Jacqlyn Riposo, MBA1; David Blaisdell, BA1; Celeste Kirschner, CAE, MHSA2; Karen Johnson, PhD3; Alan Kaplan, MD4; Gordon Brown, DO5; Franklin Gaylis, MD6; Courtney Morrow, PhD7; Samuel Stolpe, PharmD, MPH7
1Market Access, Real Chemistry, New York, New York
2 LUGPA, Chicago, Illinois
3American Urological Association, Linthicum, Maryland
4Department of Urology, Georgetown University Medical Center and Washington VA Medical Center, Washington, DC
5New Jersey Urology, Cherry Hill, New Jersey
6Unio Health Partners, San Diego, California
7Healthcare Quality Strategy, Johnson & Johnson, Washington, DC
KEYWORDS:
Urology; quality of health care; health care quality, access, and evaluation; practice management; patient care management; value-based health care; Medicare Access and CHIP Reauthorization Act of 2015
Abstract
The Centers for Medicare & Medicaid Services (CMS) Merit-Based Incentive Payment System (MIPS) program assesses quality, cost, and other performance categories to guide clinicians’ annual Medicare payment adjustments. To tie performance more closely to clinical specialty, CMS established MIPS Value Pathways (MVPs) measure and activity sets focused on specialties, episodes of care, and patient populations to reduce complexity and burden of reporting. Despite the impact of prevalent and costly urologic conditions, such as prostate cancer, on Medicare, the first MVPs for reporting in 2023 did not include urology. To address this gap, Johnson & Johnson, in collaboration with the American Urological Association and LUGPA and with support from Real Chemistry Market Access, convened multistakeholder consultants to build consensus among clinicians, administrators, payers, and patient advocates for an ideal set of measures and activities to include in a prospective urology MVP. The resulting Optimal Care for Patients With Urologic Conditions MVP was finalized by CMS for reporting in 2025. It reflects quality priorities for conditions such as urinary incontinence, kidney or ureteral stones, benign prostatic hyperplasia, bladder cancer, and prostate cancer. The MVP also incentivizes urologists to engage patients about social drivers of risk that may affect access to care or treatment outcomes, advance care planning, patient experience, and fall risk. Implementation of this urology MVP creates an opportunity to establish a bridge from Medicare’s pay-for-performance incentives under MIPS toward future value-based models that comprehensively consider the value that urology specialists provide for patients.
Since the passage of the Patient Protection and Affordable Care Act in 2010,1 the US health care system has increasingly adopted alternative payment model (APM) approaches that aim to link reimbursement for services to high-quality, low-cost patient-centered care. Despite acceleration toward these models, there has been a lack of focus on urologic procedures and services. Value-based programs focused on accountable care for broad populations, such as the Medicare Shared Savings Program for accountable care organizations, tend to focus on primary care and do not emphasize improvement in urology-focused quality measures. Unlike the oncology specialty, where the Centers for Medicare & Medicaid Services (CMS) Innovation Center has established the Enhancing Oncology Model, there are no urology-specific APMs for urologists to participate in. Although LUGPA proposed an APM for initial therapy in patients newly diagnosed with organ-confined prostate cancer, the US Department of Health and Human Services ultimately did not test or implement it.2
In 2017 the Medicare Access and Children’s Health Insurance Program Reauthorization Act, passed by Congress in 2015, replaced the Sustainable Growth Rate for clinician payment adjustment with the Quality Payment Program, which includes 2 tracks for participation3 : the Merit-Based Incentive Payment System (MIPS) and Advanced APMs. The MIPS track allows eligible clinicians to earn positive, neutral, or negative payment adjustments based on performance in 4 categories: (1) Quality, (2) Cost, (3) Improvement Activities to create incentives for care process improvement, and (4) Promoting Interoperability through electronic health records (previously known as meaningful use). Under “traditional MIPS,” participants can select from an inventory of the approximately 200 approved quality metrics and 100 approved improvement activities for reporting measures and activities that are relevant to their practice.
