When David Scamurra, MD, needed a better, more cost-effective platform for C. difficile testing, he did the only thing he could do: He asked hospital administration to purchase it. And he waited. And waited. “And two years later, they bought the equipment,” he says.
End of story, yes? If you belong to an ACO, maybe not. Dr. Scamurra is president of Eastern Great Lakes Pathology, an independent pathology group that provides services to the Buffalo, NY-based three-hospital Catholic Health System. The group’s pathologists are members of Catholic Medical Partners, a network of 975 independent physicians and the Catholic Health System facilities that was selected last year to participate in the CMS shared savings ACO program.
It’s not that Dr. Scamurra had a problem waiting for the new C. diff platform: “I understand the budget constraints.” What he worried about instead was how this inability to complete a project (in this case an equipment purchase) in the new performance-driven reimbursement model may affect future pathology profit-sharing payments.
“I can suggest this new test, I can ask for it, but if the administrator decides it’s not in the budget this year, does that mean I fail as a pathologist? No,” he says. In other words, it’s hardly fair to penalize someone for not cutting costs when they’re simply not able to get their hands on the scissors (metaphorically speaking).
The question of exactly how pathologists should be incentivized under the ACO model was the central theme of “ACOs: An Independent Pathologist’s Observations of an Evolving Concept,” a talk Dr. Scamurra delivered in March at the American Pathology Foundation’s spring conference in Las Vegas. Dr. Scamurra subsequently shared with CAP TODAY some of the observations from his talk.
From a pathologist’s point of view, the fundamental problem is that “most of the ACO incentives so far have been centered around primary care practices, and the metrics they use to pay, pretty much, are directed toward primary care,” he says. “And in many specialty groups, like dermatology or allergy”—or, of course, pathology—“it’s difficult to figure out how that relates in terms of metrics. How does what we do fit into what the goal of the ACO is, that is, better quality and lower costs?”
Take a routine cholecystectomy, for example. “Absent looking at the slide of a gallbladder,” he says, “what does the pathology laboratory do that makes that a better, more cost-effective experience and therefore earns a share of the year-end ACO surplus? How do you measure that? How much is it worth? And that’s what everybody’s struggling with across the country.”
What Dr. Scamurra has been told by his ACO, he says, is that incentives cannot be paid for “outcomes consistently achieved, as well as for basic competency of practice.” In his view, if that standard is strictly enforced, “much of what we do to contribute to the success of an integrated delivery system are things that would be disqualified.”
Such as? “Understanding and explaining how to use a test. Reviewing the data to see how doctors are actually using it. Doing outcome studies. Those are things we do on a consistent basis that provide a level of quality that’s necessary for the ACO to deliver its clinical side of the equation. But theoretically, those do not qualify for incentive dollars. Instead, we have to have some kind of impact on decreased utilization. And my contention is, we have limitations on our ability to do that.”
He points to the time he discovered that physicians were “grossly over-ordering” a BNP test. He tried all the usual interventions: educating physicians directly, working with the IT department to develop an ordering system that would theoretically discourage inappropriate usage, and enlisting the support of department heads.
“What we found was that we could get the horse to the water, but we couldn’t get it to drink,” he says ruefully. “In other words, I could tell them this stuff, but when it comes to them ordering it, I can’t really prevent them from doing it. The physician order-entry system doesn’t have the capability to recognize that this order is inappropriate and block the test. The best you can do is flip up a warning saying, ‘This test may not be indicated,’ and the doc can say, ‘Thanks a lot,’ flip a button, and order it anyway.
“In other words,” he adds, “I can’t directly control the actions of the clinicians inside their own departments. And I don’t think that’s pathology’s role, to go in and cancel an individual test on an individual patient. There are sometimes reasons to order outside the guidelines, and if we start saying no to certain tests without putting our hands on the patient, we’re practicing medicine at a different level than we really should be.” So what’s pathology’s role? he asks. “It’s to provide timely, reliable, quality test results that are cutting-edge, and to serve as an information source to use and interpret tests. In my view, it remains the role of the clinical side to order tests optimally. And if they don’t do that, it doesn’t mean pathology failed” and should therefore not be eligible for incentive payments.
Here’s one way that, in Dr. Scamurra’s view, this issue could be addressed differently. Eastern Great Lakes Pathology is working now with Catholic Medical Partners to determine incentives around oncology testing, specifically molecular testing for tumors. “So here’s how we’re going to try to handle it,” he says. “I’ve met with all the oncologists, and we decided on a core group of tests that we felt have been adequately studied, have real clinical impact, and are worth ordering. I’m going to meet with our oncologists twice a year to look at this group of tests and keep updating it. So that’s my contribution.” In addition, he and colleagues are going to record all molecular tests ordered outside the pathology departments. “If the ordered test is in the group, fine. Let it go. If it’s in the non-accepted group, at that point the technician or the supervisor will stop and call the pathologist, who will call the oncologist and ask him or her about the circumstances. If they still want to order it, we’ll send it out, and we’ll record what happened. And every two months, we’ll send that information to the ACO.”
Here’s where the incentives come in. “The complementary incentive for the oncologist is going to be two things: One, you must attend those meetings, and two, there’s going to be some kind of incentive scale for the degree to which they adhered to the guideline. But my incentive dollars are not going to be paid depending on whether the oncologist stuck to the list or not, because I can’t stop them from ordering it. That’s the separation of church and state that needs to happen.”
To pathologists who find themselves negotiating with ACOs, Dr. Scamurra urges assertiveness. “Don’t sit on your hands. You need to not be afraid to say what needs to be said,” he says. “When they sit there and talk about â€˜cost cost cost,’ you’ve got to throw right back at them the quality you give that they’re not going to get if they look at cost alone. You need to be prepared to say, â€˜You need me, and here’s the reasons why, and here’s why you need to put me in the network and reimburse me for it.’
“They can’t achieve their quality and cost goals if they have unreliable, outdated tests and if a pathologist isn’t there to prevent that and help them choose the types of tests that need to be ordered,” he adds. “They can’t do that on their own. And that’s what we need to be paid for, not whether something I do results in a 10 percent decrease in hemoglobin A1c orders.” He likens it to a city that has to have clean water. “If you don’t have clean water, you don’t have a city. And pathology provides that clean water. If you can’t trust my calcium levels, and they’re bounding all over the place, you’re going to be doing a lot of unnecessary work on your patients, and you’ll never get to quality and cost containment.”
Somehow, he says, the ACO model has to be changed to allow pathologists to access those dollars based on their contribution. “And there are ways to measure that, such as CME credits, that you can use to hold us accountable. But that hasn’t happened yet. It’s all been lumped into a one-size-fits-all metric. And that’s not going to work in pathology.”
Anne Ford is a writer in Evanston, Ill.