Sen. Kirk Visits Chicago’s Rush University Laboratory
Illinois Senator Mark Kirk (R) toured Rush University Medical Center’s Pathology Laboratory on April 20. CAP Member Robert P. DeCresce, MD, led the tour. Sen. Kirk is on the Senate Committee on Appropriation, and the Committee on Health, Education, Labor and Pensions (HELP).
Dr. DeCresce is Director of Rush Medical Laboratories and Chairman of Rush University Medical Center’s Department of Pathology.
Mass. Rep. Keating Tours Jordan Hospital’s Pathology Lab
Freshman Congressman William Keating (D-MA) recently toured the pathology laboratory at Jordan Hospital in Plymouth, Mass. CAP member Ronald G. Bardawil, MD, FCAP, led the tour of the laboratory, which performs an estimated annual volume of one million tests per year.
Dr. Bardawil told Statline that this lab tour was an important opportunity to emphasize how pathologists are engaged in all aspects of patient care—from preventative to tertiary care. “We have a cancer center at Jordan, and I was able to show Rep. Keating how the organization’s pathologists are integral to the diagnosis and treatment of patients, and explain how we work intimately with oncologists, surgeons, and other specialty providers in this environment,” he explained.
In addition, Congressman Keating learned how pathologists are key to delivering patient care rooted in personalized medicine. “As pathologists, we are well suited to take a prominent role in personalized medicine and other emerging diagnostic technologies like genetic testing,” said Dr. Bardawil, who is also the President-Elect of the Massachusetts Society of Pathologists, as well as a fellow in the International Academy of Cytopathology. “This includes emerging delivery models like coordinated care. We’re not just laboratorians, we are well suited to take a leadership role in working with our colleagues to coordinate patient care.”
Just Launched: 2011 Practice Characteristics Survey
The CAP 2011 Practice Characteristics Survey is now live. All practicing CAP fellows are encouraged to complete the survey, which is a key component of informing College’s advocacy efforts of the regional market pressures and environmental changes impacting pathologists. By completing the survey, respondents are helping the College collect vital practice characteristic data and information on challenges facing pathology practices. In addition, the survey provides useful compensation and practice related data to all CAP members. Those who complete the survey by June 3, 2011, will be invited to participate in three weekly prize drawings. Prizes include a global registration to the 2011 CAP Annual Meeting in Grapevine (Dallas/Fort Worth) TX, valued at $945; a $500 discount registration; and a $250 discount registration. Winners will be selected randomly each week from all eligible entries and notified by email.
Survey answers are kept strictly confidential and the results will only be reported in aggregate form or in a manner that does not identify information about an individual. Any questions about the survey can be addressed by Nonda Wilson, Advocacy Division, by email or by phone at 202-354-7116.
CMS Unveils Advanced Payment, Pioneer ACO Initiatives
CMS announced three new initiatives to allow broader participation in accountable care organizations (ACOs), one of the reform law’s most ambitious attempts to overhaul health care delivery. The agency’s proposed rule comment period is drawing to a close on June 6.
At a May 17 audioconference, CMS Administrator Donald Berwick, MD, detailed two new programs and one proposal under the newly created Center for Medicare and Medicaid Innovation, also known as the Innovation Center:
- Pioneer ACO Model: A program for organizations and providers who have already begun coordinating care for patients. It’s designed to work in coordination with private payers to achieve cost savings and improve quality across the ACO;
- Advanced Payment ACO Initiative: The Innovation Center is seeking public comments on whether to offer a program allowing certain ACOs access to up front savings. This initiative would help providers with limited access to capital develop the infrastructure and make the staff investments necessary to launch an ACO;
- Accelerated Development Learning Sessions: The Center will offer an upcoming series of free education sessions about the necessary steps to improve care delivery and how to develop an action plan to develop a coordinated care model.
The proposed Advanced Payment initiative addresses an issue cited by many critics of the proposed rule, with many policy experts and health care organizations stating that many provider groups will not have access to the amount of capital investment needed to participate in an ACO. In announcing these initiatives, Dr. Berwick said that this proposal focuses on providing financial resources to appropriate providers. “This is to help early comers get started sooner, help novices learn faster, and help those that need capital,” he explained. Comments on this proposal are due June 17.
Applications are now open to become part of the Pioneer ACO model, explained Innovation Center Acting Director Richard Gilfillan, MD. “We are trying to align the relationships these organizations have with a series of payers—commercial and Medicare—so they are rewarded for providing quality outcomes for all patients,” he said. “The hope is to move these organizations from fee-for-service to shared savings to population-based payments for Medicare patients. For private payment arrangements, this would accelerate the shift from shared savings to population-based payment.” This model is estimated to save Medicare $430 million over three years.
