A newly proposed urology-specific alternative payment model (APM) could save up to 37% on costs of care, partly by giving physicians incentives to pursue active surveillance (AS) rather than active intervention (AI), according to the Large Urology Group Practice Association (LUGPA).

The model is predicated on the belief that a subgroup of patients who typically receive AI could benefit from deferred AI, “thus avoiding overutilization of services while reducing morbidity and cost,” LUGPA said in a statement.

LUGPA estimates that in 2015, 79,000 Medicare fee-forservice beneficiaries were newly diagnosed with prostate cancer, and 79% of those cases were localized to the prostate. Of those diagnosed with localized disease, 77% received AI. LUGPA believes that a subgroup of this population can safely defer AI and thereby avoid overutilization of services while reducing morbidity and costs. LUGPA said that, based on an analysis, an average AI episode of care costs Medicare over 2.5 times more than an AS episode, a difference of over $20,000.

LUGPA’s model would use a specialized payment model to give physicians more of an incentive to choose AS in cases where it is medically appropriate. The model, which has been submitted to HHS for consideration, would provide fees during AS for care management of beneficiaries diagnosed with localized prostate cancer. Also, physicians would receive performance-based payments that reward them for increased use of AS.

LUGPA stated that it believes the APM proposal is groundbreaking. “This is the first and only urology-specific proposal to be submitted and is one of only a handful of submitted proposals across all of healthcare,” said Deepak A. Kapoor, MD, chairman of LUGPA’s health policy committee.

The LUGPA APM has been submitted to the HHS’ Physician-Focused Payment Model Technical Advisory Committee for review. The public comments period has ended, and the payment model now will be considered by a review team that will assess the proposal, additional information, and public comments. After formulation of recommendations, the APM proposal will be brought to a full advisory committee for deliberation and a public vote. Finally, the application will be sent with a recommendation for consideration by the Secretary.

The proposed APM is designed for both independent and hospital-based urologists and is specifically for initial therapy of patients with newly diagnosed organ-confined prostate cancer.

In the APM, episodes of care are divided into 12-month blocks. LUGPA proposes that for patients who are receiving AS or AI, the initial episodes of care should begin with a prostate biopsy and a diagnosis of prostate cancer. For patients who remain on an AS program, it is advised that they continue with additional 12-month episodes of care.

A number of quality measures would be used to evaluate results in the model, including efficiency and cost reduction, communication and coordination of care, clinical outcomes, and patient-reported outcomes. LUGPA is predicting that the proposed APM could save $138 million in healthcare costs over 5 years, with Medicare’s share of that savings being approximately $51 million.

“We believe our proposed APM achieves the Triple Aim of improving both patient care and societal health outcomes, while also reducing total expenditures,” stated Neal D. Shore, MD, president of LUGPA, in a press release.2 “If approved by CMS, this APM should positively affect US urologic care.”

The APM proposal comes at a time when costs related to prostate care may be on the rise. Various groups—such the American Urological Association, the American Society for Radiation Oncology, and the Society of Urologic Oncology&mdash;have issued guidelines for increased screening for clinically localized prostate cancer, potentially spawning a rise in prostate biopsies. These guidelines state that patients who elect AS should receive a systematic biopsy with ultrasound or MRI-guided imaging as part of disease staging and should be encouraged to have a confirmatory biopsy within the initial 2 years and surveillance biopsies thereafter.

Large Urology Group Practice Association. LUGPA advanced payment model for initial therapy of newly diagnosed patients with organ-confined prostate cancer. HHS website. https://aspe.hhs.gov/system/files/pdf/255906/LUGPAAPM.pdf. Published July 5, 2017. Accessed August 14, 2017.

LUGPA submits first of its kind urology-specific APM [news release]. Schaumburgh, IL: Large Urology Group Practice Association; July 14, 2017. http://lugpa. org/press-release-lugpa-submits-first-of-its-kind-urology-specific-apm/. Accessed August 14, 2017.

Physician-Focused Payment Model Technical Advisory Committee. Physicianfocused payment models: PTAC proposal submission instructions. HHS website. https://aspe.hhs.gov/system/files/pdf/255906/ProposalSubmissionInstructions.pdf. Updated August 4, 2017. Accessed August 21, 2017.

American Urological Association. Clinically localized prostate cancer: AUA/ASTRO/SUO guideline. AUA website. http://www.auanet.org/guidelines/clinicallylocalized-prostate-cancer-new-(aua/astro/suo-guideline-2017). Published May 9, 2017. Accessed August 21, 2017.

Articles

A newly proposed urology-specific alternative payment model could save up to 37% on costs of care, partly by giving physicians incentives to pursue active surveillance rather than active intervention, according to the Large Urology Group Practice Association.

Incentivizing the Lower-Cost Decision: LUGPA Believes It Knows How

 defines artificial as “humanly contrived often on a natural model: man-made” and intelligence as “the ability to learn or understand or to deal with new or trying situations: reason.” Do artificial intelligence (AI) and computerized learning (CL) bring us closer to the ideal of what Dr Mayo promulgated nearly a century ago? At some point in their careers, usually when interviewing for medical school or a residency program, most physicians are asked the singular question: Is medicine more a science or an art? I suspect the answer put forth by the majority of us is that it is a combination. For surgeons and urologists, “more art than science” might be the prevalent answer. But I also predict that this, too, is changing as time passes.

The majority of the great diagnosticians of the modern era— Osler, Halsted, Cushing, Harrison, and Taussig, to name just a few&mdash;were dependent on their physical examination skills paired with a precise intake of a complete and accurate history. Generations of physicians learned to compose their notes using the standard SOAP protocol (subjective, objective, assessment, and plan). They had limited serological testing. The use of a microscope for urine and blood evaluation was performed personally and not by an automated system. Imaging involved plain films only.

