2011 Policy Meeting Report: CAP Kicks Off Accountable Care Advocacy
Efforts may still be underway to unravel the Affordable Care Act (ACA) in state courts and in Congress, but in Washington, implementation of the health care reform law has already begun.
Policy makers in oversight agencies such as HHS, DOJ, IRS and others are working on regulations that will define the laws enacted by Congress, including clearing the way for accountable and coordinated care. At the same time, Congress continues to tweak health care-related laws and guide the growth of personalized medicine.
Dentzer, Leavitt Discuss Pathologists’ New Roles
This year’s Policy Meeting featured headliners Susan Dentzer, editor of journal Health Affairs. and health policy analyst for PBS “NewsHour”; and former HHS Secretary Michael O. Leavitt. Both speakers discussed how pathologists can contribute to new coordinated care delivery models, respond to the increased focus by government and private payers on reimbursement based on value rather than volume, and harness new technologies such as genetic testing.
After talking with numerous CAP members who are involved in ACOs, Dentzer said pathologists can be key agents in ensuring quality, safety, value, and lower costs throughout the health system. “Pathologists can serve as interpreters of increasingly more sophisticated lab results for patients and guides in shared decision-making,” she explained.
Leavitt said that pathologists have the ability to create value by helping to identify the right treatment a the right time based on a diagnosis. “Creating this will really require you to step up and engage in the current health care debate,” he added.
To educate policymakers on the unique role of pathologists in patient care, the CAP kicked off a new advocacy program at the 2011 Policy Meeting last week, spotlighting the importance of pathologists in improving patient outcomes, reducing health care delivery costs, and advancing personalized medicine.
The CAP’s Advocacy effort will focus on a broad platform of issues relating to the valuable role pathologists have in improving patient care. Here is a portion of CAP’s newly focused narrative:
As emerging accountable care delivery models seek to promote better patient outcomes and minimize costs across multispecialty patient health care teams, pathologists will have an expanding role in providing highly specialized diagnostic care.
- Getting to the right diagnosis faster and more precisely, with fewer tests, is one important way pathologists can improve a patient’s experience, improve outcomes and reduce costs.
- Identifying ways to prevent disease or minimize its impact, including an understanding of genetic precursors of disease, and monitoring patient populations, will also become increasingly valuable strategies to enhance patient outcomes and control health care costs.
- Building, aggregating and interpreting individual and population health data and information to both inform clinical decision making and measure performance are central features of accountable health care systems, and pathologists already oversee and manage this laboratory data.
With pathologists’ unique contributions in mind, CAP members and staff are working with policymakers to address the key issues that will enable (or could disable) pathologists’ ability to improve patient care and treatment efficacy. These issues include pathologists’ role in accountable care, meaningful use of health information technology, measuring quality and performance, and emerging roles in personalized medicine.
CAP members who carried this message to Capitol Hill were well received in over 70 one-on-one meetings with congressional leaders and staffers last week.
The CAP policy meeting featured top-ranking policymakers, including House Majority Leader Eric Cantor (R-VA) and other members of Congress, former Utah Governor Mike Leavitt, top policy advisors from NCQA and the Brookings Institution, regulators from HHS, CMS, and FDA, pollster Bill McInturff, and Washington pundits Susan Dentzer and Morton Kondrake.
In assessing the political landscape, Kondrake, Executive Editor of Roll Call, said that the two political parties are now more polarized like never before. Looking ahead to the 2012 Presidential elections, both Kondrake and McInturff predicted that the campaigning will hinge on the economy. “If the economy and unemployment remain in trouble, then Obama will be in trouble,” said Kondrake.
A staunch critic of the health care reform law, Rep. Cantor pledged to continue working to repeal the law.
Another leading lawmaker, Sen. John Barrasso, MD (R-WY), Vice-Chairman of the Senate Republican Conference, was also critical of the legislation.
Democratic lawmaker, Rep. Jim Matheson (D-Utah) turned his attention to the Sustainable Growth Rate formula, and said he expected Congress to consider a multi-year SGR patch this year. Although Health Affairs editor, Susan Dentzer also predicted a multi-year fix, new SGR legislation has yet to be introduced.
Not surprisingly, accountable care organizations (ACOs) garnered much attention as CAP members and regulators focused on the proposed ACO rule released in March 2011. While the final rule will ultimately define requirements for ACOs under Medicare, there are few provisions that specifically impact pathologists.
This panel was moderated by Donald S. Karcher, MD, FCAP, of the George Washington University School of Medicine in Washington, D.C. Dr. Karcher is Chair of the CAP ACO Network Steering Group.
CMS Deputy Administrator and Director of the Center for Medicare Management, Jonathan Blum, provided CMS’s view on ACOs, acknowledging concerns from providers on the proposed rule, and indicating feedback from providers would be carefully considered.
Blum noted that ACOs are not designed to be a one size fits all, and that the agency would pay careful attention to all stakeholder comments. The comment period is set to conclude on June 6. The final rule is set for release later this summer per Blum.
