Government Affairs

LUGPA Government Affairs Update — June 2017

Political advocacy is an essential component for LUGPA to fulfill our mission to preserve and advance the independent practice of urology. LUGPA has been evaluating and preparing comment on current and potential future healthcare policy that is positioned to affect patient and physician access to care. This year, LUGPA health policy and advocacy efforts have actively engaged on the following issues: 


USPSTF Recommendation on Prostate Cancer Screening

LUGPA continues our ongoing review of the recently-released USPSTF recommendation on prostate cancer screening updated from its earlier 2012 recommendations — those which our Association strongly opposed. In summary, the updated recommendation changes the grade for PSA-based screening from “D” to “C” for men aged 55-69 years. As a result, the USPSTF now recommends that clinicians may consider discussing with men aged 55-69 what the potential benefits and harms of prostate (PSA) screening entail. For men aged 70 years and older, the USPSTF maintained its “D” recommendation that men 70 and older should not be screened for prostate cancer. Furthermore, the new recommendation did not adequately address men younger than 50 years old which could include higher-risk populations, inclusive of African American men and men with increased hereditary familial risk. Additionally, for men age 70 and older, who enjoy good health and are desire shared decision discussion with their physician, the USPSTF recommendations were lacking.

While the change in recommendation from “D” to “C” softens the impact regarding PSA screening with respect to men aged 55-69, LUGPA is still concerned regarding the USPSTF’s continued use of arbitrary age cutoffs in issuing its recommendations, both for younger and older men. In fact, LUGPA believes that the recent increase in newly diagnosed advanced prostate cancer with more aggressive biology is in part due to those earlier, misguided recommendations. Regrettably patients diagnosed with these higher-grade and higher-stage cancers have less likelihood for cure.

LUGPA has always recommended that patient-physician shared decision making requires thoughtful and clear communication with men of all ages that might be at risk for prostate cancer diagnosis. For those patients newly diagnosed with prostate cancer, LUGPA believes a full discussion of all treatment options (including active surveillance and approved interventions) is required.

LUGPA continues its review of the USPSTF draft recommendations and will work collectively with all experts in the field and will issue comments reflecting LUGPA’s commitment to the rights of individual men to access appropriate screening services. LUGPA will share with its members our subsequent official comments on the USPSTF draft guidelines and will continue to appraise member practices of any new developments.


Developing Urology-Specific Alternative Payment Models (APMs)

Recently, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) accepted LUGPA’s Letter of Intent (LOI) outlining our inaugural APM proposal for newly diagnosed, localized prostate cancer. To date, there have only been 17 LOI submitted nationally, and none of them are GU specific; LUGPA’s proposal is the first Urology disease specific APM. In conjunction with the leadership contributed by LUGPA’s APM and Health Policy Committees as well as our strategic partners, we have continued ongoing dialogue with Center for Medicare and Medicaid Innovation (CMMI). LUGPA will be formally submitting this inaugural APM very soon. This LUGPA APM model proposes episode-based payments for newly diagnosed, localized prostate cancer patients. Evidence-based literature confirms that a subgroup of this population can safely defer or avoid active intervention therapies, thus avoiding or reducing potential morbidities and healthcare costs. LUGPA has proposed an episode-based payment model which aligns incentives for physicians to recommend active surveillance in clinically appropriate patients.,. The LUGPA-developed APM will incentivize patient-physician shared decision making, compensating physicians for the management time required to responsibly evaluate and manage these patients on active surveillance. Benchmarks would be defined based upon a hybrid of an individual practice’s historical clinical decision making and regional decision-making patterns, considering prior use of active surveillance and interventional therapies. If total episode spending is less than the designated benchmark, and the practices continue to provide measurable, quality care, then groups would be eligible for a performance-based payment.

Although LUGPA designed the APM with our members in mind, the proposal is designed to allow participation for all urologists, regardless of practice size, affiliation or ownership of ancillary services. This proposal aligns the financial incentives of urologists with patient/physician shared decision making to appropriately care for very low and low risk prostate cancer patients. The LOI can be accessed here.

While LUGPA and its strategic partners are in the midst of submitting the LUGPA localized prostate cancer APM to government bodies for approval as outlined above, additional work in APM development is ongoing in conjunction with more than 40 LUGPA groups.

About 33 of these groups are in the midst of a best practice pathway process that includes retrospective analysis of each groups’ active surveillance pattern, development of a LUGPA prospective active surveillance protocol, and prospective measurement of protocol adherence once adopted by the groups. This process with be critical in understanding the ability of a wide range of LUGPA practices to actually implement an active surveillance protocol and participate in the LUGPA APM once approved.

In addition, another 11 LUGPA groups are assessing their ability to adopt and adhere to a common infection prophylaxis regimen for prostate biopsy. Data suggests that adherence to a common prophylaxis protocol, tailored to the particular pattern of microbial antibiotic resistance in local regions, is the single best way to reduce infectious complications after prostate biopsy. Depending upon the results of this study, as well as financial analysis of the cost of infectious complications after prostate biopsy in the Medicare population, LUGPA is hoping to develop another APM surrounding prostate biopsy.