In 2023, CMS began its transition from traditional MIPS to allow optional reporting through MIPS Value Pathways (MVPs). According to CMS, MVPs will “offer more meaningful groupings of measures and activities, to provide a more connected assessment of the quality of care . . . [clinicians will] select, collect, and report on a reduced number of quality measures and Improvement Activities (as compared to traditional MIPS).”4 Initially, selecting and reporting MVPs will be voluntary and aimed at aligning and connecting measures and activities across performance categories to reduce complexity and burden. Individual MVPs will be focused on a given specialty or medical condition.5 These discrete sets of measures are further intended to create a glide path toward readiness for specialty-focused APMs in the future.
This article will discuss (1) the consensus-building process that led to the development of the urologyfocused MVP that was proposed to CMS, (2) the opportunity for urologists to transition to MVPs before they are required to do so, and (3) measures and activities available for reporting in the finalized MVP.
Despite the initial development and adoption of several MVPs across various specialty areas, CMS did not finalize an MVP for urology care in the first round of proposals for performance year 2023.6 The Advancing Cancer Care MVP included 1 quality measure assessing bone density evaluation for patients with prostate cancer who are receiving androgen-deprivation therapy, but none of the first MVPs substantively assessed quality of care for patients with prostate cancer or urology conditions more broadly. The CMS acknowledged the need for a urology MVP in its February 2022 “Needs and Priorities” document, which listed urology as a specialty for stakeholders to consider for future MVP submissions.7
To address the lack of MVPs applicable to urology and prostate cancer care, Johnson & Johnson, in collaboration with the American Urological Association and LUGPA (the Collaborative) and with support from Real Chemistry Market Access, convened a group of multistakeholder consultants to build consensus among urology clinician, oncologist, payer, and patient advocate representatives for measures and activities to include in a urology MVP submission to CMS (Table 1).
The consensus-building process began in 2022 (Figure 1) when Johnson & Johnson, with support from Real Chemistry Market Access, conducted a targeted literature review and quality measure scan to understand (1) key issues related to the quality of urology care and (2) challenges and opportunities in urology quality of care and value-based payment. Real Chemistry Market Access conducted 5 interviews with key opinion leaders to validate research findings and identify additional gaps and opportunities related to urology and prostate cancer quality.
Based on the initial research findings and interviews with key opinion leaders, the Collaborative hosted a series of virtual and in-person convenings with members of a multistakeholder advisory board to build consensus for developing a urology-focused MVP that included a wide range of measures and activities. The goals of the convenings were to
obtain consensus on the relevant and appropriate components of a urology-related MVP focused on the key quality issues and conditions within urology;
develop and refine a draft MVP with input from a multistakeholder advisory board; and
finalize the MVP for submission to CMS for consideration in the calendar year 2025 Physician Fee Schedule rulemaking cycle.
During the convening process, the advisory board reviewed and prioritized quality measures, improvement activities, and cost measures they determined to be relevant and cross-cutting, urology focused, or focused narrowly on urologic cancers. Prioritization of quality measures and improvement activities occurred through an exercise in which attendees were asked to select 4 or more quality measures, 2 or more Improvement Activities, and 1 or more cost measures from a subset of MIPS measures and activities of high relevance and importance to urology. The advisory board achieved consensus for a refined list of measures and activities through subsequent group discussion.
Figure 1. Timeline and process for developing the Optimal Care for Patients With Urologic Conditions MVP Abbreviations: CMS, Centers for Medicare & Medicaid Services; MVP, Merit-Based Incentive Payment System Value Pathway.
Based on the results of the advisory board convenings, the Collaborative submitted a draft MVP with the measures and activities prioritized by the advisory board to CMS for consideration in June 2023. As part of the MVP development process, CMS provided written feedback about the contents of the MVP and hosted a virtual meeting to discuss their questions and comments. The Collaborative submitted written responses to CMS’s feedback, with the rationale for keeping or excluding certain components of the urology MVP. In December 2023, CMS posted a candidate urology MVP for public comment as part of the pre-rulemaking process.8 In 2024, CMS proposed and finalized the Optimal Care for Patients With Urologic Conditions MVP in the 2025 Physician Fee Schedule rule.9 The measures and selected activities that were part of the finalized MVP closely aligned with the first version that the Collaborative originally submitted to CMS.