Drilling down to specific concerns with the proposed rule, another panelist, Lawrence Kocot, Deputy Director of the Brookings Institution’s Engelberg Center for Health Care Reform, said it was unrealistic to require data collection for 65 quality measures. “The general feeling that I’ve heard from many organizations is that the quality measures are just daunting,” he explained.
In addition, Kocot said that the proposed rule’s financial and paperwork demands are too burdensome for small providers, and CMS’s plan to withhold 25% of any shared savings until the end of the agreement period poses additional financial uncertainty and would likely be a deterrent to participating in the program. With regard to pathologists, Kocot said pathologists need to define what their role will be and how strong a role they need to play. He said reducing duplication of tests jumps out as an opportunity for pathologists. The proposed rule specifically mentions redundant testing.
The third panelist was Margaret O’Kane, President of the National Committee for Quality Assurance (NCQA). The NCQA recently completed a pilot test of draft ACO accreditation standards. The month-long test analyzed how 10 health care organizations collected and submitted data based on draft ACO accreditation criteria released by NCQA late last year. The CAP’s Nov. 19, 2010, comments on the draft criteria can be found online.
“ACOs are the best hope that we have of being able to afford high quality health care in the future,” she said. “However, we need to better align incentives and reward providers based on what the public, as well as the government, wants.” She also acknowledged that the state of the art in health care delivery, including IT capabilities, are not where they need to be in order to best support ACOs, and said even those who have robust systems are not maximizing their care management capabilities.
Turning her attention to pathologists, O’Kane said pathologists have a role in reducing redundant lab tests within an ACO. She encouraged physicians at integrated systems to participate in ACO development, and encouraged pathologists to speak with their hospital finance areas about their electronic health records as pathologists can help curb testing costs.
Many health care reform initiatives—such as the ACO and Meaningful Use Electronic Health Record (EHR) Incentive programs—are relying on quality measures to evaluate performance. However, this is a concern for many specialty providers, including pathologists, as many measures do not apply to their practice, leaving them unable to qualify for incentives.
This panel was moderated by Jonathan L. Myles, MD, FCAP, of The Cleveland Clinic Foundation and Chair of the CAP Economic Affairs Committee.
While acknowledging problems caused by this issue, speaker Mark Antman of the AMA’s Physician Consortium for Performance Improvement (PCPI) program noted that the CAP is farther along in developing quality measures compared to many specialties. (Earlier this year, PCPI approved five new pathology measures involving Barrett’s esophagus, radical prostatectomy pathology reporting, immunohistochemical evaluation of HER2 for breast cancer patients, as well as bone marrow and fine needle/direct specimen acquisition. CMS is currently reviewing these measures for inclusion in the 2012 PQRS. In addition, the National Quality Foundation (NQF) has been notified that the measures are ready for its endorsement process.)
“CAP has already demonstrated that they can develop measures on their own and receive endorsement from PCPI,” said Antman. “Many specialties don’t yet have that infrastructure in place. That being said, the PCPI recognizes that if we can’t develop measures that address multiple specialties, then we need to support specialties in developing their own measures.” He cautioned, however, that PCPI’s resources are extremely limited. Forthcoming measures are being prioritized based on meeting the needs of multiple specialties simultaneously and the usefulness of measures at the ACO level, among other considerations.
Pathologist participation in the Office of the National Coordinator’s Meaningful Use of Health IT program also continues to be complicated, as the objectives and measures are unworkable for pathologists, even though they meet the definition of eligible providers (EPs).
CAP Governor David L. Booker, MD, FCAP, moderated the HIT panel.
Elizabeth Holland, Director of the HIT Initiatives Group in CMS’s Office of E-Health Standards and Services, explained that the agency’s proposed rule for Stage 2 of the program will address the issue of adjusting payments for non-hospital based EPs that are not a clear fit for the program. This is an issue for not only pathologists, but also radiologists and anesthesiologists.
In addition to panels on HIT, ACOs, and pay-for-performance, the meeting also featured a panel discussion on personalized health care.
Debra Leonard, MD, PhD, FCAP, of the Weill Cornell Medical College and member of the Council on Government and Professional Affairs, moderated this panel.
Panelists included Eric Green, MD, PhD, Director of NIH’s National Human Genome Research Institute and Alberto Gutierrez, PhD, Director of FDA’s Office of In Vitro Diagnostic Device Evaluation and Safety. Dr. Gutierrez emphasized that his office is still pursuing a risk-based approached to the oversight of laboratory developed tests (LDTs). The FDA is looking to develop a framework to close regulatory gaps and address high-risk LDTs, he explained. However, he said the agency is looking at possible exceptions for tests that diagnose rare diseases, as well as those that deal with emerging infectious agents.
Reform Implementation the Focus of 2011 State Presidents’ Meeting
Health care reform implementation is kicking into high gear at the state level according to CAP leaders and state regulatory experts at the recent 2011 State Pathology Society Leadership Meeting, held in Washington, D.C., on May 1.
CAP President Stephen N. Bauer, MD, FCAP, convened this year’s meeting of leaders from 23 state pathology societies. Featuring policy experts on state health care initiatives, the program touched on a range of issues, from health care reform implementation and emerging new business economics for pathologists, to communicating with members and growing membership.