LUGPA is very proud of the immense and widespread commitment of its rank-and-file members in the APM development process.

Stark Modernization — With the evolving transition to value based care, there is a need to develop novel payment paradigms that align physician compensation with these new practice models. Provisions in existing Stark law, which was written to curb potential abuses in fee-for-service payment, has been recognized by both regulatory bodies and legislators as a potential impediment in both the development and adoption of value-based care models. LUGPA’s Health Policy and Advocacy teams are actively working in a bipartisan, bicameral fashion to modernize Stark law — our goal is to afford independent practices the ability to develop and test alternative payment models by lessening the administrative burden on practices. These changes will make Stark law consistent with the goals espoused in MACRA, allowing for fair and balanced access to care which will assist all healthcare providers and patient clinical outcomes. LUGPA is a key member in a coalition involving nearly two dozen medical societies that are aligned in these efforts.

MACRA — LUGPA’s comments on the final MACRA regulations (released October 2016) set forth several suggestions that CMS could consider ensuring that specialty providers and integrated urology practices can participate meaningfully in the MIPS, APM incentive, and other programs under the rule. LUGPA is continuing to monitor the implementation of MACRA and will be communicating information on how best to meet the challenges of the new payment system.


Radiation Therapy Alternative Payment Model

LUGPA was part of a coalition that successfully lobbied for a statutory freeze on reimbursement for radiation oncology services — this freeze prevented potentially devastating payment cuts to services for patients with prostate cancer. These provisions of this bill, known as the Patient Access and Medicare Protection Act (PL 114-115), expire at the end of 2018; it was conceived as a pathway to the development of an APM in radiation therapy. Consequently, a part of this statute required reports to Congress on the development of such an APM; this report is due to be delivered in June 2017. In May, the Center for Medicare and Medicaid Innovation (CMMI) held a Radiation Therapy Public Forum held at CMS headquarters in Baltimore, MD; the purpose of the forum was to allow stakeholders to provide input on the design of a radiation therapy APM. LUGPA attended the forum to represent its member practices that perform radiation therapy services and which could be affected by the components of radiation therapy APMs. LUGPA CEO Celeste Kirschner provided input at the CMS meeting — of note is that LUGPA was the only non-radiation oncology organization presenting to CMS at the forum. Ms. Kirschner presented data supporting the significant role independent urology plays in overall prostate cancer radiotherapy services and reviewed the essential components that would allow independent urology groups to participate in a radiation therapy APM. 


Advocacy

This has proven to be an exemplary year for LUGPA’s advocacy efforts. Our Association has been fortunate to enjoy a record level of support and interest in LUGPA’s advocacy activities. At the 2016 Annual Meeting, more than 70 groups pledged their support for political events in 2017. Since early spring, we have been working on the distribution of the pledged funds, and LUGPA will complete a record number of political events with policymakers by the November 2017 Annual Meeting in Chicago.

The purpose of LUGPA’s Advocacy activities is to support LUGPA’s 2017 Legislative Agenda, summarized below:

  • Maintaining the In-Office Ancillary Service Exemption (IOASE).
  • Promoting Stark law reform to allow independent practices to thrive under MACRA.
  • Reform of the USPSTF, to allow for greater transparency and stakeholder engagement.
  • Monitoring regulatory implementation of MACRA.
  • Promote neutrality of physician reimbursement regardless of site of service.
  • Promote the continuation of legislatively mandated radiation therapy reimbursement freeze as radiation therapy bundles are developed.
  • Advocate for physicians’ ability to continue to provide in-office dispensing of pharmaceuticals (where allowed by state law).

LUGPA has hosted several “mini fly-ins” associated with our political events in Washington, D.C., this year. In this way, rank-and —file LUGPA members have an opportunity to join LUGPA leadership in D.C.to attend LUGPA political events, interact with members of Congress or their staff on Capitol Hill, and generally learn the process of political advocacy. LUGPA wishes to recognize not only members of the LUGPA Health Policy Committee and the LUGPA Political Affairs Committee, but the rank-and-file individuals listed below who have taken time from their practices to attend LUGPA political events and “fly-ins” this year: 

  • Dr. Matt Soroush, Academic Urology
  • Dr. David King, Urological Surgeons of Northern California.
  • Dr. Robert Bruce, Urologic Specialists of Oklahoma
  • Dr. Donald Moylan, Michigan Institute of Urology
  • Dr. Peter Knapp, Urology of Indiana
  • Dr. Bradley Orris, Urology of Indiana
  • Dr. William Swanson, Pioneer Valley Urology
  • Dr. David Kelley, Pioneer Valley Urology

LUGPA’s advocacy activities will continue throughout 2017. If your group is contributing to LUGPA political action and is interested in joining us in D.C. to witness the work of LUGPA advocacy firsthand, do not hesitate to contact Celeste Kirschner, LUGPA CEO, at ckirschner@lugpa.org.