of yours that was published in the Gold Journal. It's an incredible review on the topic of value in urology. It's entitled Value-Based Payment Shift for Independent Urology Practices, Roadmap and Barriers. Before we start tackling the specific sections of the article, I wanted to just take a second and hear from you. Can you define what value is?

Vishnukamal Golla: Yeah, of course. So one of the tough areas when we talk about value-based payment is really understanding and defining what value is. Simply put, if we want to simplify how we think about it's really aligning financial incentives with the goal of achieving higher quality care. Of course, importantly, care that matters to our patients at a lower cost. So that value equation we know very well is quality over cost. And so sounds very simple in theory, but when you think about actually implementing value-based care or value-based payments and layering in these different complexities of implementation, that's when the definition gets a little bit more tough.

Ruchika Talwar: Yeah, exactly. And I think that's kind of where clinicians, especially urologists today, struggle with what value means to them and how it can be incorporated in their practices. So along those lines, I wanted you to just maybe give us a little bit of insight on why you think value's important in our field.

Vishnukamal Golla: Absolutely. So value-based care is... It's a tough subject for a lot of specialists that really don't have opportunities to participate in different avenues for value. And urologists are unfortunately following that category. If you think about where we really see Specialist Surgeons participating in value-based care, you can think of our orthopedic colleagues. They have a really natural inroad to participating in value. They had a program put out by CMS called CJR or Comprehensive Joint Replacement Bundle, and basically they had this architect or framework for delivering value for hips and knees. If you look to urology, there isn't really as clear cut path for what value is.

Currently, if you ask the boots on the ground urologist what value is, it's they'll point to something called MIPS or the Merit Based Incentive Payment System. And really that's our big participation in value currently, where based on a pay for performance mechanism or a composite performance score where physicians are evaluated and compared to their peers based on this set criteria of quality, their fee for service payments will be either enhanced or reduced. And so right now, that's where urologists currently sit in terms of quality or value-based care. But there has been efforts made to advance into some of the more nuanced and more sophisticated areas of value-based care. Although to date... We can talk about this, to date, they haven't been particularly successful.

Ruchika Talwar: Exactly. And I thought your article did a really nice job of outlining some of these value-based endeavors. Can you pick one of the ones that you discussed in the article? Talk a little bit about its structure and maybe reasons it did or did not do well.

Vishnukamal Golla: Yeah. So I think one of the ones that is conceptually easier to understand, and just as a broad framework, there's probably three avenues for urologists as we think about it to really participate in value-based care. And this would be something again that we envision years down the road, we're not quite there yet, but if we think about the three areas, one would be something called bundle payments. And that is probably the one that's easiest to understand and probably the one where we've tried to make the most inroads as a specialty. So I'll just focus on that one first and happy to go into the other two as well. But for bundle payments really, you can think of two big categories. There's procedural bundle payments, so it's really focused on a surgery. So for example, robotic prostatectomies or kidney transplants. And then there's condition or clinical condition based bundle payments, and that's really focused on entire disease process.

And that'd be something like if you had a bundle payment for say, kidney stones or BPH, which we currently don't have. And so as an example, interestingly enough, urology has been forward-thinking, one of the first bundle payments proposed was actually the UCLA kidney transplant bundle payment. And this actually started back in the 1980s. UCLA contracted with Kaiser for what's called a lump sum payment for all kidney transplant services that were offered. And that's the core of a bundle payment. You get a lump sum for the entirety of a procedure. And they started off basically as a 90-day episode. They had a certain percentage of the lump sum paid to physicians, another percentage paid to the hospitals. And because there's this lump sum of money that goes to taking care of this population of patients, a lot of innovation is built in order to maximize amount of dollars that provide care for those patients.

So they're really spurred integration of specialty care between transplant nephrologists, between urologists at UCLA anyway, most of the transplants are done by the urology department. And then when we think about on the patient side, a lot of work goes into teaching patients, educating patients on discharge, giving them pamphlets, packets, resources, and essentially nurse navigators to help reduce the amount of readmissions or issues managing medications. So a really good example of a successful bundle payment. Now another example of a bundle payment that I think conceptually was really interesting and again highlights how innovative we can be as a field is the bundle payment proposed by the LUGPA or Large Urology Group Practice. And they basically proposed a bundle payment for localized prostate cancer. So newly diagnosed patients with organ confined prostate cancer. And they wanted to develop this bundle payment for a 12-month period where the urologists would be responsible for the total cost of care for taking care of patients and all the way from active surveillance to potentially local treatments.

