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Ruchika Talwar: Hi everyone. Welcome to UroToday's Health Policy Center of Excellence. In our series of notable health policy articles, today we will be talking with Dr. Avi Maganty, who's a urologic oncology fellow at the University of Michigan. Dr. Maganty, thanks for joining us today.

Avinash Maganty: And thanks for having me.

Ruchika Talwar: Congratulations on your article recently published in Urology Practice. It's entitled, Merit-Based Incentive Payment System Quality Reporting in Urology Practices. So if you don't mind, we'll just jump right in. Can you go ahead and give us a background on what MIPS is?

Avinash Maganty: Yeah, absolutely. So the program initially stemmed from the MACRA initiative passed in 2015, and as part of that, Medicare essentially overhauled the way in which physicians are reimbursed, and it represents actually, one of the most extensive ways in which reimbursement has changed, at least primarily for Medicare providers. And as part of that program, the Merit-Based Incentive Payment System, or MIPS, basically requires physicians to measure performance across four categories, which include quality, interoperability, improvement activities, and essentially, spending, which is measured in a number of ways, and performance across these four categories, gives them a final composite score. And based on that score, and whatever benchmarks Medicare sets of physicians, per claim reimbursement, is either adjusted up or down. And so essentially, it's sort of a first attempt by Medicare to better align quality with physician reimbursement.

Ruchika Talwar: Yeah. Thanks for that overview. There's been a lot of focus on both quality and value over the past couple years. In your opinion, what role does the MIPS program play specifically for urology practices?

Avinash Maganty: So it's, Medicare intends to get physicians and patients into these sort of value-based relationships or models. And for the most part, specialists, such as urologists, were largely excluded from a lot of the early initiatives by Medicare. Simply put, because a lot of these revolved around primary care, and MIPS, as by virtue of essentially requiring all Medicare physicians to participate based on their volume, now represents one of the ways in which urologists are almost mandated to participate in value care. And so, I think it is a very potentially new and challenging thing for providers to get used to, to understanding how quality is measured, and what that means for their patients.

Ruchika Talwar: Yeah, exactly. And I think that's why I really think your paper is tackling this issue head on and giving us a lot to think about. So let's discuss the paper then. What was the background of the study, and what were your aims?

Avinash Maganty: Yeah. So essentially, we were just really interested in understanding how urologists were engaging with this program, that had essentially been out for a couple of years now, since 2017. And so simply put, we wanted to know what urologists were reporting, in terms of the quality measures within MIPS, understanding that most of these measures are not really relevant for specialists, specialty care, and in particular, urology. Now there are certainly a few measures that revolve around urologic care and a little bit of prostate cancer, but we weren't sure exactly what urologists were choosing to track and report. And so, that's sort of the background of why we did this and what our interest was.

Ruchika Talwar: Got it. Got it. So what did you find?

Avinash Maganty: Yeah. So interestingly, and perhaps unsurprisingly, we found that, amongst the most frequent measures reported, almost none of them were relevant to urologic conditions, or things that your patients with urology problems might present with. Most of them, if not all of them, were primarily related to primary care. Things related to obesity screening, diabetes management, blood pressure. And some of this certainly may be by virtue of physicians participating in larger groups. But even when we analyze this across the way in which physicians report, which could be as an individual, or as part of a group, or as part of a kind of value-based alternative payment model, the measures were still really just relevant to primary care. And when we specifically looked at measures that could be relevant to urologic conditions, so we kind of classified that ourselves, based on all the measures within MIPS and other clinical registries, even amongst that, about 10% use used any of those measures for urologic conditions. So it kind of raised concern, at least on our end that, does this program really be impactful for patients with urologic conditions?

Ruchika Talwar: Yeah, exactly. And does it really just become another box to check, and another driver of things like physician burnout? Why do you think the urology practices that you analyzed chose those specific measures?

Avinash Maganty: Yeah. And that's a great question, and one that we've been trying to understand, in terms of ways forward. And simply one, I think one possibility is that, these are measures that are, number one, maybe easy to report, easy to track within the electronic health record, or maybe readily available to measure. I think if going beyond that, and trying to actually develop an infrastructure to track measures that urology patients would care about, I think, could be both financially challenging and time-consuming for physicians that may not really have such a time or the financial infrastructure to really support.

Ruchika Talwar: Yeah. I think those are definitely possibilities. It's challenging, because I think we, as a field of medicine, but also obviously, a field of urology, do want to be stewards of high value care. But I think a lot of people are pretty frustrated with the rollout of things like MIPS, that become burdensome requirements, although well-intentioned. So what can we do as urologists moving forward to try to align our goals with the goals of this CMS program?