Though not mandatory for 2025, the voluntary option to begin reporting the Optimal Care for Patients With Urologic Conditions MVP will allow urologists to implement processes in their practice to address any implementation challenges in advance of eventual mandatory MVP reporting. In addition, transitioning from traditional MIPS to MVP participation would help urologists10
report on a more meaningful group of measures and activities for urology for a more connected assessment of quality of care;
streamline the process for selecting and reporting measures and activities most relevant to urology, reducing administrative burden;
enhance performance feedback by comparing urology clinicians’ performance with that of peers reporting the same MVP; and
potentially reduce reporting burden in overall CMS reporting programs as the CMS Innovation Center designs new models that align with MVPs, where possible.
Participation in the MVP program also allows reporting at the individual, group, and subgroup levels. The subgroup option allows multispecialty clinics to select a subset of clinicians to report the Optimal Care for Patients With Urologic Conditions MVP. For example, a multispecialty clinic could select a subset of urology specialists and midlevel urology care clinicians to report as a subgroup, focusing on clinically relevant performance measures.11
The Optimal Care for Patients With Urologic Conditions MVP establishes a set of relevant quality measures, cost measures, and Improvement Activities that urologists can report to earn credit under the MIPS program (Table 2).
Quality measures in the MVP are divided into 3 broad categories:
Narrow urologic cancer–focused measures. Cancer-focused measures are specific to bladder cancer and prostate cancer:
– Bladder cancer measures include repeat transurethral resection of bladder tumors and intravesical BCG administration.
– Prostate cancer measures include active surveillance, bone health, and safety (eg, infectious complications after prostate biopsy).
General urology-focused measures. Quality measures focused on noncancer urologic conditions include topics such as urinary incontinence, benign prostatic hyperplasia (BPH), and stones.
Broad, cross-cutting measures. These measures apply to patients with a broad array of diagnoses that extend beyond urologic conditions but include those populations (eg, measures with denominators that assess care for all patients 65 years of age and older that are applicable to the care urologists provide). The Optimal Care for Patients With Urologic Conditions MVP cross-cutting measures include fall risk, health equity, and patient experience. This list includes various types of measures and data-collection mechanisms to allow various urology care clinicians to report measures that are most applicable to their practice.
Improvement Activities are patient-centered practice interventions that aim to optimize care for beneficiaries. They are organized under 8 quality domains in MIPS:
Achieving Health Equity
Behavioral and Mental Health
Beneficiary Engagement
Care Coordination
Emergency Response and Preparedness
Expanded Practice Access
Patient Safety and Practice Assessment
Population Management
The group’s priorities within select Improvement Activity quality domains were submitted to CMS and ultimately finalized for 2025 reporting (see Table 2 for the list of included Improvement Activities):
Achieving Health Equity. These activities recognize efforts to use patient-reported outcome tools to better understand patient needs. Tools that solicit information directly from patients help urologists more effectively characterize symptom burden and health-related quality of life (QOL) and inform clinical decision-making.12 Furthermore, these activities are linked to quality measures recommended for the MVP that focus on collecting and using patient-reported survey tools (eg, Q476).
Beneficiary Engagement. These activities assess practices’ ability to engage patients and their caregivers by evaluating experience of care surveys and conducting care planning. Gauging patient experience and satisfaction can help ensure that urologists are providing timely care that meets patient expectations. Furthermore, these activities incentivize improving methods for establishing goals and a care plan for treatment of urologic conditions (eg, urinary incontinence, urologic cancers).