Unfortunately, they proposed this to the physician technical advisory committee. There's a couple of policy reasons that it didn't pass, but it ended up not being ultimately successful. Some of the reasons for not being successful is that, one, it's really hard for practices to mobilize and really implement some of these things so we can have real world data on how a bundle payment might look. And then the other thing is that, and we can talk about this in the other avenues, but accountable care organizations have, and health system have waivers in place that really allow physicians and hospital systems to share in savings. Meaning if you meet certain benchmarks or you suppress certain benchmarks that you can actually receive financial incentives on this shared pool of money. And those don't really exist for independent practices, which is what the LUGPA was trying to target with their particular bundle payment. So ultimately not successful, but it speaks to a lot of expertise and a lot of kind of grit when trying to innovate in this space.

Ruchika Talwar: Yeah, thanks. That was great. Before we get to the other two buckets, which I do want to at least briefly mention to people, I want to make a case for why an employed or academic physician would care about this. I think you hit the nail on the head when you said LUGPA was motivated, they wanted to share in some of those potential savings if they take on risk, it's like a risk reward model. But if I'm an urologist who works for an academic health system or a big nonprofit and I'm employed, why does this matter to me?

Vishnukamal Golla: Yeah, absolutely. And you hit the nail on the head when we talk about this is just the lack of clarity on why this matters. And I guess before I feel like I'm going to give out the magic answer to the group, there isn't a nice cookbook or a recipe for this, and I'll preface this by saying that the main issue when we think about health system employees is, a lot of these health systems and big hospitals fall under what's called an accountable care organization. They're essentially responsible for the entirety of costs and quality for entire population patients. And they brought in specialists to help manage this population. The thing is, if we look to the literature, there isn't a lot of good data. In fact, the data's fairly mixed that shows that urology care, so if we look at prostate cancer care and how ACOs or health systems might impact their care, that quality or costs actually improve.

And so what does that mean? It just means that financial incentives have not been figured out for specialists like urologists to figure out how they might fit into this big health system and actually be motivated to improve quality and costs. And really as we get to value, the idea is to uncouple from volume and really be focused on that quality and costs and those financial incentives are just unclear. I will make the case that we're entering I think a different time right now. We're really at an inflection point where ACOs before that was the last 10 years of what we focused on building. I mean, I really want to believe that the next 10, 15 years is how do we get specialty care where costs are rising, really fit into ACOs because ultimately those specialty costs will hurt their bottom line. And so as a specialty, figuring out internally how do we improve our quality, how do we improve our costs, will be really, really exciting for ACOs to see because then they might be interested in actually participating and working with certain groups of urologists.

Ruchika Talwar: Yeah, I agree. I agree. And just my own editorialization, I think although somewhat we are still fee for service with our incentives being aligned towards RVUS and things, I think the model's shifting, I think it's not sustainable. So I think even if you are employed in a big health system, we'll notice over the next 10 to 15 years that perhaps things will shift in that regard too. Before we get too carried away, because I know you and I can talk about this forever, can you just very briefly touch upon the other two buckets?

Vishnukamal Golla: Yep. So we talked about bundle payments as being one avenue and the other two avenues are... They're called either accountable care organizations, which we just talked about or population-based models. And then the third route is something called global payment. So this second umbrella of accountable care organizations, we kind of dove into maybe some of its limitations. One of the things that I want to flag is that it's really important to see where policy is headed. And the elephant in the room is obviously CMS and CMMI and dictating how Medicare patients receive care. They have their mission statement, it's laid out in their recent 10 year CMMI refresh for anybody interested in where policy is going in terms of value-based payment. I think that's a really great read, but their goal is by 2030 to have all Medicare patients in some sort of accountable care relationship.

So as I look at my calendar here, it looks like we're far away, but those things will be here sooner than we think. And so when we think about that, that means really specialists are going to be brought into this conversation very quickly for all the reasons that we talked about before, because specialists money and costs are going to really weigh into accountable care organizations, think about their bottom line and their total cost of care. So real opportunity for urologists to figure out at a condition level or a surgical level or a surgeon level, what is quality? What is costs? How much does it cost me to take care of a patient with BPH with all these innovations that are coming? Because those are the metrics that ACOs when they want to pair with the urologist are going to be interested in order to identify that high value urologist.

