As Congress Faces SGR Deadline, CAP Urges Permanent Repeal
Lawmakers are staying focused on ending the cycle of temporary fixes to Medicare’s sustainable growth rate (SGR) formula, which has threatened to destabilize physician payments since 2003. New legislation to repeal the SGR includes a provision advocated for by the CAP offering pathologists more flexibility to meet quality program criteria in Medicare.
In December 2013, Congress passed a three-month temporary fix to stop SGR cuts of about 24%. The fix provided a 0.5% raise in Medicare pay to physicians through March 31. If a bill to permanently repeal the SGR isn’t passed by the end of March, Congress will have to extend the temporary fix or physicians will again face significant cuts.
The CAP has supported a permanent repeal of the SGR and urged Congress to address Medicare payment reform in 2014. On February 12, the CAP sent an action alert to encourage pathologists to contact their federal representatives and support recently introduced SGR legislation.
Rep. Michael C. Burgess, MD, (R-TX) introduced the SGR Repeal and Medicare Provider Payment Modernization Act (HR 4015) on February 6. Companion legislation also was introduced in the Senate (S 2000) by Sen. Max Baucus (D-MT). The legislation is a consensus bill among the House Ways and Means, House Energy and Commerce, and Senate Finance Committees. The CAP worked to ensure the legislation included language that addressed concerns about Medicare quality initiatives designed for office-based physicians and were problematic for specialty physicians, especially pathologists.
The legislation would provide 0.5% payment increases for five years. It also includes pathology language that would allow the Centers for Medicare & Medicaid Services (CMS) to use alternative measures to fulfill the goals of the performance categories—Physician Quality Reporting System (PQRS), Electronic Health Record Meaningful Use (EHR MU), the Value Based Modifier (VBM), and a new performance category termed Clinical Practice Improvement Activities. Payments to physicians would be adjusted based on performance categories beginning in 2018.
The CAP was one of 111 specialty and state medical societies to sign and send a February 10 letter in support of the legislation.
“This bill puts medicine back in charge and allows providers to work collaboratively with CMS to determine the appropriate methodology to accurately measure quality,” Dr. Burgess said.
No PQRS Measures? Call QualityNet Help Desk to Confirm
Pathologists who are uncertain about which Medicare Physician Quality Reporting System (PQRS) measures apply to their practices should call or email a federal contractor tasked with helping physicians with the pay-for-reporting program.
The CAP obtained relief from PQRS penalties for pathologists who do not have applicable quality measures. Responding to CAP advocacy on this issue, the CMS has assured the CAP it will not penalize pathologists who do not have any PQRS measures that fit their practices.
The CMS encourages physicians who do not think any of the PQRS measures apply to their practice to double check by contacting the QualityNet help desk at 866-288-8912 or firstname.lastname@example.org.
Pathologists must be certain of the PQRS measures they are eligible to report. If a pathologist, for example, has three applicable measures, he or she must report on those three measures in 2014 to prevent the 2016 penalty. If a physician has no applicable measures, then he or she will not be later penalized, the CMS told the CAP and other medical specialties. The CMS noted that less than 1% of physicians have no measures, but recognized that pathologists in particular may fall into this group.
The CMS is required by law to reduce Medicare pay for physicians who do not report PQRS measures. The agency will use the 2014 PQRS reporting year to determine which physicians will have their 2016 Medicare payments reduced by 2%. The CAP has advocated for pathologists without sufficient PQRS reporting opportunities to be exempt from the penalty—and the CMS has agreed.
The CAP has additional information about PQRS available online on a CAP-produced webinar giving comprehensive information on the 2014 PQRS and the VBM. The webinar is archived and available to view anytime.
CMS Chief Medical Officer to Speak at 2014 CAP Policy Meeting
Patrick Conway, MD, will address CMS goals for testing new models to improve quality and lower the cost of care at the 2014 CAP Policy Meeting in Washington, DC, on May 5 at 1:30 PM.
“The new payment and delivery models being tested by the CMS Innovation Center will have an important impact on practicing pathologists,” said Jonathan L. Myles, MD, FCAP, chair of the CAP’s Economic Affairs Committee. “Dr. Conway is uniquely qualified to shed insights on a range of CMS value-based purchasing programs in order to help pathologists understand how payment policies will drive how cost and quality benchmarks are implemented and used.”
Dr. Conway serves as deputy administrator for innovation and quality. The CMS Center for Medicare and Medicaid Innovation is responsible for developing and implementing innovative health care service delivery programs that will help improve and update the nation’s health care delivery systems. This center has a growing portfolio testing various payment and service delivery models that aim to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system.
Dr. Conway also is deputy administrator of the Center for Clinical Standards and Quality, which is responsible for all quality measures for the CMS for all settings, quality improvement programs in all 50 states, value-based purchasing programs, clinical standards and survey and certification of all providers across the nation, and all coverage decisions for treatments and services for the CMS. The center’s budget exceeds $1.3 billion annually.
Register today for the 2014 CAP Policy Meeting.
NY State Should Revise Regulations Inhibiting Pathologist-Patient Contact
The CAP has called on New York state health officials to repeal a regulation prohibiting pathologists from conferring with patients on their laboratory test results.
In a February 11 letter, CAP President Gene N. Herbek, MD, FCAP, urged the state to address its health regulations in light of new federal regulation expanding patient access to laboratory tests. The CAP requested repeal of the New York regulation that prohibits patient contact with the pathologist medical director of the laboratory providing their diagnosis. Instead, the state regulation instructs the clinical laboratory to direct patient inquiries regarding test results to the ordering physician.
