Episode of Care Models, Urology-Specific QCDR, Physicians Feeling the Increasing Pressures, FDA Approves Hyrimoz


Episode of Care Models Create Both Risk and Value for Practices

The value-based care initiative has driven public and private payers to redesign reimbursement models that focus on care quality and healthcare costs. Bundled payments represent one form of alternative payment models (APMs) that are designed to move toward value-based care.

Under a bundled payment model, providers and/or healthcare facilities are paid a single payment for all the services performed to treat a patient undergoing a specific episode of care. An “episode of care” is the care delivery process for a certain condition or care delivered within a defined period of time.

For example, if a patient undergoes a surgical procedure, payers would traditionally reimburse the hospital, surgeon, and anesthesiologist separately for their part in the treatment. Through a bundled payment model, the payer would collectively reimburse the providers involved, using a set price for the episode of care, which is usually based on historical costs.

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Urology-Specific QCDR Ready for 2018 Reporting

Earlier this year, IntrinsiQ Specialty Solutions began offering a QCDR (Quality Clinical Data Registry) to UroChart practices utilizing Quality Reporting Engagement Group services. The QCDR is a Centers for Medicare & Medicaid Services-approved entity that collects data from individual MIPS-eligible clinicians, groups and/or virtual groups for data submission.

Those MIPS-eligible providers can submit a broader set of measures, including up to 30 measures approved by CMS.

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Physicians Feeling the Increasing Pressures on their Practices

A recent study from the Medical Group Management Association (MGMA) found that physicians are increasingly burdened with both financial pressures on their practices and regulatory issues dealing with reimbursement.

With 426 medical practices responding, the majority (from 68% – 88%) were concerned with regulations around, in order of the top five:
  • The Centers for Medicare & Medicaid Services’ (CMS) Quality Payment Program (MIPS/APMS) – as a point of reference, only 9 percent of the respondents in the study were satisfied or very satisfied with the performance feedback in MIPS
  • Obtaining Prior Authorizations
  • Lack of electronic health record (EHR) interoperability – as different vendors move toward their own version of interoperability, practices feel the software is becoming too costly to implement
  • Government EHR requirements
  • Audits and appeals processes

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FDA Approves Hyrimoz, But Entry into U.S. Market Delayed

The United States Food and Drug Administration (FDA) has approved Sandoz’ biosimilar adalimumab, Hyrimoz (adalimumab-adaz) for the treatment of rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, adult Crohn disease, ulcerative colitis, and plaque psoriasis.

However, the drug will not enter the U.S. market until 2023 due to a global settlement of patent disputes with AbbVie. Additionally, the biosimilar adalimumabs from Amgen (Amgevita™) and Boehringer Ingelheim (Cyltezo™) will also be delayed in the U.S. until 2023.

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