So that's ACOs. And then the third bucket is probably on the far end of the spectrum of value where we would love to get to, but we are unfortunately pretty far away and it's called global payment model. And so in this setting, urologists or the provider would receive an upfront payment and basically it's called a PM or per member, per month payment to basically take care of a population of patients. And this is, again, a little different than how ACOs receive their financial incentives. The global payment can be upfront how much money you have in your bucket to spend on care. So you're not kind of scrambling at the end of the year. Whereas in an accountable care organization you have benchmarks, you hopefully do better than what the benchmark is stated. If you do, you'll receive some sort of financial incentive at the end of the year or a retrospective payment. So global payment is totally uncoupled from volume. You're getting these payments to really take care of your patients the best way that you can. There aren't currently any examples of that in urology though.

Ruchika Talwar: That's a great overview. I was going to ask you where do you think the future is going? But I think we've touched upon that as we've discussed every bucket. So let's talk barriers right now. What are some barriers to implementation for all of this that urologists are currently facing?

Vishnukamal Golla: So a couple of things I think as we talk again about how to identify that high value urologists, it's really understanding what are the quality metrics that are important to us as a specialty. And I think that is still remains a very big issue. We talked about MIPS. There aren't really that many urology specific quality metrics that you could... A provider can engage in. You look at what MIPS is becoming, which is something called the MIPS Value Pathway or MVP. It's more specialty focused, which is great, but again, urology is not included. And so what as an institution or what as a specialty practice do we want to highlight as a quality metrics for all these wide ranging diseases that the patients we take care of and diseases that we have to deal with? One of my colleagues at Michigan, we, it should be coming out soon, but Avi Maganty just put out this paper that he led and we looked at MIPS measures and the fact that most urologists basically sign up for what are called topped out measures in MIPS, meaning they're at the highest level they can be to maximize payment.

But if we look at internal registries for quality, something called like AQUA for example, only 3% of urologists are really using AQUA. And we don't quite know why that's necessarily the case. I'm sure there's a lot of many reasons why it's not easy to use, but thinking about how to maximize the resources we have because building new quality measures can be really tough. So I think that's a big barrier is... That's a big part of what's difficult. Two, I think is what you brought up, was the idea of what does it mean to be a health system employee urologist, and what does it mean to be an independent urologist? And the incentives for these are on very two different tracks, I mean, frankly. Independent urologists have the advantage of working places where the facility fees are lower. They might have a little bit more ability and maybe closer relationship with some of their primary care doc or fragmented, it could go either way.

Whereas health systems have all the tools at their disposal, but it takes forever for those financial incentives trickle down. So trying to figure out how to build a system that accounts for both of these different independent and health system employee urologists is also really difficult. And really the last thing I think is just, this is maybe more of an editorialization of what I've seen, but we have spent so much time because there's so much to learn and so much to improve in our own field, it's really hard to be knowledgeable about this area of value-based payment or why it's even meaningful to learn.

I was able to dedicate time to this as you are because of the mentorship we have and the path we took in fellowship, but that's not always the case. There's a lot of rigorous research, there's a whole new language and of jargon and terminology to learn, to be able to be proficiently implementing value-based care. And so not expecting everyone to know all the details, but at least to understand what is CMS, where is CMS heading, what is the current state and what are the things that the gaps that we need to understand in order to improve care for our patients, I think is really important, which was the impetus for the paper that we wrote.

Ruchika Talwar: Absolutely. I agree with everything you've said. And a common theme I'm hearing you reference, not directly state, but is engagement. We need urology specific engagement. We need urologists at the table when CMS is gathering information or when other, be it health systems, be it payers when they're trying to formulate these novel programs, we need to make sure that urologists are there to identify barriers ahead of implementation so that we can stay ahead of the eight-ball. And to your last point, I think it's really challenging to understand this world. I learned from you and other colleagues every day more and more about this. So my hope is that this series that we're doing on Uro Today on some of these relevant health policy topics can help make this information a bit more digestible and more accessible to urologists across the spectrum of academic practices, employed physicians and the independent practitioner.

So with that, thank you so much for giving us, well, I should say sharing your expertise and then giving us a deep dive into this paper. It is amazing. It's a great place to start. I'm glad that it is in a journal with a wider audience that's urology specific because I think we need to do a good job of making sure that this sort of information is accessible to the whole field. Thank you so much, Kamal. I really appreciate your time and thanks for listening. Joining us at Uro Today. I hope you'll be on the lookout for some more relevant health policy content. Thanks so much.

Vishnukamal Golla: Thank you so much.