Care Coordination. These activities include interventions for improving care coordination training processes, promoting bilateral information exchange with patients, and incentivizing the use of patient navigator programs. There is also an activity focused on engaging community resources to address social drivers of health that provides a link to the Screening for Social Drivers of Health (Q487) quality measure.
Expanded Practice Access. These activities expand patient access by providing 24/7 access to medical record information, implementing telehealth services, and collecting and using patient satisfaction data on access to care. Telehealth services are particularly important for urology; a researcher has stated that “up to 80% of first urology consultations don’t need an initial physical exam” and can be conducted virtually, reducing patient burden.13 Access to care from urologists is generally challenging because of clinician shortages in rural areas.14 Activities focused on incentivizing use of advanced practice practitioners in appropriate clinical scenarios may also improve access to care.
Patient Safety and Practice Assessment. These activities promote participation in private payer clinical practice improvement, fostering a quality improvement culture within a practice and participation in Qualified Clinical Data Registries for quality improvement, which provides a linkage with the quality measures in the American Urological Association Quality registry.
Population Management. Activities promoting participation in population health research may be valuable for certain urologists, including those who monitor and manage the quality of active surveillance in low-risk prostate cancer populations.15 Additional activities focus on incentivizing participation in federal or private population health research projects and advance care planning.
Under MIPS, CMS uses administrative claim data to calculate cost measure performance. The MVPs are intended to include cost measures that are relevant and applicable to the MVP clinical specialty or medical condition. The CMS finalized 3 episodebased cost measures in the 2025 Optimal Care for Patients With Urologic Conditions MVP:
Renal or Ureteral Stone Surgical Treatment
Medicare Spending per Beneficiary Clinician
Prostate Cancer (finalized for reporting beginning in 2025)
The advisory board raised substantial concerns about the scope of the Medicare Spending per Beneficiary measure in relation to the role urologists may play in inpatient hospital episodes, including whether urologists would be accountable for decisions made by the hospital that could affect Medicare spending and whether they would be attributed to episodes where their role was predominantly consultative. Despite these concerns, CMS ultimately added Medicare Spending per Beneficiary to the Optimal Care for Patients With Urologic Conditions MVP finalized for 2025, noting that episodes may be attributed to urologists who practice in a hospital setting and that episodes are most frequently attributed to urologists for Medicare Severity Diagnosis Related Groups for Kidney and Urinary Tract Infections and Kidney and Ureter Procedures.
The advisory board also raised concerns about the new prostate cancer cost measure, which was ultimately finalized and included by CMS in the 2025 Optimal Care for Patients With Urologic Conditions MVP. Claims data are limited in their ability to accurately account for cancer severity because of the absence of important clinical factors and the rapid pace of change in cancer diagnosis and treatment. When commenting on this measure and its inclusion in the urology MVP, experts cautioned that there could be unintended consequences of care stinting or gaming of risk adjustment factors to avoid MIPS penalties. This possibility is of particular concern in advanced prostate cancer, which may necessitate genetic testing, advanced imaging, or novel treatments. In the absence of meaningful clinical or patient-reported outcome performance measures for this population, incentivizing spending reduction without corresponding quality measures could disincentivize appropriate care.
Through the convening process, the advisory board explored opportunities to expand on the current quality priorities covered by measures and activities within MIPS, recognizing that innovation in urology care and prostate cancer often outpaces measurement. The CMS has indicated that MVPs implemented in MIPS will be maintained and updated as new measures are added to the program or as topped-out measures or activities that are no longer relevant are removed. The following quality-related priorities that the advisory board explored may translate into future measure or activity development opportunities:
Antimicrobial resistance stewardship for urology procedures. Incentivizing appropriate nonantibiotic prevention strategies is critical to avoid antimicrobial resistance in urologic infections. Asymptomatic bacteriuria (the presence of bacteria in the urine without symptoms of an infection) is common and contributes to antibiotic misuse, which leads to antimicrobial resistance.16
Functional status and QOL. Symptom burden affecting function and QOL is an important patient-centered measure of the effectiveness of treatment. Examples include overactive bladder, urinary incontinence, and urologic cancers.17-19
Health equity and social drivers of health. To recognize changing demographics and the importance of diversity, equity, and inclusion, it is important to pay rigorous attention to health care disparities (eg, racial, rural, or underserved populations) as part of quality improvement. The advisory board emphasized the need to advance quality measures that assess interventions for patients who screen positive for social drivers (eg, transportation, food, or housing barriers) and measure a clinician’s ability to address these factors to improve care outcomes.
