College of American Pathologists
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September 12, 2013  •  Volume 29, Number 19
Next Issue: September 26, 2013
© 2013 College of American Pathologists

In This Issue:

CAP Continues Campaign to Reverse Dangerous Cuts to Pathology

On September 6, the College of American Pathologists (CAP) submitted comments to the Centers for Medicare and Medicaid Services (CMS) urging the agency to withdraw proposed cuts that could threaten patient access to vital pathology services.

The comments were made in response to CMS’ proposed rule (CMS-1600-P) to reduce Medicare spending on physician pay by linking payment for pathology services on the Physician Fee Schedule, to lower rates paid under Medicare’s Hospital Outpatient Prospective Payment System, the fee schedule used by CMS for hospital outpatient services.

CAP’s Position

CAP strongly opposes these cuts and argues that, if finalized, the proposed rule would adversely impact a number of pathology services that are critical to the diagnosis and treatment of patients each year. CAP notes that reimbursement for 39 pathology services for non-hospital patients could be cut by as much as 80 percent, depending on the service.

Prominent Washington law firm Sidley Austin LLP, in a memo prepared for the College concluded, “the proposal violates the statutory requirement that Medicare practice expenses be resource-based.” The proposal “relies on faulty assumptions and inapplicable facility resource data,” and “does not reflect actual resource costs in the non-facility setting—contrary to law and regulation and CMS’ stated policies and past practices.” Furthermore, according to the memo, “Application of CMS’ proposed OPPS/ASC payment cap in the non-facility PE RVU methodology is not resource-based for the practice setting and is unlawful.”

Additionally, CAP submitted comments to CMS calling for the withdrawal of CMS’ Hospital Outpatient Prospective Payment Proposed Rule (CMS-1601-P), which attempts to bundle pathology physician services and nearly all clinical laboratory tests into Medicare’s payments to hospital outpatient departments. CMS’ proposal to “bundle” over 1,000 clinical laboratory tests into the payments for hospital outpatient procedures could create financial disincentives to perform medically necessary testing, or shift testing from out-patient settings to hospital settings, creating new burdens for patients and higher costs for the healthcare system. CAP noted that many of pathologists’ services would be affected by the bundling proposal.

Actions Taken

With the CMS comment period now closed, CAP continues its campaign to reverse these cuts, focusing its advocacy efforts on Capitol Hill. To date:

  • More than 900 CAP Members have responded to multiple action alerts.
  • 3,000 messages have been sent to Capitol Hill.
  • 37 in-district meetings with respective Members of Congress were held during the August Congressional recess, with more planned in the coming weeks.

On September 18, CAP is planning a targeted member Capitol Hill “fly-in” to maximize advocacy efforts during Congress’ short legislative session. CAP members will lobby key members of the House Ways and Means, Energy and Commerce, and Senate Finance Committees.

In an effort to continue coordination with our coalition partners, CAP, AMA and members of our coalition have met with CMS to express our concerns regarding the proposed cuts (CMS-1600-P). CMS is receiving tremendous push back on the proposed rule, with more than 10,073 comments posted on the rule to date, much of which have been in response to our grassroots campaign. On August 29, CAP, in collaboration with AMA and others, submitted the following comments to CMS Administrator Marilyn Tavenner.

On September 6, the Cancer Leadership Council, a patient-centered forum of national advocacy organizations, also submitted comments to CMS on behalf of cancer patients, physicians and other healthcare providers, outlining how payment caps under the proposed rule (CMS-1600-P) would have a significant impact on pathology, radiation oncology and laboratory services that are important for cancer patients. CAP, along with 18 other cancer patient advocacy organizations, including the Leukemia & Lymphoma Society, Susan G. Komen Advocacy Alliance and the American Society for Radiation Oncology, among others, signed on to the comment letter.

Due to our strong grassroots efforts, Congress is hearing the message and taking action. U.S. Rep. Jim Gerlach (PA-06) and U.S. Rep. Bill Pascrell (NJ-09), key members of the House Ways and Means Committee, are circulating a letter to CMS and among their colleagues opposing the proposed rule. In support of this effort, an action alert will be going out, urging CAP members to contact their Member of Congress and asking them to sign on to the letter as well.

