Value-Based Payment Models and Management of Newly Diagnosed Prostate Cancer - Avinash Maganty

May 6, 2024

Ruchika Talwar welcomes Avinash Maganty to discuss research on value-based payment models in prostate cancer management, published in Cancer Medicine. Dr. Maganty explains that following the MACRA initiative of 2017, urologists had to adapt to payment models like MIPS and accountable care organizations, which potentially influence treatment decisions, especially in discretionary cases like low-grade prostate cancer. The study analyzed Medicare claims to assess how these payment models affect treatment decisions and spending in prostate cancer care. Findings indicate that the payment models did not significantly alter treatment approaches or spending, suggesting a minimal impact of these models on prostate cancer management. This discussion underscores the importance of designing meaningful payment models that truly enhance value in healthcare.


Avinash Maganty, MD, MSCR, Urologist and Urologic Oncology Fellow, University of Michigan, Ann Arbor, MI

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

Read the Full Video Transcript

Ruchika Talwar: Hi everyone. Welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar, and today, I'm joined by Dr. Avi Maganty, who is a Urologic Oncology fellow at the University of Michigan. Dr. Maganty is joining us today to discuss his recent work in value-based payment models and the management of newly diagnosed prostate cancer. This work was recently published in Cancer Medicine. Thanks, Dr. Maganty, for being here with us today.

Avinash Maganty: Yeah, sure. It's my pleasure. As you alluded to, I'm here to share some work entitled "Value-based Payment Models and the Management of Newly Diagnosed Prostate Cancer." Our interest in this topic was several-fold, and the primary impetus was as a result of the MACRA initiative, which required physicians, including urologists, to participate in some form of value-based care delivery, beginning in 2017. The models most relevant to urologists at this time were the merit-based incentive payment system and accountable care organizations with or without financial risk. Now, the incentives and financial risks embedded within these models vary and, therefore, have the potential to influence the management of prostate cancer, particularly in circumstances in which the decision to treat could be discretionary. For instance, men with low-grade prostate cancer, those who may not otherwise benefit from treatment due to comorbid conditions, face a more complicated decision whether or not to proceed with treatment.

And so, our aim was to understand how urologists' participation in value-based payment models might impact prostate cancer management, which is one of the more common conditions urologists manage, but similarly, an expensive and common condition nationally. We hypothesized that the varying incentives or strengthened incentives within the payment models could differentially influence prostate cancer management. To get at this question, we leveraged a 20% random sample of Medicare claims and developed a national cohort of roughly 31,000 Medicare beneficiaries with a new diagnosis of prostate cancer between 2017 and 2019, following the MACRA initiative, with follow-up through 2020. Our primary exposure was the value-based payment model to which the primary urologist was aligned. So, we defined this as the urologist being aligned to MIPS, to an ACO without risk, or to an ACO with risk, based on Medicare ACO files and publicly available MIPS reporting through CMS.

Now, the outcomes we were particularly interested in examining for this study were general use of any local treatment for these men with a new diagnosis of prostate cancer and the potential for overtreatment, which we defined as treatment among men with a very high risk of non-cancer mortality, which we modeled independently. Then, finally, spending for prostate cancer care in the 12 months after diagnosis. We used a multi-level modeling approach, based on the structure of data, and accounted for various patient characteristics, as well as characteristics of the urologist's practice, and then some of the local market characteristics that could be relevant to how urologists engage with specific payment models. And so, the first question we wanted to examine was, what was the distribution of urologists participating in payment models over time? And what we see here is that, particularly following the MACRA initiative initiated in 2017, we see certainly a rise in those participating in MIPS, because effectively, that's mandatory. But there were very few urologists that actually participated in ACO models with financial risk associated with them.

And those are shown there in the dotted green line. So what we found was that most urologists are either participating in MIPS or in an accountable care organization without financial risk. And looking at our outcomes of interest, we first examined treatment across these various payment models and found that treatment did not vary by the value-based payment model to which the urologist was aligned, shown here in the left panel. Treatment rates were roughly 66% across all model types. And similarly, as shown in the right panel, there was no difference in the likelihood of receiving treatment among men with a very high risk, which we defined as greater than 75% risk, from our modeling approach of non-cancer mortality, potentially a group of men who may not benefit from treatment. And so, treatment among these men also did not vary by payment model and was roughly around 55% across all models to which the urologists were aligned.