Men’s health. Advisory board members proposed that urologists could be assessed on the effectiveness of holistic care for men’s health generally (eg, assessing improvements in adverse events associated with prostate conditions and testosterone-related issues and how diagnoses and treatment may lead to other problems, such as higher rates of hypogonadism in men contributing to sleep apnea).
Opioid use for urologic procedures. The advisory board highlighted the need to measure and improve opioid prescribing for urologic surgical procedures. Urologists can contribute to the negative effects of the opioid epidemic by overprescribing as part of surgical procedures.20 Measuring use of standardized prescribing regimens or avoiding unnecessary opioid prescribing can help mitigate these challenges.
Utilization measures as proxies for cost. Given the challenges of creating cost measures that accurately benchmark spending and attribute costs to urologists, measures that evaluate lowvs high-resource utilization may serve as effective proxies. For example, a utilization measure could consider whether certain urologic procedures were performed in the ambulatory or hospital setting.21 Another resource utilization measure could assess length of stay in the hospital after prostatectomy procedures.
Cost measures for BPH. Benign prostatic hyperplasia is a common condition that affects a growing number of men, including men in the Medicare population, and it can lead to severe QOL concerns. With a variety of treatment options available that may contribute to high costs, the advisory board identified an opportunity to develop episode-based cost measures focused on BPH care.22
Advanced prostate cancer. Although there are more measures available in the MIPS program for prostate cancer than for other urologic conditions, there are no measures that assess care for patients with advanced prostate cancer. Advisors indicated that future measure development should prioritize measures for advanced prostate cancer based on the shifting evidence base and standard of care, such as identification of high-risk disease, imaging (positron emission tomography/computed tomography, magnetic resonance imaging), genetic testing, and immunotherapy.
Appropriate screening for prostate cancer. Underscreening and overscreening of patients with prostate cancer are distinct quality concerns that depend on age groups and risk factors (eg, overscreening older populations and underscreening high-risk patients). Measurement related to appropriate screening should ensure that prostate-specific antigen testing is being performed during various stages of disease and in the appropriate populations.
Concordance with nationally recognized guidelines. The advisory board emphasized the need to standardize care in alignment with nationally recognized cancer treatment guidelines, such as those developed by the American Urological Association and the National Comprehensive Cancer Network. For example, National Comprehensive Cancer Network guidelines provide treatment pathways based on evidence and value that can be used by clinicians for quality improvement, including the standardization of practice assessed by quality measures.
Shared decision-making. Advisors agreed that goal setting and shared decision-making to ensure that treatments are meeting those goals are crucial to ensure that patient-centered care is being provided. Meaningful shared decisionmaking measures may involve assessment of patient-reported outcomes related to whether patients’ understanding of treatment options changed or whether patients felt that clinicians were meaningfully involving them in care decisions. Advisors also recognized that the importance of such measures may depend on patient preference, and they should be flexible enough to account for situations where patients defer to clinicians.
The Optimal Care for Patients With Urologic Conditions MVP finalized for reporting in 2025 includes the majority of the Collaborative’s submitted measures and activities. It reflects quality priorities that affect a range of urology subspecialists and the patients they treat, including for conditions such as urinary incontinence, kidney or ureteral stones, BPH, bladder cancer, and prostate cancer. Furthermore, the MVP incorporates opportunities for urology specialists to engage patients in discussions about social drivers of risk that may affect access to care or outcomes of treatment, advance care planning, patient experience, and important general health concerns such as fall risk.