Over the past few decades, we have gradually ceded our diagnostic skills to technology. History-taking now involves an electronic medical record that is laborious and, clinically, not that helpful. Computerized axial tomography and ultrasound were the first breakthroughs in the 1960s and ’70s. We have now moved into the era of molecular-based imaging, which will provide us more physiologic information rather than just pure anatomy. With the aid of AI and CL, does this possibly make our radiology colleagues an endangered species?

The successful completion of the Human Genome Project in 2003, coupled with enhanced laboratory technology, has led to an explosion of next-generation sequencing and “panomic” testing: genomics, transcriptomics, proteomics, metabolomics, etc. Whether our pathologists will also follow the road of near extinction, as molecular testing rather than histopathology may be the sine qua non for diagnosis, remains to be seen.

This issue becomes even more germane with the ever-increasing understanding of tumor heterogeneity and approval of drugs based on molecular drivers and presence or absence of mutations and not the organ of origin. Could we have a molecular Gleason grade? Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) and CRISPR-associated protein 9 (Cas9) splicing technology potentially allows us to delete and modify the genome to accomplish 1 of Dr Mayo’s goals: disease prevention.

We are all well aware of how the field of urology is, surgically, becoming ever more noninvasive, especially with the advent of robotic technology. As mentioned, next-generation imaging will have a tremendous impact on our specialty. We know that in the United Kingdom, there is movement toward prostate cancer screening using multiparametric—magnetic resonance imaging rather than digital rectal exam and PSA. It does not hurt that the cost is borne by the government and at a fraction of the price patients pay in the United States. Next-generation imaging will also lead us down the road of combining diagnostic and therapeutic modalities into a single agent, known as theranostics.

Despite what seems to be the negative tenor of this missive, all these advancements, I believe, will result in the second premise that the esteemed Dr Mayo put forth: prolonging life. The technology and science are mind-boggling, especially considering the rapidity with which they are being published and approved. As physicians, we again owe it to our patients to stay current with the literature and have a better understanding of the potential and shortcomings of these developments.

I do know, however, there is 1 area that AI will never usurp and that Dr Mayo has not given enough credit: the doctor—patient relationship. Our patients depend on us to provide and present the best up-to-date information possible and formulate a lifelong plan in a trusting and compassionate fashion, taking the time to sit down and discuss their plight. This basic concept will ensure our survival.

Over the past few decades, we have gradually ceded our diagnostic skills to technology.

Are We Headed for Extinction?

With cancer being such a difficult disease to understand, treat, and—of course&mdash;cure, any knowledge that advances practice is invaluable. It naturally follows that sharing that knowledge is essential, so that researchers and clinicians can gain from the power of collaboration. This starts by providing physicians with a platform to share their knowledge with other medical professionals, which we do in this issue of Urologists in Cancer Care® with our lead story on advanced urothelial carcinoma (UC), “Checkpoint Inhibitors Herald a New Era for Treating UC.”

Matthew D. Galsky, MD, a professor of medicine in the Division of Hematology and Medical Oncology at the Icahn School of Medicine at Mount Sinai, New York, and the director of Genitourinary Medical Oncology at the Tisch Cancer Institute at Mount Sinai, shares his professional expertise on the subject. Checkpoint inhibitors are increasingly common and useful in clinical practice, and more research is focused on their use in combination with other therapies.

“Central to the immune system is a set of inhibitory pathways regulated by proteins commonly referred to as immune checkpoints, among which are cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed death 1 (PD-1), and the programmed death ligand 1 (PD-L1) are the most well characterized,” Galsky says in the article.

There are currently 5 agents that are major players in the PD-1 and PD-L1 space: pembrolizumab (Keytruda), nivolumab (Opdivo), durvalumab (Imfinzi), atezolizumab (Tecentriq), and avelumab (Bavencio). Galsky explains these agents, the studies that led to their approvals, and how they are helpful in treating have been very few completed clinical trials exploring CLTA-4 blockade in UC, despite preclinical evidence that this class of drugs could be effective, according to Galsky. More research is needed in this area, lest we overlook a potentially successful treatment.

With regard to our own efforts to foster collaboration, OncLive® recently hosted 2 State of the Science SummitsTM on genitourinary cancers: 1 at Duke Cancer Institute, and 1 at the University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center.

One example is “PSMA-PET Agents Poised to Become Major Step Forward in Prostate Cancer Imaging,” in which Thomas Hope, MD, an assistant professor of abdominal imaging and nuclear medicine at UCSF, said that use of imaging agents with prostate-specific membrane antigen-PET can help clinicians locate the very small, subcentimeter sites of disease typical of prostate cancer in cases where disease previously would have been undetectable.

Daniel J. George, MD, a medical oncologist at Duke Cancer Center, explained that although hormonal- based therapies are a standard component of the treatment landscape of metastatic castration- resistant prostate cancer, other agents are available for first-line use that have the potential to improve outcomes in “Expert Discusses Optimizing Sequence of Non-hormonal Therapy in mCRPC.”

We should all continue to collaborate, sharing expertise and research, to help find better treatments for genitourinary cancers.

With cancer being such a difficult disease to understand, treat, and&mdash;of course&mdash;cure, any knowledge that advances practice is invaluable.

October 2017 | Oncology Live Urologists in Cancer Care®

Incentivizing the Lower-Cost Decision: LUGPA Believes It Knows How

Are We Headed for Extinction?

Kicking Off the Fall Season With Collaboration in Mind