An estimated 30 facilities are expected to participate, agency officials indicated on the call. Many of these facilities are likely to come from a pool of leading U.S. health care systems considered early adopters of coordinated care systems. These could include systems such as Rochester, Minn.-based Mayo Clinic, Geisinger Healthcare System in central Pennsylvania, and the Cleveland Clinic, as well as other systems who are establishing ACO models.
Recently, however, many of these systems expressed concerns about the proposed ACO rule. In a May 11 letter to Dr. Berwick, members of the American Medical Group Association (AMGA) stated their primary concerns with the proposed rule included issues related to the risk sharing requirement, retrospective attribution, quality measurement requirements, and the Minimum Savings rule. AMGA’s members include the aforementioned entities, as well as Intermountain Healthcare (Salt Lake City, UT), suburban Chicago’s NorthShore University Health System, and Carilion Clinic in Roanoke, Va.
In response to these most recent proposals, however, at least one AMGA member appears to believe that CMS is beginning to address some of these concerns.
“While we are still reviewing the details of the Pioneer ACO program, these are the kinds of programs that will allow more innovative and iterative learning to determine the best way to transition to a pay for value system,” said Thomas Graf, MD, Chair of Community Practice for Geisinger Health System in a statement to Statline. “I believe different kinds of organizations will find different CMMI proposals helpful and the Pioneer program will be of interest to many.”
AMA Proposes SGR Replacement Strategy Before House Subcommittee
AMA President Cecil B. Wilson, MD, revealed at a House subcommittee hearing in early May a three-prong Medicare physician payment plan calling for repealing the current sustainable growth rate (SGR) formula, implementing statutory updates for five years followed by transitioning to multiple payment models, including capitation and private contracting between patients and physicians. Medicare payments for physicians are set for a 29.5% cut beginning Jan. 1, 2012, the expiration date of the current SGR fix.
AMA’s Menu of Physician Pay Options
: An ACO receives a per-patient, monthly payment to cover costs of services for beneficiary group.
Virtual partial capitation
: Instead of an upfront fee, an ACO receives a per-patient budget for a group of beneficiaries. Physician payments would be adjusted to stay within that budget.
: Group of physician receives a fixed amount to care for a specific patient condition, such as congestive heart failure.
Accountable medical home
: Group of physicians receives upfront resources to restructure the way they deliver primary care. In return, the practice or group commits to reducing hospital admission rates in patients.
Inpatient care warranties:
Physicians and hospitals set Medicare payment rates and give warranties for inpatient treatment, agreeing not to charge more for infections and complications.
: Medicare offers financial and technical support to small physician practices working with regional health improvement collaboratives.
: Patients and physicians freely contract for services, allowing them to agree on rates for services without having to forgo Medicare payment.
Source: Statement of the AMA
before the House Energy and Commerce Committee Subcommittee on Health, Re: The Need to Move Beyond the SGR, May 5.
“Repealing the SGR and implementing a period of stable payments, while testing new models that would lay the pathway for a new payment system, must be enacted concurrently to ensure an optimal reform approach,” testified Dr. Wilson at the May 5 House Energy and Commerce Subcommittee on Health hearing.
The five-year period of statutory updates will allow various proposed payment options to be tested, explained Dr. Wilson. These models focus on shared savings, gain sharing, payment bundling across providers and episodes of care, and care provided through a medical home (see box for details on these proposals).
“We envision physicians choosing from a menu of payment models, selecting ones that best address their patients’ needs, specialty, practice type, capabilities, and community,” he said. “We believe that statutory payment updates for five years will allow time for demonstrations and pilots of new Medicare and private sector payment models to take place.”
While most of the payment models appear to focus on paying for quality rather than volume of services, the AMA’s proposal to allow private contracting between patients and physicians is complicated. Current law prohibits physicians who bill Medicare from accepting payments that are different from CMS-determined rates. If a physician decides to contract privately with patients, they are not allowed to participate in Medicare for two years. In addition, patients cannot accept any Medicare reimbursement for services provided by that doctor.
The AMA’s proposal and similar legislation recently introduced in early May by Rep. Tom Price, MD (R-GA) would change these contracting restrictions. The Medicare Patient Empowerment Act (H.R. 1700) would allow patients and providers to freely contract for Medicare services without incurring a penalty. The AMA is supporting the bill.
However, to truly attack the rising cost of health care, the focus needs to be on utilization, according to Austin Frakt, PhD, a health care economist with Boston University, frequent contributor columnist at Kaiser Health News, and one of the authors of The Incidental Economist blog. “The modest annual SGR updates are not to blame for the escalating costs of health care, it’s the utilization,” he explained.
