College of American Pathologists
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June 7, 2012  •  Volume 28, Number 12
Next Issue: June 21, 2012
© 2012 College of American Pathologists

In This Issue:

CAP Leaders at the White House to Discuss Coordinated Care

This week the White House invited leading physicians—including three leaders from the College—to participate in a discussion on coordinated care. CAP President Stanley J. Robboy, MD, FCAP; President-Elect Gene N. Herbek, MD, FCAP; and Council of Government and Professional Affairs (CGPA) Chairman Richard C. Friedberg, MD, PhD, FCAP, attended the June 6 event to emphasize the important role that pathologists play in improving quality and reducing costs in coordinated care models, such as accountable care organizations (ACOs).

The convening of over 200 physicians included mostly primary care physicians, but also a number of specialty physicians, including anesthesiologists, pediatricians, orthopedists, gynecologists, and cardiologists, in addition to pathologists. Following a welcome address by HHS Secretary Kathleen Sebelius, a panel of physicians active in accountable care organizations opened the meeting. Richard J. Gilfillan, MD, Director of the Center for Medicare & Medicaid Innovation was also on this opening panel.

While this discussion centered largely on the role of primary care, it was clear that specialty physicians are vital to true delivery reform, Dr. Friedberg explained to Statline after the event. “A number of the panelists made an important statement that specialists own appropriateness,” he added. “This is especially true as primary care expands to encompass areas of medicine not typically thought of as part of internal medicine, such as behavioral health. Their plate will be expanding significantly and specialists like pathologists will be needed more than ever to guide appropriateness of patient care.”

Guidance in Ordering, Utilization

Following the panel, the highlight of the event was a discussion between attendees and CMS officials. This exchange provided an opportunity to focus on innovative ways that physicians are implementing accountable care in their facilities and communities.

“The majority of care and treatment decisions are based on pathologists’ expertise,” Dr. Robboy stated during the discussion. “Pathologists have long been practicing accountable care because it’s the right thing to do. We are instrumental in developing test ordering protocols and other utilization analysis that reduce costs associated with unnecessary testing and promotes better outcomes.”

The pathologists’ consultative role in test selection is especially important in genetic testing, Dr. Herbek told Statline. “Pathologists can contribute to coordinated care through accurate diagnosis and as laboratory consultants, particularly when physicians are looking at ordering molecular pathology tests,” he said. “Many of these tests are expensive and have uncertain reimbursement, and helping to determine their necessity can significantly reduce costs.”

Regulatory Challenges

The discussion portion of the event was also an opportunity to air challenges that physicians face in reforming health care delivery, including significant regulatory barriers. Dr. Robboy explained that pathologists are restrained from fully participating in accountable care models by regulatory barriers, namely those related to performance measures and the federal electronic health record (EHR) meaningful use program. For example, pathologists rarely, if ever, e-prescribe or take a patient’s vital signs.

“One size doesn’t fit all for federal regulations, when it comes to specialty physicians like pathologists,” explained Dr. Robboy, a comment echoed by other participants. “Particularly in the case of meaningful use, we can’t comply with the standards, but yet we are certain to be penalized.”

Following the discussion, CMS leaders pledged to establish communication channels that will work into the future, so physicians can share their ideas, propose innovations, and relay their concerns to the agency. This was a highlight achievement of the meeting, said Dr. Robboy. “CMS and White House leaders were receptive to all of the participants’ thoughtfulness and frustrations,” he stated. “By committing to facilitating communication on accountable care between physicians and regulatory leaders, we have a beginning—and not the end—of increasing engagement on these issues.”

CMS to Hold July Public Meeting on New Tests for 2013 Fee Schedule

At a recently announced July 16-17 public meeting, CMS will hear public comments on recommendations for establishing payment for new CPT codes being considered for Medicare payment under the clinical laboratory fee schedule (CLFS) for 2013.

In the May 29 meeting announcement in the Federal Register, the agency acknowledged that some of the tests under review are molecular pathology tests. However, it is important to note that the agency’s decision on code placement will not be final until the final CY 2013 Physician Fee Schedule (PFS) is released in November, following the comment period.

While stakeholders in the molecular pathology community continue to debate whether Medicare should pay for molecular pathology tests under the CLFS or the physician fee schedule (PFS), CMS is requesting that for this meeting, recommendations be limited to the appropriate basis for establishing payment amounts for the new tests under the CLFS. Additional comments on fee schedule placement of the molecular pathology tests should be provided in response to the CY 2013 PFS proposed rule, expected out later this summer.