Avinash Maganty: Yeah. And I think, putting our patients first, and advocating for what would be best, is sort of the overall step, I think. And as you've said that, I think these broad sweeping measures that clinicians are forced into, is just not really going to work. I think a one size fits all solution is challenging, especially depending on the practice context, and certainly, the specialties. I mean, perhaps one thought that we may advocate for is, as Medicare is more interested in getting people into value-based alternative payment models moving forward, is that, we can put forth, as a urologist community, a alternative payment model that will be relevant for our patients, and simply focus on that one. I know a model in a prostate cancer or active surveillance was proposed a while back and did not get through, but similar efforts like that, I think, targeted condition specific models that urologists can focus on, solely engaging with just that, and not worrying about these sort of other ancillary performance measures, could be more impactful.

Ruchika Talwar: Yeah, absolutely. I think the key really is specialty level engagement. Because I suspect, that as urology faces these challenges, so do other subspecialties, such as ENT, I've heard of similar studies in gastroenterology, et cetera. So I think you bring up really good points. I know that prostate cancer model wasn't successful, but there have been other programs, such as the kidney transplant program, et cetera, that have had better luck. So I agree completely, and I think that studies like yours are just the first step here, to hopefully opening up more urology specific quality measures in this program. And with the other changes that were brought by MACRA as a whole.

Question for you about your results. Any difference that you noted based on urology practice settings such as individual practice, group practice, elective style practice versus academic, et cetera?

Avinash Maganty: Yeah. So we broadly looked at individual, versus group, versus a more kind of multi-specialty alternative payment model group. And what we noticed, that those in individual practices were perhaps, more likely to use at least one urology measure, that was related to urinary incontinence evaluation in females. Whereas, those reporting as part of groups, were less likely to use any of those measures. Which perhaps, makes some sense, as perhaps, these groups are, in fact, multi-specialty, and their focus is more on primary care. But nonetheless, a urologist is sort of implicated with their performance, and their score, and their measurement, yet, it may not do anything for their patients.

Ruchika Talwar: Yeah. So you just mentioned a urology specific measure there. Could you share some more details about other urology specific measures that people would be able to choose from?

Avinash Maganty: Yeah, absolutely. So MIPS has, within the actual Medicare MIPS, there are several measures that are perhaps more relevant for urologic conditions, urinary incontinence being one of them, and some other things within the prostate cancer realm, such as avoidance of bone scan in lower risk patients. But there are other clinical registries that are approved by Medicare, one being through Michigan's urologic collaborative for those practicing within Michigan. And then the AUA AQUA Registry actually supports a set of measures that are extremely relevant to urologic care, obviously, and span the spectrum of urologic conditions, from benign to on oncologic conditions. And so, those are sort of readily available and people are able to engage with those through the AUA.

Ruchika Talwar: Yeah. That's great. I think people don't realize that MUSIC, Michigan's urologic collaborative, as well as AQUA, provide opportunities for other practices to avoid some of these big burdensome requirements. So although it may be easier to check a box for blood pressure screening or obesity, you bring up a great point that there are ways for urologists, who are in more individual settings, to set themselves up to be measuring urology specific quality metrics, without taking on a lot of that costly and burdensome infrastructure that comes with trying to implement it. So that, I admit, was a bit of a pointed question. But I know that the AUA has had challenges engaging folks with AQUA specifically. Any thoughts on why that might be?

Avinash Maganty: Yeah. That's a great question, and I don't exactly know the precise answer. And it would be great to understand some of the barriers that urologists are facing, and their general kind of knowledge of these registries, if whether or not they're available, I suspect, perhaps costs may be some sort of factor, but perhaps, lack of awareness may be another. And if there's a way that Medicare can facilitate these perhaps smaller practices, and other people who are having difficulties with tracking and measurement, to engage with these specialty specific programs and registries, I mean, that would be fantastic. But yeah, I'm not totally sure why the engagement with, at least in this performance here, was seemingly low.

Ruchika Talwar: If I had to guess. I suspect a lot of it is, as you mentioned, lack of awareness. So again, I think this paper's fantastic, and it does a good job of shedding light on this topic that is often just sort of looped in with the alphabet soup of letters that CMS requires. So congratulations, and thanks for spending some time chatting with us about it.

Avinash Maganty: My pleasure. Thank you for having me.

Ruchika Talwar: Thanks so much to our audience for joining us in another spotlight on an excellent health policy article, and we hope to see you again soon.