Downloaded from http://journals.lww.com/fpmrs by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/28/2020 Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence Developed by the AUGS Payment Reform Committee Jerry L. Lowder, MD, MSc,* Matthew A. Barker, MD,† Tanaz Ferzandi, MD, MBA, MA,‡ Haley Gardiner, MPH,§ Evelyn F. Hall, MD,|| Mikio Nihira, MD, MPH,¶ Adam Holzberg, DO,** Eric Hurtado, MD,†† Simon Patton, MD,‡‡ Jill Rathbun, MHSA,§§ Jonathan P. Shepherd, MD, MSc,|||| and Daniel Biller, MD, MMHC¶¶ Abstract: Historically, our health care system has been based on a fee- for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a para- digm in which health care providers are incentivized to provide cost- effective, coordinated, value-based care in an effort to control costs and en- sure high-quality care for all patients. In 2015, the Medicare Access and Children’s Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was cre- ated and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development. Key Words: alternative payment models, advanced Alternative Payment Model (aAPM), Merit-based Incentive Programs (MIPS), payment reform, episode of care, care pathways, quality measures, stress urinary incontinence (Female Pelvic Med Reconstr Surg 2020;00: 00–00) H istorically, our health care system has been based on a hospital- and clinician-centered fee-for-service model with incentives for volume. Although this system has afforded clini- cians a great deal of autonomy, it has resulted in high-cost and fragmented care. To control costs and ensure high-quality care for all patients, the Center for Medicare & Medicaid Services (CMS) is moving toward a more patient-centered and sustainable paradigm in which health care providers are incentivized to pro- vide cost-effective, coordinated, value-based care. To this end, the Medicare Access and Children’s Health Insurance Program Reauthorization Act was signed on April 16, 2015. The act repealed the Sustainable Growth Rate and the fee-for-service model and re- placed them with a 2-track system. First, in the Merit-based Incentive Payment System (MIPS), health care providers report performance data in four areas: (1) Quality, (2) Improvement Activities, (3) Pro- moting Interoperability, and (4) Cost. Health care providers are then rewarded (receive higher reimbursements) for meeting benchmarks and penalized (receive lower reimbursements) for failing to meet benchmarks. Second, in the advanced Alternative Payment Model (aAPM) system, a specialist or subspecialist organization develops a model that incorporates all aspects of treating patients with a particular clinical condition, including relevant treatments or pro- cedures, costs for services, and anticipated quality outcomes. Once an aAPM is approved by the CMS, a clinician or practice committed to follow it will receive higher or lower reimbursement according to whether they meet the aAPM metrics of providing high-quality and cost-efficient care. Recognizing that the aAPM will be an important mecha- nism by which our members ensure they are appropriately re- imbursed for providing high-quality and cost-efficient care, the American Urogynecologic Society (AUGS) Executive Board created a Payment Reform Committee (PRC) in 2016 and tasked it with developing aAPMs for pelvic floor disor- ders. The PRC was initially charged to focus on an aAPM for stress urinary incontinence (SUI) for several reasons. First, SUI is a common diagnosis, affecting approximately 25%– 50% of women. 1–3 Second, SUI treatment costs up to $12 bil- llion annually in the United States. 4 Third, of all of the pelvic floor disorders AUGS members treat, SUI is theoretically the least complex, so an aAPM for SUI should be a good starting point for aAPMs for more complex pelvic floor disorders such as pelvic organ prolapse. Finally, women with SUI are treated by a diversity of health care providers (eg, primary care physi- cians, general gynecologists, urologists, and female pelvic medicine and reconstructive surgery (FPMRS) specialists) and have numerous treatment options (including but not lim- ited to behavioral modification, pelvic floor physical therapy, continence pessary use, and surgical intervention with urethral bulking, synthetic midurethral sling or urethropexy). Thus, an aAPM that is acceptable to multiple health care provider groups and encompasses numerous treatment strategies should serve as a model for APMs for other pelvic floor disorders. To accomplish this task, the PRC began meeting in September 2016 in collaboration with the Washington University in St. Louis Center for Advanced Database Research, which has ac- cess to CMS administrative claims data. Additionally, an indepen- dent consultant and representatives from the American College of Surgeons and the Society of Gynecologic Oncologists who have created APMs in their specialties are also a part of this initiative. *Obstetrics and Gynecology, Washington University in St. Louis School of Med- icine, St. Louis, MO; †Obstetrics and Gynecology, University of South Dakota, Sioux Falls, SD; ‡Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; §Obstetrics and Gynecology, University of Texas at Austin, Austin, TX; ||Obstetrics and Gynecology, Brown University, Providence, RI; ¶Ob- stetrics and Gynecology, University of California, Riverside, Riverside, CA; **Obstetrics and Gynecology, Rowan University School of Osteopathic Medi- cine, Stratford, NJ; ††Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic Florida, Westin, FL; ‡‡Obstetrics and Gynecology, Kansas Uni- versity School of Medicine-Wichita, Wichita, KS; §§Galileo Consulting Group, Arlington, VA; ||||Trinity Health of New England, Hartford, CT; ¶¶Obstetrics and Gynecology, Vanderbilt University, Nashville, TN. Correspondence: Jerry L. Lowder, MD, MSc. E-mail: lowderj@wustl.edu. Authors are listed in alphabetic order (except for the first and senior authors) in recognition of equal contribution to this work. The authors report no conflict of interest. Copyright © 2020 American Urogynecologic Society. All rights reserved. DOI: 10.1097/SPV.0000000000000997 AUGS RESEARCH REPORT Female Pelvic Medicine & Reconstructive Surgery • Volume 00, Number 00, Month 2020 www.fpmrs.net 1 Copyright © 2020 American Urogynecologic Society. Unauthorized reproduction of this article is prohibited.