Value-based payment models and management of newly diagnosed prostate cancer

Abstract

Objective: To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer.

Methods: Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis.

Results: Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]).

Conclusions: How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.

Keywords: Medicare; prostate cancer; quality of care; value‐based payment.

FIGURE 1

Percent of urologists participating value‐based payment models before and after MACRA initiation in 2017 (indicated by dotted line).

FIGURE 2

Adjusted percent of (A) all men with newly diagnosed prostate cancer receiving treatment and (B) those with greater than 75% risk of non‐cancer mortality within 10 years, stratified by payment model of urologist. Models adjusted for age, comorbidity, socioeconomic status, race, rural residence, practice organization, year of diagnosis, urologist density, radiation oncologist density, number of hospital beds per 100K residents, and Medicare advantage penetration.

FIGURE 3

Adjusted spending for prostate cancer services per beneficiary in the 12‐month period after diagnosis by payment model among (A) all beneficiaries and (B) those who received treatment, stratified by single specialty and multispecialty urology groups. Models adjusted for age, comorbidity, socioeconomic status, race, rural residence, practice organization, year of diagnosis, urologist density, radiation oncologist density, number of hospital beds per 100K residents, and Medicare advantage penetration. SSG: single specialty group; MSG: multispecialty group.