How You Can Help

During the weeks of September 23 and October 14, CAP is encouraging CAP members to meet with Members of Congress back in their congressional districts. If you have not requested an in-district meeting, please do so now.

CAP Partners with 58 Pathology Groups to Promote Inclusion of Pathology Measures in the PQRS

On September 6, CAP collaborated with 58 state pathology societies and national pathology organizations, to submit comments on the Physician Quality Reporting System (PQRS) provisions of proposed rule (CMS-1600-P). PQRS is a program created by CMS that uses payment incentives to encourage the reporting of quality information.

In the comments, CAP expressed concern that many pathologists have no applicable PQRS measures, and that while CAP recommended three new PQRS measures for 2014, they were not included in the proposed rule. Considering these changes, CAP and its partner organizations called on CMS to reconsider including the three proposed measures, as they would allow some pathologists, who currently have no measures, to participate in PQRS. Furthermore, CAP called on CMS to not penalize those pathologists who will still have no measures, even if the three proposed measures are added.

In the Meantime, Don’t Forget PQRS Registration Ends October 15

PQRS registration for the Group Practice Reporting Option (GPRO), the Administrative Claims Option and for the Value-Based Modifier (VBM) Quality Tiering Option ends on October 15.

Registration is required for those who plan to report on PQRS measures as a group using any of the reporting options available. Individual physicians who do not wish to report measures as a group or as an individual, or do not have any applicable measures in the PQRS program, must register for the Administrative Claims option during the open registration period if they want to avoid a -1.5% payment adjustment in 2015.

Who does not need to register? Eligible professionals who are participating in the PQRS as individuals through claims or registries, or those who are in one of the excluded categories (e.g. a participant in an ACO in the Medicare Shared Savings Program) do not need to register on the PQRS website.

An active Individuals Authorized Access (IACS) account to the CMS computer system is needed to register for PQRS and VBM options. CMS is urging representatives of group practices and EPs to request a new IACS account or modify an existing account on the CMS Applications Portal to name a PQRS representative as soon as possible. In order to register, the practice’s representative will need the group’s Tax ID number (TIN), the eligible professionals (EP) National Provider Identification (NPI) and Provider Transaction Access Numbers (PTANs).

Specific instructions for becoming a PQRS representative are available.

Looking for Your 2012 PQRS Feedback Reports?

Individual eligible professionals (EPs) who submitted 2012 PQRS data can now access their PQRS Feedback Reports through the following methods:

  • National Provider Identifier (NPI)-level reports can be requested through the Communication Support Page.
  • Taxpayer Identification Number (TIN)-level reports, which contain NPI-level detail, are available for download on the Physician and Other Health Care Professionals Quality Reporting Portal available on QualityNet.

All medical groups with 25 or more physicians and other practitioners who participated in 2012 PQRS Group Practice Reporting Option (GPRO) will also be able to access PQRS feedback through the 2012 Quality and Resource Use Reports (QRURs), which will be available beginning September 16. The 2012 QRURs will include the group’s performance on PQRS quality measures, outcome measures and cost measures that indicate the groups’ resource use as well as information on PQRS incentive eligibility.

Authorized representatives can access the QRURs. Information about QRURs and the required IACS roles is available on the CMS Physician Feedback Program website under QRUR Templates and Methodologies.

For EPs or group practices that did not earn the 2012 PQRS incentive payment, but believe a payment was earned, CMS has implemented an informal review process for the 2012 PQRS.

Why Is This Important to Me?

The new QRUR reports will allow groups to drill down to information on individual patients and will serve as the basis for the value-based modifier (VBM) that was mandated under the Affordable Care Act (ACA), and which will lead to payment adjustments for physicians in groups of 100 or more starting in 2015 (based on performance in 2013).

In 2016, CMS is proposing to apply the modifier to groups of 10 or more based on cost and quality data for 2014. Therefore, it is extremely important for practices with access to QRUR reports to review them carefully.

