APM Proposed for Prostate Cancer Treatment

National urology association estimates its alternative payment model could save Medicare $51 million in five-year period.

The first urology-specific alternative payment model for Medicare beneficiaries has reached a key milestone in the U.S. Department of Health and Human Services approval process.

The APM for Initial Therapy of Newly Diagnosed Patients with Organ-Confined Prostate Cancer was submitted to HHS in July. It will be deliberated Tuesday at the Physician-Focused Payment Model Technical Advisory Committee.

If PTAC gives a favorable recommendation of the APM, the office of the secretary of HHS would make the final approval decision.

The payment model was crafted by the Large Urology Group Practice Association, with assistance from West Palm Beach, Fla.–based Integra Connect and Salt Lake City–based Myriad Genetics.

According to LUGPA's proposal for the APM, a key goal of the payment model is to boost financial support for active surveillance that monitors patients. Active intervention is 2.5 times more expensive on average than surveillance, with the cost difference more than $20,000 per episode of care, LUGPA says.

Active interventions for cancer localized to the prostate include radiation therapy, prostatectomy, and hormonal therapy. LUGPA says interventions put patients at risk of several negative outcomes such as diminished sexual function, urinary incontinence, bowel dysfunction, and urinary irritation.

LUGPA's APM proposal contends that the Medicare fee-for-service payment system is skewed in favor of active interventions for prostate cancer patients. "This has created a misalignment of incentives which results in decision making that promotes [active intervention] for men with localized prostate cancer—data suggests that some of these patients are appropriate candidates for active surveillance."

In 2015, about 63,000 Medicare fee-for-service patients were newly diagnosed with localized prostate cancer, and 77% of those men received an active-intervention treatment, according to LUGPA.

The LUGPA APM features yearlong episodes of care:

• An initial 12-month episode of care, beginning with a prostate biopsy and a cancer diagnosis, for men receiving active surveillance or active interventions.
• Subsequent 12-month episodes of care for men who remain on active surveillance at the end of an initial yearlong active surveillance episode.

The APM includes a two-part payment model:

• A $75 monthly care management fee for initial and subsequent active surveillance episodes capped at $900 per episode.
• A performance-based payment for enhancing utilization of active surveillance compared to a historical period.

LUGPA estimates its APM would save Medicare millions. "Medicare claims data suggest that the LUGPA APM could reduce expenditures by $138 million in five performance years, with Medicare saving approximately $51 million."

Editor's note: This story has been updated to include entities that assisted in the crafting of the payment model.