The first advanced APM sheds surprising light on treatment preferences.

Alternative payment models, or APMs, have been gradually emerging in medical disciplines since the Centers for Medicare and Medicaid Services (CMS) repealed the fee-for-service structure in 2015.

Now, advanced APMs, or aAPMs, are being developed to reward practitioners who take on more risk related to patient outcomes. This approach gives added incentives for high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or to a population.

Recognizing that aAPMs will likely be key tools for its members, the American Urogynecologic Society (AUGS) began working on such a model for a condition often encountered in its specialty, stress urinary incontinence, (SUI).

“Through our work to develop this aAPM for what we thought was a fairly simple condition, we discovered just how complex and challenging the process can be,” said  Daniel Biller, M.D., an associate professor of obstetrics and gynecology at Vanderbilt University Medical Center and chair of the development committee.

Not only is the team developing a workable aAPM but they have learned something about their patients’ treatment preferences, as well.

Value = Quality/Cost

“With the Affordable Care Act, the government began shifting medicine towards value-based care and away from fee-for-service,” Biller said. He said that value-based care emphasizes “value” over “volume,” as opposed to the fee-for-service model based on “incentives that often lead to more services being provided than may be necessary or are evidence based.”

Adopting value-based care involves the use of a formula where value is defined as “quality over cost,” Biller explained. “The challenge with any particular condition is figuring out how to increase the numerator – quality – or shrink the denominator – cost, or ideally to do both at the same time.”

“Now, interest in aAPMS is being reinvigorated, and appropriately so.”

An aAPM is ideally based upon expert guidelines developed by professional societies and the medical literature, which was the approach the committee employed. The process was similar to Vanderbilt’s previous efforts to offer  value-based health care, such as treatment bundles for maternity care, which administrators say have shown benefits for the institution and patients.

Distributing Risk

Among the benefits of aAPMs include financial risk sharing, quality care delivered through evidence-based  pathways, and better integration of care, Biller explained.

“A successful aAPM will include a component designed to spread the risk among the provider, the payer and the hospital,” Biller said.

The model also analyzes the variety of care options available to patients and uses quality incentives to benchmark reimbursement, Biller added.

“This kind of framework gives physicians, hospitals and payers the flexibility they need to redesign care pathways to be more efficient.”

At the same time, Biller says the process ensures accountability for all entities.

Starting with ‘Simple Condition’

Stress urinary incontinence was chosen for the department’s first aAPM because it was seen as a straightforward and well defined condition. “In the end, it has turned out to be neither,” Biller said.

The condition has several different causes and possible treatments.

“Within these treatment protocols, there’s significant variation, not only among physicians, but also in terms of patients’ desires,” he explained.

“We wanted our aAPM to be based on data and evidence from the literature. We didn’t want to assume anything.”

In their report, the AUGS committee noted SUI affects between 25 and 50 percent of women in the United States, costs up to $12 billion annually and is a prominent health concern. The condition occurs when support tissue from the mid-urethra is damaged.

“Damage can occur with labor and delivery and because of gravity. It can also be affected by obesity,” Biller said.

Physicians use a variety of treatment approaches and technologies to address the condition, including biofeedback, physical therapy, the use of pessaries and the mid-urethral sling operation.

Analyzing a Mountain of Data

To formulate their recommendations, the committee members turned their attention to “real-world clinical data,” Biller said.

The committee partnered with the Center for Administrative Data Research at Washington University in St. Louis, which provided statistical support and analysis. The data were drawn from records of 19,426 Medicare beneficiaries treated for stress incontinence between Jan. 1, 2008, and Dec. 31, 2013. 

“Whatever the reason, we are finding that patients often choose these nonsurgical therapies. And they actually work pretty well, too.”

Data collected included information on use of services, reimbursements to physicians and hospitals, and other interventions to calculate the true cost of the care provided. Nonsurgical therapies surprisingly prominent.

Open to the Unexpected 

Although the standard sling operation is often considered a go-to treatment based on patient satisfaction, physical therapy and pessary devices also proved popular.

It is possible that patients choose these alternatives based on perceptions of a  lighter treatment burden and lower cost, Biller speculated. Another factor could be that many were treated by their primary care physicians or other non-surgical provider.

“Whatever the reason, we are finding that patients often choose these nonsurgical therapies,” Biller said, “And they actually work pretty well, too.”


Daniel Biller, M.D., MMHC

Daniel Biller, M.D., is an associate professor in the Department of Obstetrics and Gynecology at Vanderbilt University Medical Center and executive medical director of Vanderbilt’s Center for Women’s Health. His major clinical interests include patient-reported outcomes following surgical and non-surgical interventions for urinary incontinence and pelvic organ prolapse. His research interests include the transition from fee-for-service to value-based health care delivery systems.