“This regulation constitutes a legal impediment to physician pathologist’s ability, in their capacity as laboratory medical directors, to confer with patients regarding their test results and reports to which patients are now entitled, under federal law, to receive directly from the laboratory,” Dr. Herbek wrote. “This legal impediment is based upon an anachronistic practice paradigm that has placed New York patients at a significant medical disadvantage compared with patients in other states who are able, without state legal constraint, to seek and receive pathologist medical input on their diagnosis, prognosis and even course of therapy.”
The Department of Health and Human Services (HHS) granted greater patient access to laboratory results in a federal regulation published February 3. The HHS rule, which adopted several CAP recommendations, allows patients to request and receive test results from the laboratory. It also preempted state laws that impede patients directly receiving test results from the laboratory.
The CAP has developed a frequently-asked-questions document to review key components of the HHS rule. For instance, laboratories will need to update their Notices of HIPAA Privacy Practices by the October 6 compliance date. HIPAA-covered laboratories must revise their notices to inform individuals of their new access right and include a brief description of how to access the right as well as remove any contrary statement and must make the revised notice available.
The CMS also has written FAQs on the final rule (PDF, 40 KB).
Cigna Adopts Genetic Counselor Exception
In response to CAP outreach, the private insurer Cigna has added an exception to its national genetic testing payment policy that will allow for coverage of the services when provided by certain additional genetic counselors.
Cigna notified the CAP that the exception will be published as part of Cigna’s national policy on February 15. Under the exception, a genetic counselor employed or contracted with a laboratory, which also is part of an integrated health system that routinely delivers health care services, may see patients and secure prior authorization for testing, according to Cigna. Previously, these genetic counselors were not permitted to provide services nor secure authorizations for testing to be performed at their integrated delivery systems under Cigna’s policy.
Under Cigna’s genetic testing policy effective September 15, 2013, Cigna became the first US health insurer to require genetic counseling and prior authorization nationwide before covering tests for hereditary breast and ovarian cancer, colon cancer, and a heart disorder, long QT syndrome. The genetic counseling occurs either face-to-face or over the phone through a Florida firm. Cigna indicated its intent with the new requirement was to guide patients to appropriate testing.
The full guidance from Cigna would state the insurer covers genetic testing as medically necessary when a recommendation for the service is confirmed by one of the following:
- An independent board-certified or board-eligible medical geneticist;
- An American Board of Medical Genetics or American Board of Genetic Counseling-certified genetic counselor not employed by a commercial genetic testing laboratory (Genetic counselors are not excluded if they are employed by or contracted with a laboratory that is part of an integrated health system that routinely delivers health care services beyond just the laboratory test itself); or
- A genetic nurse credentialed as either a genetic clinical nurse (GCN) or an advanced practice nurse in genetics (APGN) by either the Genetic Nursing Credentialing Commission (GNCC) or the American Nurses Credentialing Center (ANCC) who is not employed by a commercial genetic testing laboratory (Genetic nurses are not excluded if they are employed by or contracted with a laboratory that is part of an Integrated Health System that routinely delivers health care services beyond just the laboratory test itself).
Without the exception in the parenthetical to the second bulleted item, genetic counselors that are part of these integrated health systems would not be able to provide the testing. A genetic counseling professional unaffiliated with the genetic testing laboratory performing the results must make the recommendations for testing by these systems.
CAP Members in Florida, Ohio Lead Laboratory Tours for Their Representatives
Emphasizing the physician role and how pathologists are key members of the health care team, Jonathan L. Myles, MD, FCAP, hosted Rep. Jim Renacci (R-OH) for a tour of the Cleveland Clinic’s Robert J. Tomsich Pathology & Laboratory Medicine Institute.
“The lab tour provided the opportunity for us to establish a beginning of an ongoing relationship with Rep. Renacci,” Dr. Myles said. “During the visit, we demonstrated the role pathologists play in patient care such as the performance and interpretation of HER2 molecular tests in breast cancer.”
Dr. Myles, who chairs the CAP Economic Affairs Committee, led the tour on January 22. The CAP helped organize the meeting by providing contacts for the congressman’s office and background materials for conducting the tour, which allowed for Dr. Myles to talk about the specialty of pathology and medical work that’s done in the laboratory. The CAP can help any member host a tour with his or her congressional representatives.
“Rep. Renacci was able to see how a pathology reference laboratory provides high-quality jobs in Northeastern Ohio, which is helping revitalize the region,” Dr. Myles added.
For information about leading a tour with your representatives, watch this PathNet video. Contact Laura Brigandi if you have questions or need more information about leading a tour.
A group of board-certified pathologists met with Rep. Steve Southerland II (R-FL), and discussed pathology issues and the SGR in Tallahassee, Florida, on January 21.
“We talked at length, and he gave us an overview of current issues in Washington,” said Margaret H. Neal, MD, FCAP. “We felt that he heard our concerns and he clearly understood the complexity and difficulties facing small business owners.”
Dr. Neal practices in a group of 15 pathologists in two large hospitals in Tallahassee and facilities in Lake City, Florida, who in addition travel weekly to outlying hospitals. They also serve as medical examiners for their district and medical directors of the local blood center.
“Our group of pathologists met with the congressman several years ago when he toured our large hospital clinical laboratory, and we requested this meeting as we were interested in discussing our current pathology issues of SGR and self referral,” Dr. Neal said.
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