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Submit Your Comments on the Proposed Urology MVP

Over the last couple of years, the American Urological Association (AUA) worked alongside other interested stakeholders to develop a urology-specific MIPS Value Pathway (MVP). If approved by CMS, this new MVP would allow urology care providers to submit a specialty-specific MVP for MIPS reporting purposes in the 2025 performance year (PY) and beyond.

The AUA is excited to announce that a modified draft of this MVP, titled “Optimal Care for Patients with Urologic Conditions MVP,” has made it into the 2025 Medicare Physician Fee Schedule Proposed Rule. This MVP focuses on assessing optimal care for patients treated for a broad range of urologic conditions such as kidney stones, urinary incontinence, bladder cancer and prostate cancer. The table below lists the components included in the proposed MVP:

Measure Key

^ New proposed measures and improvement activities

* Existing quality measures and improvement activities with proposed revisions

** Quality measures that are proposed for submission only when included in an MVP

! High priority quality measures

!! Outcome measures

~ Improvement activities that include a health equity component

% Attestation to IA_PCMH provides full credit for the improvement activities performance category

 

Optimal Care for Patients with Urologic Conditions MVP

Quality

Improvement Activities

Cost

(!) Q050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
(Collection Type: MIPS CQMs Specifications)

 

(!) Q318: Falls: Screening for Future Fall Risk
(Collection Type: eCQM Specifications)

 

(!) Q321: CAHPS for MIPS Clinician/Group Survey
(Collection Type: CSV)

 

(!) Q358: Patient-Centered Surgical Risk Assessment and Communication
(Collection Type: MIPS CQMs Specifications)

 

(*) Q462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
(Collection Type: eCQM Specifications)

 

(!!) Q476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
(Collection Type: eCQM Specifications)

 

(!) Q481: Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer
(Collection Type: eCQM Specifications)

 

(~)(!) Q487: Screening for Social Drivers of Health
(Collection Type: MIPS CQMs Specifications)

 

(*)(!!) Q503: Gains in Patient Activation Measure (PAM®) Scores at 12 Months
(Collection Type: MIPS CQMs Specifications)

 

(!!) AQUA8: Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy
(Collection Type: QCDR)

 

(!!) AQUA14: Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment
(Collection Type: QCDR)

 

(!) AQUA15: Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures
(Collection Type: QCDR)

 

AQUA16: Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease
(Collection Type: QCDR)

 

(!) MUSIC4: Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low-Risk Prostate Cancer Patients
(Collection Type: QCDR)

(~) IA_AHE_3: Promote use of Patient-Reported Outcome Tools
(High)

 

(~) IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
(High)

 

IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings
(High)

 

IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care
(Medium)

 

IA_CC_7: Regular training in care coordination
(Medium)

 

IA_CC_13: Practice improvements to align with OpenNotes principles
(Medium)

 

IA_CC_17: Patient Navigator Program
(High)

 

IA_EPA_2: Use of telehealth services that expand practice access
(Medium)

 

(*) IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff
(Medium)

 

(**) IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
(High)

 

(%) IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation

 

IA_PM_17: Participation in Population Health Research
(Medium)

 

IA_PM_21: Advance Care Planning
(Medium)

 

(~) IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
(Medium)

 

IA_PSPA_12: Participation in private payer CPIA
(Medium)

 

IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvement processes
(Medium)

 

IA_PSPA_21: Implementation of fall screening and assessment programs
(Medium)

Renal or Ureteral Stone Surgical Treatment

Medicare Spending Per Beneficiary (MSPB) Clinician

(^) Prostate Cancer

 

Foundational Layer

Population Health Measures

Promoting Interoperability

(!!) Q479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit Based Incentive Payment Systems (MIPS) Eligible Clinician Groups
(Collection Type: Administrative Claims)

 

(!!) Q484: Clinician and Clinician Group Risk standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
(Collection Type: Administrative Claims)
  • Security Risk Analysis
  • High Priority Practices Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
  • e-Prescribing
  • Query of Prescription Drug Monitoring Program (PDMP)
  • Provide Patients Electronic Access to Their Health Information
  • Support Electronic Referral Loops By Sending Health Information

AND

  • Support Electronic Referral Loops By Receiving and Reconciling Health Information

OR

  • Health Information Exchange (HIE) Bi-Directional Exchange

OR

  • Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
  • Immunization Registry Reporting
  • Syndromic Surveillance Reporting (Optional)
  • Electronic Case Reporting
  • Public Health Registry Reporting (Optional)
  • Clinical Data Registry Reporting (Optional)
  • Actions to Limit or Restrict Comp

The AUA encourages all stakeholders to provide feedback to CMS on the proposed measures and activities. Formal comments can be submitted to CMS during the 60 day public comment period, which closes on September 9, 2024. CMS will consider comments submitted by this deadline as it works to finalize the 2025 rule. Comments can be submitted at: https://www.regulations.gov/ (in commenting please refer to file code CMS-1807-P).

Lastly, the AUA is also interested in hearing your thoughts about this proposed MVP, regardless of whether you submit formal comments to CMS. Please let us know if you are likely to 1.) report via this MVP next year (if it is approved), 2.) what questions you have about this MVP, and 3.) any feedback regarding the measures and activities included in this MVP. Please send all correspondence to quality@auanet.org using the subject line “Comments on the Urology MVP.”  

Dates to Remember

April 1, 2024 –December 2, 2024
- 2024 MVP registration window.
- To register, sign into the QPP website with your HCQIS Access and Roles Profile (HARP) account. **A HARP account is required to complete registration.**

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