reimbursement Archives

LUGPA Talk: Healthcare Landscape, Reimbursement

by Jeffrey M. Spier, MD | Nov 2024

Jeffrey M. Spier, MD, focuses on reimbursement, healthcare policy, and the role of advocacy in the current urology healthcare landscape. In this 10-minute presentation, Spier highlights LUGPA, which represents independent urology practices, promoting best practices, business acumen in urology, and policy advocacy.

Spier emphasizes the importance of urologists and healthcare professionals engaging in legislative advocacy to address issues such as reimbursement cuts, regulatory burdens, and rising operational costs. He notes that healthcare consolidation can negatively impact patient care and stresses the need for reform, particularly in areas like the Medicare fee schedule.

Spear advocates for unity within the urology community. He remains optimistic, calling for collective efforts to secure better outcomes for both physicians and patients while urging professionals to engage at local and national levels to make meaningful change.

2025 Medicare Part D Changes: Physician’s Perspective

by Neal D. Shore, MD, David S. Morris, MD, FACS and Mark N. Painter, CPMA, MBS | Oct 2024

Mark N. Painter, CPMA, MBS, Managing Partner, Consulting LLC, CEO, PRS Urology Service Corporation, Vice President of Coding and Reimbursement Information and CEO Relative Value Studies, Inc. is joined by Neal D. Shore, MD, FACS and David S. Morris, MD, FACS to discuss the physician’s perspective on the upcoming Medicare Part D updates. They share the benefits of these changes and the possible hardships as well.

In this third part of this series, Mark briefly highlights the Medicare Part D changes, such as the reduction of the maximum out-of-pocket expenditure and the Medicare Prescription Payment Plan (MPPP) or “smoothing option”, that the first part of this series covers in more detail. Neal D. Shore, MD, FACS and David S. Morris, MD, FACS then join Mark to share their point of view as physicians on how they are planning to maneuver these changes in the best way. David S. Morris, MD, FACS discusses how he thinks these changes will give a positive outlook to a patient’s finances, for example with the smoothing option or through grants. Also, Neal D. Shore, MD, FACS shares how offices have to prepare to help patients through the process of understanding and taking advantage of these upcoming updates.

This 15-minute discussion concludes with all speakers agreeing that the financial burden on the patient is key when it comes to medications, but they are cautiously optimistic that these upcoming changes will benefit patients, although many will still rely heavily on grants and funding to get the medications they need. Both physicians share in their hope that the upcoming Medicare Part D changes will be a step in the right direction to making healthcare more accessible to all patients and a reminder: Open Enrollment begins October 15, 2024, and runs through December 7, 2024.

2025 Medicare Part D Changes: Overview of the 2025 Plan

by Mark N. Painter, CPMA, MBS | Oct 2024

Mark N. Painter, CPMA, Managing Partner, Consulting LLC, CEO, PRS Urology Service Corporation, Vice President of Coding and Reimbursement Information and
CEO Relative Value Studies, Inc. reviews upcoming 2025 Medicare Part D changes and what they aim to achieve. This 13-minute discussion goes into detail of each new update to Medicare Part D, including the reduction of the maximum out-of-pocket expenditure, the Medicare Prescription Payment Plan (MPPP), and “Likely to Benefit Letter” and how these can affect different patients, including those that are eligible for grants or subsidies.
Dr. Pohlman then brings up emerging complementary tests that mitigate the weaknesses of PSA alone, like the EpiSwitch® Prostate Screening (PSE) Blood Test. He explains that the EpiSwitch® PSE combines five epigenetic biomarkers with a standard PSA test in prostate cancer screening. He briefly discusses how the simplified test can be implemented in practice and how the test results are quickly and clearly delivered in patient-friendly formats to facilitate shared decision-making.

Dr. Pohlman then discusses the validation processes behind the EpiSwitch® PSE test, including its high accuracy, specificity, sensitivity, and positive/negative predictive values, which reduce the need for unnecessary prostate biopsies. He presents data supporting the benefits of using non-invasive biomarker tests like the EpiSwitch® PSE test in prostate cancer screening prior to MRI and/or prostate biopsy.

Dr. Pohlman concludes by presenting case studies where the EpiSwitch® PSE test would have prevented unnecessary biopsies and MRIs. He discusses his practice’s success in using the EpiSwitch® PSE tests to screen for prostate cancer without defaulting to invasive testing.

Update on PROBASE Trial: Baseline PSA in Young Men (Aged 45 and 50)

by Jeffrey M. Spier, MD | Oct 2024

Jeffrey M. Spier, MD, focuses on reimbursement, healthcare policy, and the role of advocacy in the current urology healthcare landscape. In this 10-minute presentation, Spier highlights LUGPA, which represents independent urology practices, promoting best practices, business acumen in urology, and policy advocacy.

Spier emphasizes the importance of urologists and healthcare professionals engaging in legislative advocacy to address issues such as reimbursement cuts, regulatory burdens, and rising operational costs. He notes that healthcare consolidation can negatively impact patient care and stresses the need for reform, particularly in areas like the Medicare fee schedule.

Spear advocates for unity within the urology community. He remains optimistic, calling for collective efforts to secure better outcomes for both physicians and patients while urging professionals to engage at local and national levels to make meaningful change.

Socioeconomic Aspects of Prostate Brachytherapy

by Peter F. Orio III, DO, MS | Jun 2022

As part of a special course on brachytherapy for prostate cancer from the American Brachytherapy Society (ABS) and Grand Rounds in Urology, Peter F. Orio III, DO, MS, Vice Chair of Network Operations for Dana-Farber/Brigham and Women’s Cancer Center Department of Radiation Oncology and Associate Professor of Radiation Oncology at Harvard Medical School in Boston, Massachusetts, discusses socioeconomic influences on the use of prostate brachytherapy. He begins by listing nine factors that he believes have led to a decline in the use of prostate brachytherapy: (1) a decrease in PSA screening and prostate cancer diagnosis; (2) an increase in patients electing active surveillance; (3) Nuclear Regulatory Commission requirements; (4) an increase in the number of robotic prostatectomies; (5) a suboptimal volume of prostate brachytherapy procedures being performed; (6) negative press about brachytherapy from procedures performed at the Philadelphia VA; (7) the increased technical sophistication of external beam radiation technologies; (8) a lack of knowledge of brachytherapy’s efficacy; and, most significantly, (9) markedly decreased reimbursement rates for brachytherapy. Focusing on this last point, Dr. Orio considers a report by the Government Accountability Office which found that if there was a self-referring interest in a center that offered intensity-modulated radiation therapy (IMRT), use of IMRT would increase by about 50%, while radical prostatectomies would decrease by 27% and brachytherapy procedures would decrease by 50%. He explains that in a fee-for-service model, a treatment like brachytherapy which requires one implant is reimbursed for far less than a treatment like IMRT which requires weeks of treatment over the course of multiple sessions. This creates, Dr. Orio argues, a disincentive to perform brachytherapy even though it is less expensive and results in better quality of life than IMRT. He suggests that implementation of the radiation oncology alternative payment model (RO-APM) may solve this problem. Dr. Orio explains that the RO-APM, which is being tested in certain zip codes, represents a shift to value-based care and is intended to simplify coding and reduce Medicare costs. Under the RO-APM, he notes, regardless of the modality of treatment, the payment is the same, so brachytherapy monotherapy will likely benefit from an increase in payment. Dr. Orio concludes that the RO-APM may lead to a resurgence in prostate brachytherapy by removing financial disincentives to performing the procedure.