The College, along with other members of the Alliance for Integrity in Medicare (AIM) is also concerned about the role utilization plays in increasing health care costs. Specifically, loopholes in the in-office ancillary services (IOAS) exception to the physician self-referral law that can drive unnecessary overutilization of services, particularly regarding anatomic pathology testing services. The College is a member of the AIM, a coalition whose members include the American College of Radiology, the American Society for Radiation Oncology (ASTRO), the American Society of Clinical Pathology, and the American Physical Therapy Association. The AIM is focused on closing the self-referral “loophole”, based on concerns about abuse of four services under the IOAS exception: advanced imaging, anatomic pathology, physical therapy, and radiation therapy.
In response to a request for SGR reform proposals from the House Committee on Ways and Means, AIM members outlined these and related concerns in a May 11 letter to Chairman Dave Camp (R-MI). AIM also sent a similar letter to the House Committee on Energy & Commerce on Apr. 28.
“As a way to help offset part of the costs of repealing the Sustainable Growth Rate formula before moving to a new payment system, we recommend Congress remove advanced diagnostic imaging, anatomic pathology, physical therapy and radiation therapy from the IOAS exception, while preserving the ability of robust, integrated multi-specialty group practices to offer these services,” stated the letter to Chairman Camp. “Not only would removing these services from the IOAS exception represent sound health care policy, aligning incentives to reward independent medical judgment, patient choice and quality over financial benefit, but it also could potentially produce substantial savings to the Medicare program that could be used to pay for part of the costs of a physician payment fix.”
One aspect of the AMA’s strategy is sure to face a tough fight—the five-year statutory updates to physician payments under Medicare. With an SGR fix estimated to total $300 billion over 10 years according to the Congressional Budget Office, the price tag for AMA’s proposal appears to be half that amount—$150 billion.
Given the intense debate over raising the federal debt ceiling, the pressure is on to cut spending in entitlement programs like Medicare, not bring in additional costs, making the political climate an especially difficult one for this to move forward, explained Dr. Frakt.
While flawed, Dr. Frakt does believe that one positive element of the SGR is that it serves as a negotiating incentive. “The one advantage to the current SGR situation is that it brings members of Congress to the table, as they are concerned about any impact on Medicare beneficiaries,” he added. “However, it does not do any good if it just means kicking the can down the road.”
CAP Testifies Before ONC on Meaningful Use Challenges
Pathologists cannot meet the majority of current objectives in the federal Meaningful Use program to qualify for an incentive, as they are outside the scope of the specialty’s practice, noted David L. Booker, MD, FCAP, a member of the CAP Board of Governors, during his testimony at a federal HIT hearing on May 13. Therefore, they would be at risk for penalties under Medicare, starting in 2015.
The HHS Office of the National Coordinator (ONC) Health Information Technology Policy Committee’s Meaningful Use Workgroup held the hearing which focused on specialty care and Meaningful Use. The College, along with the American Society of Anesthesiology (ASA) and the American College of Radiology (ACR), requested in December that HHS hold a hearing to discuss the challenges faced by the three specialties in meeting Meaningful Use requirements. The Workgroup is in the process of finalizing its recommendations on the second of three stages of Meaningful Use Objectives.
Dr. Booker testified at the hearing that pathologists generally do not use—nor have access to—EHRs. Rather, they have long relied on sophisticated computerized laboratory information systems (LISs) in order to support the work of analyzing patient specimens and generating test results. “It is with these LISs that EHRs or enterprise-wide clinical information systems exchange laboratory and pathology data,” he explained.
Through these LISs, pathologists use decision support tools, including rules to generate interpretive comments on complex test results and algorithms to automate reflex testing. Pathologists oversee the creation of rules that determine critical test results that must be immediately communicated to other physicians in life-threatening situations and ‘flags’ that ensure that results out of the normal range are more effectively displayed in LISs and EHRs,” explained Dr. Booker.
One of the biggest obstacles for pathologists in this area is the lack of access to the EHR, said Dr. Booker during the discussion session following the testimony. Other panelists, including representatives from the ACR and the Agency for Health Care Research and Quality (AHRQ) concurred with this issue. “In some cases, pathologists do not have full access to the EHR to the detriment of patient care, compromising their ability to advise on appropriate test selection and resulting follow-up care,” stated Dr. Booker during his testimony.
House Committee Approves CAP-Supported Malpractice Reform Bill
Members of the House Energy and Commerce Committee approved a bill earlier this month that sets a cap of $250,000 on non-economic damages in malpractice cases, as well as other restrictions on lawsuits against doctors. The Help Efficient Accessible, Low-Cost, Timely Health Care Act or the HEALTH Act (H.R. 5) passed 30-20 after a day of mark-up. The bill will now go to the Rules Committee before a full vote on the House floor.