Implementing this Optimal Care for Patients With Urologic Conditions MVP creates an opportunity to help bridge Medicare’s pay-for-performance incentives under MIPS to future APMs that comprehensively consider the value that urologists provide to their patients. The MVP also establishes a foundation and landing place for new quality measures and activities that address identified gaps, such as patient-reported outcome–based performance measures for functional status and QOL, health equity, surgical measures focused on appropriate pain management and antimicrobial stewardship, and measures for appropriate advanced prostate cancer care.
In reflecting on the measures and activities currently available in MIPS, the advisory board noted important gaps. Development of new measures and activities should be prioritized to close gaps and enable maintenance of the implemented Optimal Care for Patients With Urologic Conditions MVP in future years to ensure that urologists have clinically meaningful options to understand and improve performance based on innovation in their specialty.
The Collaborative encourages urologists to become familiar with the components of the Optimal Care for Patients With Urologic Conditions MVP and begin reporting in 2025. The voluntary option to begin reporting will allow urologists to implement processes in their practice to address any challenges to implementation in advance of mandatory MVP reporting in future years. The measures and activities available for selection in the Optimal Care for Patients With Urologic Conditions MVP closely align with the items the Collaborative submitted to CMS and can help improve urologic care.
Patient Protection and Affordable Care Act, Pub L No. 111-148, 124 Stat 119 (2010). Amended through Pub L No. 117-2, enacted March 11, 2021. Accessed November 21, 2024. https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf
Kapoor DA. LUGPA Advanced Payment Model for Initial Therapy of Newly Diagnosed Patients with Organ-Confined Prostate Cancer: A Proposal to the Physician-Focused Payment Model Technical Advisory Committee. LUGPA. July 5, 2017. Accessed December 18, 2024. https://aspe.hhs.gov/sites/default/files/private/pdf/255906/LUGPAAPM.pdf
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Gaylis FD, Leapman MS, Ellis SD, et al. Feasibility of pay for performance and transparency interventions on the selection and quality of observational management for patients with low-risk prostate cancer in the community practice. Urol Pract. 2025;12(2):241-248. doi:10.1097/UPJ.0000000000000745
Bacteria in urine doesn’t always indicate infection—testing, antibiotic treatment often unnecessary, say IDSA guidelines. News release. Infectious Diseases Society of America. March 21, 2019. Accessed November 21, 2024. https://www.idsociety.org/news--publications-new/articles/2019/BACTE-RIA-IN-URINE-DOESNT-ALWAYS-INDICATE-INFECTION/
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Suskind AM, Dunn RL, Zhang Y, Hollingsworth JM, Hollenbeck BK. Ambulatory surgery centers and outpatient urologic surgery among Medicare beneficiaries. Urology. 2014;84(1):57-61. doi:10.1016/j.urology.2014.04.008
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Published: October 5, 2025.
Conflict of Interest Disclosures: J. Riposo and D. Blaisdell are employed by Real Chemistry, a health care consulting firm with a variety of life sciences clients. C. Morrow and S. Stolpe are employees of Johnson & Johnson and have company stock interests. No other authors have conflicts to report.
Funding/Support: Johnson & Johnson provided funding support for research, the MVP development process, and manuscript development.
Author Contributions: All authors contributed equally to the development, editing, and review of this article.
Data Availability Statement: The data cited in this article are publicly available.
Acknowledgments: The authors thank the advisory board participants listed in Table 1 for their input throughout the MVP development process. They also thank Donna Dugan, David Parker, Greg Pettis, Tom Valuck, Dhaval Patel, and Kendall Logan for their contributions throughout the project.
Citation: Riposo J, Blaisdell D, Kirschner C, et al. Development of a MIPS Value Pathway reporting option for urology payment. Rev Urol. 2025;24(3):e107-e119.
Corresponding author: Jacqlyn Riposo, MBA, 199 Water St, 12th Floor, New York, NY 10032 (jriposo@realchemistry.com)