Policy experts who spoke at the meeting emphasized that one of the immediate concerns to states is the health care reform law’s mandate to launch health insurance exchanges by 2014. This gives states less than four years from now to create the infrastructure to develop these exchanges. While some states have already begun this process, this is not a lot of time to implement such a complex program, particularly with limited resources, as most states are still struggling to recover—or climb out of—the recession.
“States are confronting a climate of falling revenues and rising health care needs and costs, while facing the need to build insurance exchanges and confront health information technology (IT) obstacles as part of the health care reform law,” said speaker Leif Wellington Haase, Senior Fellow with the New American Foundation’s Health Policy Program.
The aggressive timeline of some of these initiatives, as well as uncertainty arising from current legal challenges and congressional efforts to slow implementation, is further complicating the economic burden faced by states and local governments, explained another speaker, Joy Johnson Wilson, Health Policy Director at the National Conference of State Legislatures.
Nevertheless, the New America Foundation’s Haase believes that despite current congressional and legal efforts, the health care reform law will not change in any major way. Rather, with implementation shifting to states, movement will primarily be rooted in delivery reform at the local level. “Implementation will rely on clinicians in local communities working together in coordinated teams of providers rather than more government involvement, in order to really bring costs down,” he predicted.
In addition to economic pressures at the state level, there are also market forces affecting the laboratory and pathology industry, noted the CAP’s CEO Charles Roussel. These forces include macroeconomic shifts and changing business models that are likely to result in continued consolidation across the medical and health care sectors.
Roussel believes that these forces can unite pathologists. To this end, the College is seizing opportunities borne out of this revolutionary time in health care, such as defining the pathologists’ role in coordinated care and future roles rooted in technology shifts. Whole genome sequencing, in vivo microscopy—these and related technologies will create opportunities for pathologists in new areas of medicine. “Pathologists are pivotal to new scientific, technological, clinical, and business models reshaping health care and how it’s delivered,” said Roussel. “I believe that pathologists can emerge stronger from the current confluence of change if we define our roles in these new opportunities.”
To carve out these roles, Roussel announced the CAP will actively engage members at the state and local levels through the College’s Transformation Initiative. CAP’s Transformation Initiative focuses on defining, modeling, and demonstrating a new set of value-added services that no other physician specialty can perform as well as pathologists and that creates new economic opportunities for pathologists and improves patient outcomes.
Connecting with members in their home states will allow CAP leaders to get a clear sense of the most significant challenges facing the future of pathology practices and the resources members need to confront these challenges.
While stressing the importance of planning for future challenges, the meeting attendees also discussed current issues confronting state societies.
Specifically, there are multiple economic and technological forces that will disrupt the current practice of pathology, noted several members. “We’re looking down the tunnel at ACOs and related reform initiatives, but right now, self-referral and joint ventures are truly a threat,” said Robert E. Thomas, Jr., MD, FCAP, President of the South Carolina Society of Pathologists.
In response, CAP leadership noted that in addition to pursuing legislative solutions at both the State and Federal level to current challenges, the CAP is embarking on a multi-year effort to evolve and clarify the role of pathologists in coordinated care and other new health care delivery paradigms. These efforts are focused on preparing CAP members for changes in healthcare delivery due to health care reform, innovation, and shifting economic realities.
CMS Releases 2009 PQRS Data for Pathology
In 2009, over half (58.9%) of eligible pathologists participated in CMS’s Physician Quality Reporting System (PQRS), according to recent data released by the agency in the 2009 PQRS and ePrescribing Experience Report. In addition to providing a summary of the PQRS program, this report also contains specialty specific data on participation among other specialties, as well as data on incentives and performance.
This pathologist participation rate is significantly above the total eligible physician participation rate of 20.9%. CMS counted eligible pathologists if they self identified as pathologists, and if they filed at least one claim that met the measure denominator specifications, whether or not they reported on it. The report does not indicate the number of pathologists participating in Medicare, but were unable to participate in the 2009 PQRS.
The report also analyzed data on successful reporting, incentives, and performance for participating pathologists:
- Successful reporting: In 2009, 2,617 pathologists out of 4,543 who participated in the PQRS successfully reported on 80% of their relevant claims. The success rate of 57.4% for pathologists compares favorably to the overall success rate of 50.1% for all physicians who participated in the program.
- Incentive: The average bonus for pathologists who successfully participated was $1,680. The average bonus for all physicians who participated was $2,274.42.
- Performance: Overall, performance on PQRS measures improved in 2009 compared to 2007 and 2008. Pathologists who reported on the two measures performed very well. The mean performance rate for Measure #99 Breast Cancer Reporting was 96.6%; and the rate for Measure #100 Colorectal Cancer Reporting was 97.5%. Further, 89% of pathologists who reported on the breast cancer measure achieved greater than 90% performance rating; 93% of those reporting on the colorectal cancer measure achieve a greater than 90% performance rating.
The full 2009 PQRS and ePrescribing Experience Report is available on CMS’ website.
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