And finally, we looked at adjusted spending per beneficiary for prostate cancer care, particularly in the twelve-month period right after diagnosis. And effectively, we found that spending essentially did not vary across any of these model types. When we look at all beneficiaries in the top row, roughly $16,000 was spent in that twelve-month period, and similarly, among those who received a form of treatment, whether that be surgery or radiation in the bottom two rows, the spending was effectively similar. And so, what we concluded here was that, regardless of what payment model the urologists were participating in, the men that they were treating did not have differential treatment, those with newly diagnosed prostate cancer and similarly, those whom we presumed would be least likely to benefit among the cohort, also did not have varying treatments. And similarly, spending did not vary by beneficiary by payment model. And so, these are our primary conclusions that the effect of payment models across these outcomes was effectively negligible.

Ruchika Talwar: Thanks, Dr. Maganty. I think these studies are really interesting, especially given the fact that, a lot of times, they end up being negative studies, or what I mean to say is we see that there's not an effect of value-based payment models. And it's important for us to put out this literature because over time, we've seen more and more of a push to engage specialists, specifically surgical subspecialties, to effectively participate in these models. But we need to make sure the models are meaningful and do generate some sort of value for both the patient, for the care provided to the patient, but also, for the clinician to participate. And we've recently actually, earlier this year, seen CMS put out a lot of press regarding the fact that they want primary care to build more bridges with subspecialty care. So I'm curious, obviously, based on the body of work that you've done in this space, but also, your general experience with looking at these sorts of payment models, what do you think the path forward is? What's the most effective way that CMS can partner with urology on this?

Avinash Maganty: Yeah, and I think that's sort of the million-dollar question: how to effectively engage specialists. And I think, moving forward, the mandate to engage in these models, particularly with some form of financial or downside risk, can become particularly concerning, especially for specialists, because simple constraints on utilization, without any link to meaningful quality for our patients, could result in unintended or negative consequences when we try to reduce spending without really making sure that quality is still being aligned. And so, I think that navigating that for specialty care is, I think, going to be particularly crucial. Traditionally, it's largely been in sort of this episode-based payment model where specialists are in charge of an episode of care, whether that be for a procedure or another specific condition. But urologists are uniquely poised because we sort of serve as the medical home for some conditions, like prostate cancer. We sort of really take care of these patients longitudinally.

And similarly for non-oncologic conditions, whether that be for stone disease or many of the conditions we treat, we are sort of the overall care provider. And so, we're very uniquely poised as specialists, I think, to be at the vanguard of this initiative. And I think, as you alluded to, moving forward, the partnership with primary care is going to be crucial, in that the primary care physicians sort of have this overarching payment model to which they're aligned and make partnerships with specialists who provide the kind of quality of care that they want. And I think that will sort of help align quality with those incentives that are provided through these primarily primary care models. And so, I think that's one particularly interesting approach. Additionally, as I said, maybe condition-specific approaches for our field could be of interest too because we are managing such expensive and relatively common conditions.

Ruchika Talwar: And I think episode-based payments carry some advantages, in that you can financially incentivize proceduralists to only do procedures when it's truly in the best interest of the patient. Now, historically, there's definitely been some concern about volume-based payment models and making sure that procedures are indeed indicated and necessary. So I think that's a rational place to start. But you're right, we can talk about active surveillance for prostate cancer, for example, as a good home for value-based care, episodic models. Kidney stones, I know here at Vanderbilt, we have launched a kidney stone episode-based payment model, that has been pretty successful, with tiers of either trial of passage or one procedure or two procedures. So it's certainly going to take some outside-of-the-box thinking. And I think you're right. I think that the big push here is to have urologists at the forefront of model creation before it becomes a mandate by CMS, right?

Like we have an understanding of our practice, we have an understanding of our patient population, and these changes are on the horizon. So I think now really is the call to action for urologists to understand risk, what that means, to understand the implications of downside risk, but also to understand how prior models, like MIPS, which were, like you said, technically mandatory and had minimal emphasis on urologic reporting, how they failed, and how they've stopped short of the goal of true quality. So kudos to you on this work. I think it's really important for us to see the gaps in prior systems but to do that while we're forward-thinking and trying to push urology to really be the leaders of value-based care in surgical subspecialties. So we appreciate you chatting with us today. Thank you so much.

Avinash Maganty: Oh, my pleasure. Thanks for having me.

Ruchika Talwar: And to our audience, thanks for joining. We'll see you next time.