The CAP urged committee members to support the bill, explaining in a letter to Chairman Fred Upton (R-MI) and Ranking Member Henry Waxman (D-CA) that pathologists are facing hardships resulting from the nation’s worsening medical liability crisis. The committee approved the bill on May 11.
“There are consequences brought on by a tort system with no mechanism to restrain excessive, runaway awards,” wrote CAP President Stephen N. Bauer, MD, FCAP, in the letter. “Damages rise beyond reason and, in the end, patients and providers suffer as the nation’s health care costs soar and access to care declines. The Health Act provides the right balance of reform—maintaining access to courts and unlimited compensation for economic damages, while limiting non-economic damages.”
The Congressional Budget Office estimates medical liability reform, such as those outlined in this bill, could reduce the federal deficit by $62 billion over ten years, according to a press release from the Committee.
Indiana is now the 18th state to have a direct billing law in place, now that Gov. Mitch Daniels (R) has signed HB1071. Earlier this year, HB1071, advocated by the CAP and the Indiana Association of Pathologists (IAP), was amended in conference committee and then was re-passed by both state chambers: the House by 95-1 and Senate by 47-3. The Indiana law will go into effect on July 1.
The CAP, along with various other state pathology societies, support direct billing laws like this one in Indiana because they protect patients from “mark-up charges” added by an ordering physician. These laws ensure that patients are billed for anatomic pathology services only by the physician performing or supervising the service.
The College and the Pennsylvania Association of Pathologists (PAP) successfully advocated to amend pending state legislation to allow physicians performing hospital autopsies to use images of the decedent for teaching and training purposes, provided the identity of the decedent is concealed.
This is a significant shift from earlier this year, when the autopsy image restriction bill introduced in the state House, PA HB298, only provided an exemption for medical examiner and coroners to use these images for teaching and training purposes. However, the CAP and PAP worked to amend the bill so the exemption extended to physicians performing autopsies who had received consent from next-of-kin.
The bill was successfully amended on May 10, then passed out of the House committee. The bill will now head to the House floor for a vote. If approved, it will then go to Senate for a committee vote.
Connecticut lawmakers recently amended a proposed bill clarifying the reporting of a patient’s test results by a laboratory upon authorization of a referring physician. The amended bill has moved out of the state Senate’s Public Health Committee, and will now go before the chamber for a floor vote.
When the bill, SB1201, was originally introduced earlier this year, the CAP and the Connecticut Society of Pathologists (CSP) expressed concerns with the legislation’s language, as it called for the pathologist, as a provider to communicate test results directly to the patient, unless doing so would be detrimental to the physical or emotional health of the patient.
Under the originally proposed version of the bill, it was unclear whether—or how—a pathologist, as a provider, would determine the patient’s mental health in the absence of an objective patient profile, outlined CSP President William G. Frederick, PhD, MD, FCAP, in a March letter to the co-chairs of the state’s General Assembly Public Health Committee. Without such a profile, physician laboratory directors “could not make insightful determinations regarding patient reactions to receiving laboratory test results, especially If such results have potential to engender confusion or apprehension regarding physical well-being of a patient,” stated the letter.
However, to address these concerns, CSP and the CAP worked with lawmakers to amend SB 1201 so that the clinical laboratory provides the test results for the requesting patient to the treating provider.
The North Carolina Society of Pathologists (NCSP), with the support of the College and the state medical society, continue working with state lawmakers to amend proposed legislation requiring health care organizations to release a patien’’s collected pathological materials upon receipt of a written request by the patient.
Listen to state Representative Diane Parfitt (D) cite concerns of the CAP, NCSP, and NCMS in her support of amendment House Bill 795 on Apr.6:
Recently, NCSP, the College, and the North Carolina Medical Society (NCMS) successfully argued for amendments to House Bill 795 to ensure that specimen transmission to patients adheres to best practices and accepted medical standards. In addition, the legislation was amended to ensure that it should not change or interfere with a provider’s medical judgment to not allow for the release of these materials. Previously, these groups urged lawmakers to reject HB 795 and to refrain from enacting overly broad laws to regulate the release of these materials.
Overarching concerns with this proposed legislation centers on public health and related issues, outlined NCSP President Kevin S. Smith, MD, FCAP, in a May 18 letter to North Carolina Senate and House members. In addition, the release of this material could potentially conflict with state law regulating biologically hazardous material and federal law—CLIA—regulating disposing of these materials and dictating laboratory specimen retention standards and practices.
The bill could also impair patient diagnosis, noted Dr. Smith. “With respect to anatomic pathology, there is no provision to ensure patient materials are available for future comparison with subsequently obtained tissue to facilitate accurate diagnosis, identification of disease progression or mutation, or assess effectiveness of treatment,” he stated in the letter.
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