The following resources are available to help you access your 2012 reports.

Addressing the Coming Pathologist Shortage

The country faces a significant shortage of pathologists in the near future at a time when pathologists will play essential roles in new care delivery paradigms. Donald Karcher, MD, FCAP, Chair of Pathology at George Washington University and President-Elect of the Association of Pathology Chairs (APC) delivered these twin messages on behalf of the CAP and the Association of Pathology Chairs (APC) on September 9 to the members of the federal Council on Graduate Medical Education (COGME).

COGME has statutory authority to advise the U.S. Department of Health and Human Services (HHS) and Congress on physician workforce policy. Dr. Karcher’s messages served to emphasize a joint statement signed by CAP, APC and eight other pathology associations. The statement complimented COGME on its recent report Improving Value in Graduate Medical Education for recognizing the need to increase funding for GME but expressed serious concerns that the report failed to include pathology as a “high-priority specialty” deserving of special attention in the GME funding paradigm.

Medicare funding for GME has essentially been frozen since 1997, with recent efforts to address shortages aimed mostly at primary care physicians. The joint pathology statement recognized the need to address primary care shortages but also pointed out that while other laboratory workers are vital, they—unlike nurse practitioners—cannot substitute for pathologists.

Dr. Karcher’s remarks and the joint pathology statement are part of CAP’s efforts to increase pathology’s presence in GME policy circles, so that policymakers will begin to understand the critical importance of pathologists in patient care and the need to address the pathology workforce.

CMS Requests Public Comments on the Potential Release of Medicare Physician Data

CMS recently issued a “Request for Public Comments” on the potential release of Medicare physician data. The request came after a Florida district court lifted an injunction that previously prohibited HHS from disclosing this data. As a result, you may now submit Freedom of Information Act (FOIA) requests for access to Medicare physician reimbursement information, and CMS will evaluate whether to provide the data on a case-by-case basis. In response, CMS is looking for input on how to modify its current data release policy with particular feedback on privacy interests, policies, and form.

In response, CAP has signed on to a letter sponsored by the AMA, which seeks to balance the need to release this information, while protecting against inaccuracies, misinterpretations and other potential harms.

Deadline to Update HIPAA Materials Is September 23

The U.S Department of Health & Human Services (HHS) has adopted new rules, which make changes to existing privacy, security and breach notification requirements in what is often referred to as the “Health Insurance Portability and Accountability Act (HIPAA) Omnibus Rule.” These new rules stem from changes made under the Health Information Technology for Economic and Clinical Health (HITECH) Act—part of the same law that created the Electronic Health Records (EHRs) Incentive Program under Medicare and Medicaid.

By September 23, all covered physician practices must update their HIPAA policies and procedures, including their Business Associate Agreements (BAAs) and their Notices of Privacy Practices (NPPs). They will also be required to understand encrypted, electronic-protected health information.

The American Medical Association (AMA) has a number of free resources to help physicians comply with these new requirements.

After Months of Anticipation, Sunshine Act Goes into Effect

Earlier this year, CMS released a final rule on the Sunshine Act, included in ACA, which requires drug companies, life sciences companies, group-purchasing organizations, medical device makers and others to report payments, gifts and investments made to physicians to CMS. The idea is to create public reporting that will allow patients to identify commercial bias.

Due to the delay, the agency will not require applicable manufacturers to report payments occurring prior to August 1, 2013. The first manufacturer reports will be due to CMS by March 31, 2014.

Under the law, physicians will have an opportunity to review the payment information reported by manufacturers and dispute any incorrect payments in 2014. To do so, physicians will need to track payments and other transfers, and manufacturers must be prepared to review the public reports once CMS makes them available.

As a result of advocacy efforts, CMS has exempted speaker fees for accredited and certified CME programs, food at conferences and patient education materials from the reporting requirements.

Sidley Austin, LLP has conducted a full analysis of the changes to the Sunshine Act, and the AMA has created a helpful toolkit to help physicians navigate these new requirements.


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