The rise in health care expenditures in recent decades has created an impetus to reconsider how care delivery should be financed. In response to increasing costs, the Affordable Care Act, passed in 2010, created the Center for Medicare and Medicaid Innovation and tasked it with pioneering payment models that prioritize value rather than volume of health care services, thereby attempting to curtail spending while maintaining or enhancing care quality.¹ More than 50 value-based care models have been deployed as part of this effort, each designed to incentivize high-value care in some fashion.¹ After a decade of experimenting with these models, health system leaders and policymakers remain committed to advancing value-based care initiatives.

As value-based care becomes an inevitability for urologists across the country, it is critical to understand how to strategically engage with these models in a way that not only optimizes physician practice but also improves the quality of care for patients with urologic conditions. Currently, the value-based payment models relevant to urologists are the merit-based incentive payment system (MIPS) within Medicare fee-for-service, episode- or condition-based bundled payments, and population-based models (ie, accountable care organizations).

By default, most urologists, with few exceptions, are subject to MIPS. MIPS, introduced as part of the Medicare Access and CHIP Reauthorization Act, determines whether a physician’s Medicare reimbursement at the beneficiary claim level is reduced or increased based on performance across 4 categories: quality, practice improvement, promotion of information technology, and spending. MIPS attempts to shift from volume toward value by linking payment to quality. Nonetheless, it is becoming increasingly evident that MIPS is unlikely to meaningfully improve quality of care for patients.^2,3 This may be due, in part, to the program’s broad measures coupled with the ability of physicians to select the measures they report, raising concern that providers may choose measures in which they already excel. In fact, recent analysis has demonstrated that few urologists report measures relevant to the conditions they treat.⁴ Furthermore, the incentives embedded within MIPS may not be strong enough to promote substantial change in clinical practice that would improve quality of care.⁵

Unlike MIPS, which remains entrenched in fee-for-service, episode- and condition-based bundled payments are models in which providers are paid a lump sum for a surgical episode or condition. This type of value-based arrangement is most applicable to surgical specialties. However, because there are so few bundled payment models for urologic conditions, engagement with this model among urologists is rare. For example, among Medicare’s bundled payment offerings, only a single model for urinary tract infections may be relevant to urology practices. Nonetheless, given the significant variation in episode spending for common urologic procedures, urologic conditions may serve as ideal candidates for application of bundled payments.⁶

Population-based payment models, or accountable care organizations (ACOs), are those in which providers are responsible for both quality and cost of a defined patient population. Financial rewards in ACOs are based on shared savings wherein those that assume downside risk (ie, penalties for exceeding spending benchmarks) keep a larger share of the savings compared to those that do not assume downside risk. Urologists may engage with ACOs directly as part of a physician group or through a hospital system. Alternatively, urologists may engage indirectly through patient referrals from primary care physicians within ACOs. Regardless, most ACOs remain primary care focused. While there are specialty care–based population models (ie, heart failure, end-stage renal disease, and oncology), none are directly relevant to urologists. Although the Oncology Care Model encompasses prostate cancer, the quality metrics utilized align with the treatment of advanced prostate cancer by medical oncologists. Consequently, the effect of ACOs on specialty conditions, including urologic conditions, has been variable and insufficient to drive meaningful improvement in clinical practice.⁷ This may be due to a combination of factors including few quality measures applicable to urologic conditions measured by ACOs, specialist compensation being largely volume-driven even within ACOs, and limited direct engagement of urologists with ACOs.

Thus far, opportunities for urologist participation in value-based care have been meager. However, engagement with value-based care remains crucial as the Centers for Medicare and Medicare Services (CMS) intends for all physicians to transition into value-based arrangements with their patients, wherein they bear fiscal responsibility for the total costs of care by 2030. There are several proposed strategies to enhance specialist integration into value-based care models.^8,9 CMS is focusing on improving the transparency of specialty performance data. Initiatives like the Making Care Primary model aim to provide primary care physicians with specialist data (eg, quality, spending, and use of low-value services) to enhance accountability and promote high-value referrals. Moreover, adding financial incentives within ACOs could also foster specialist participation, especially for complex conditions that may require surgical intervention. For example, including payment incentives for high-cost specialty conditions and allowing specialists to utilize previously exclusive primary care e-consultation, care coordination, and comanagement codes could foster collaboration and improve communication with primary care providers.⁹ The most straightforward strategy to improve specialist engagement with value-based care is expansion of the episode- or condition-based models. Urologists, who generally manage the entire spectrum of a disease from diagnosis to surgical treatment, are well positioned to engage with condition-specific models.^10,11 However, the future of episode- and condition-based models is unclear, as CMS intends to reduce its portfolio of payment models. Nonetheless, episode- and condition-based models continue to be implemented by CMS and commercial payers. For example, CMS will be initiating the Transforming Episode Accountability Model (TEAM), which aims to hold specialists accountable for the entire 30-day cost following a procedure episode with the goal of improving care coordination and transitions between providers to prevent avoidable readmisisons.¹² In the commercial sector, the Vanderbilt Medical Center health plan has initiated a bundled payment for kidney stone episodes wherein care for an episode is covered under a single prospective price, for either surgical or nonsurgical management.¹³ Moreover, the next iteration of the MIPS program, the MIPS Value Pathway, aims to align quality and spending measures more precisely with conditions or episodes.¹⁴ This could provide more targeted quality evaluation for procedures or conditions relevant to urologists. Given that there are no urology-specific value pathways, this is an opportunity as a field to propose pathways that would be most meaningful for patients with urologic conditions. In fact, several employer-sponsored insurance plans are partnering with urology departments to develop value-based care pathways (including payment models) by designating centers of excellence for conditions like prostate cancer. These pathways could then be built upon to develop more robust condition-specific models.

While the future of value-based care for specialists remains somewhat uncertain, there is a multifaceted strategy that will allow urologists to effectively engage with any model design, as they fundamentally revolve around measuring quality and spending. First, it is important to define high quality pertinent to the urologic conditions in collaboration with key stakeholders, including patient advocates. Next, spending benchmarks for the provision of high-value care must be established. Additionally, the data collection process must be augmented to accurately evaluate quality and cost, potentially at the level of the individual urologist or practice. Finally, taking a proactive role in crafting these models is of utmost importance, as these models should ultimately be designed to serve patients with urologic conditions.