Visiting Scholars, Continuing Certification

ABMS Visiting Scholar Researches Urology Practice Patterns

ABMS Visiting Scholar Researches Urology Practice Patterns

Now that Joan S. Ko, MD, a Urology Resident at the James Buchanan Brady Uro­logical Institute and Department of Urology at Johns Hopkins University, has determined that variability exists in Medicare utilization and payment among urologists, the question is how can physicians use this information to improve their practice.

Dr. Ko, who is also a scholar in the first class of the ABMS Visiting Scholars Program, was intrigued by the historic release of 2012 Medicare data on provider billing and reimbursement in April 2014. “While major media outlets provocatively published these data, the availability of this information incited a great deal of discussion in the Johns Hopkins urology clinics and operating rooms," she said. It raised research questions regarding practice patterns among urologists and the correlation of these practices to reimbursement amounts that Dr. Ko and her colleagues and mentor Misop Han, MD, Associate Professor of Urology at Johns Hopkins, set out to answer.

By participating in the Visiting Scholars Program, Dr. Ko is able to further the health policy research that was already underway at Johns Hopkins. The one-year, part-time program is intended to help scholars familiarize themselves with health policy and the external environment in which continuous certification occurs, develop their research skills and scholarship by engaging in a research project re­lated to Board Certification and Maintenance of Certification (MOC)/Continuous Certification; and contribute to the scholarship about innovations/best practices of continuous professional development, assessment, quality improvement, and health policy.

Using the recently released Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF), Dr. Ko and her colleagues reported that the total payment for 8,792 urologists (1% of all Medicare providers) participating in Medicare was nearly $1.4 billion (1.8% of total Medicare payments), with a median payment of $125,997 in 2012. After identifying 40 common services with the highest total payments, they estimated the potential cost savings of approximately $125 million (9.0% of total 2012 Medicare urologist reimbursements) if standardized service utilization was implemented.

Overall, Medicare payment correlated well with the number of patients seen by each provider, according to the study they recently published.¹ These findings suggest that the volume of patient visits, especially among established patients, is responsible for a significant portion of overall costs in urologic care, she explained.

Joan Ko.jpgHowever, some urologists received significantly more payment than would be predicted based on their number of patient visits compared with their peers. In fact, the utilization patterns of these urologists were significantly different in all of the 40 common services analyzed. As an example, they utilized pelvic ultrasound and complex uroflowmetry up to three times more often than their peers.

Dr. Ko is quick to point out that higher utilization of certain services by some providers may reflect differences in patient populations and/or practice patterns. To her point, the PUF data are not risk adjusted. As a result, based on these data there is no way to distinguish, for example, a urologist who specializes in neurogenic bladder whose patients require certain more costly procedures from a general urologist, she said. “Higher utilization is not necessarily over-utilization and reimbursement does not equate directly with profit,” she added. Although the study focused on high utilization because of the cost implications, it also revealed low utilization, indicating instances in which necessary tests are potentially not being performed.

In the case of over- or unnecessary utilization of select services, the formula that Dr. Ko and her colleagues created resulted in a significant amount of savings. In addition to identifying and eliminating low value services, they suggested that the Centers for Medicare & Medicaid Services may want to consider standardized utilization of services based on well-defined clinical guidelines and/or recommendations as a means to cut Medicare costs.

Dr. Ko believes this project has implications for the American Board of Urology (ABU), which requires its diplomates to submit a six-month practice log as a part of its MOC program to assess practice patterns and management decisions. “Our process has the potential to objectively assess and identify variability in practice patterns,” she said. It goes beyond case logs and looks at procedures, diagnostic tests, and treatments, creating a broader picture. Using the PUF data and this methodology, ABU would potentially be able to identify performance deficiencies, analyze variation, and report analysis results. Moreover, using this methodology and a standardized utilization approach for providers in other specialties could result in substantial savings to Medicare, leading to more efficient and accountable health care delivery.

In order to move forward with this approach, however, the PUF data must account for variable patient characteristics, which are needed to accurately determine appropriate service utilization, Dr. Ko stated. Currently, the data lack this information. “If we were able to access all the patient clinical characteristics for each provider, we could determine whether or not high utilization really means over-utilization. I suspect in some cases, it probably doesn’t and, in some cases, it may,” she said adding, “That would make using the data for the MOC process much more meaningful because the Member Boards would have a mechanism for ensuring that their diplomates were choosing procedures and tests wisely.”

In the meantime, Dr. Ko hopes the data will be used to facilitate a dialogue. “These data put the ball in the physician’s court,” she said. “Many studies show that physician self assessment isn’t that effective. But if I see that I’m using a service two to three times more often than the typical urologist, it should move me to think whether I am doing the right thing for my patient population,” Dr. Ko concluded. “I could use this information as the focus for reflection or a quality improvement project, or a means to identify gaps.”

1. Ko JS, Chalfin H, Trock BJ, Feng Zhaoyong, Humphreys E, Park SW, et al. Variability in Medicare utilization and payment among urologists. Urology 2015; 85(5): 1045-51.