While the agency said that it intends to post proposed determinations in the final CLFS in September, these determinations can change based on comments set forth in the PFS proposed rule.

The CAP members and staff will be attending this July meeting, continuing to recommend to CMS that these codes be paid under the PFS. Last year, the College worked with the American Medical Association (AMA)/Specialty Society RVS Update Committee (RUC) to develop relative value unit recommendations, as well as practice expense direct inputs for medical supplies, equipment and clinical staff for approximately 100 of these new codes.

Legal Experts Forecast Potential Impact of SCOTUS Decision on Accountable Care

Accountable care will continue forward regardless of the Supreme Court’s upcoming decision on the health care reform law, although its impact could be blunted without federal leadership, stated legal experts at this week’s Third National ACO Summit in Washington, D.C. The Summit was sponsored by the Brookings’ Engelberg Center for Health Care Reform.

“After the decision, the underlying issues driving accountable care—the need to improve quality of patient care and reduce costs—will be no different,” said Douglas A. Hastings, a partner at the law firm Epstein, Becker & Green, and past president of the American Health Lawyers Association, who spoke on the potential implications of the Supreme Court decision during a preconference legal session on June 6.

Hastings said that he views the payment and delivery aspects of the reform law—which encompass accountable care, value-based purchasing, and bundled payment initiatives, among others—as “pretty severable” from the rest of the law, namely the controversial individual mandate and Medicaid expansion provisions.

Even if only these contentious elements of the reform law are stricken down, it could impact accountable care implementation, explained Hastings. Specifically, if the Justices strike down just the individual mandate, accountable care may proceed in both public and private markets, but the pool of enrollees would shrink, diminishing the impact of the delivery reform. In addition, insurer costs would increase, thus triggering payment issues in the private sector and disrupting payer/provider relationships.

Of course, the impact of accountable care will also be diminished if the Justices strike down the law in its entirety, but coordinated care will not fade away, asserted Hastings. Another speaker, Engelberg’s Deputy Director Larry Kocot, concurred. “This movement has already begun, and in some form accountable care will continue, it may just not have federal leadership,” he concluded at the end of the session. “It may then need to become a political issue in order to advance.”

CAP Outlines Genetic Data Privacy Concerns to Presidential Commission

As “physician stewards” of patient specimens, the CAP submitted comments to the Presidential Commission for the Study of Bioethical Issues last month, supporting privacy restrictions that protect both patients and physicians while advancing genomic research and enhanced care.

The Commission requested comments on issues of privacy and access regarding human genome sequence data. In response, the CAP commented that while genomic information is already subject to protections under HIPAA—and the Common Rule for research—additional clarity on issues such as informed consent may be necessary.

This is especially true in the case of biospecimens, particularly residual specimens for research or non-research use. “CAP policies on informed consent state that potential future uses of specimens should be clearly covered by the text of the informed consent document,” state the comments.

The CAP also underscored the importance of ensuring that the entity collecting the specimen—rather than the pathologist—obtain informed consent. “The pathologist would in the vast majority of instances be unable to contact the contributor of the specimen for the necessary re-consenting process,” said the CAP.

CMS Awards First Contracts Under MAC Consolidation Plan

CMS awarded its first claims processing contracts under the consolidation effort to Noridian Administrative Services (NAS) and Novitas Solutions. These awards are part of the agency’s plans to consolidate the number of part A/B Medicare Administrative Contractors (MACs) from the current 15 numbered jurisdictions to 10 alphabetical jurisdictions.

The NAS contract is for Jurisdiction F. This includes the former A/B MAC jurisdictions 2 and 3 and the following states: Alaska, Arizona, Idaho, Montana, North Dakota, South Dakota, Oregon, Utah, Washington, and Wyoming.

The Novitas contract is for Jurisdiction H—formerly Jurisdiction 4 (Colorado, New Mexico, Oklahoma, and Texas) and 7 (Arkansas, Louisiana, and Mississippi).

Moving forward, CMS is expected to issue the final three solicitations for the remaining consolidated jurisdictions. This includes initially combining Jurisdictions 5 and 6, followed by 13 and 14, and finally 8 and 15. The award and consolidation is not expected to be completed until 2015 or 2016. The new contractors will be required to develop and implement a common set of Local Coverage Determinations (LCDs) to cover the entire jurisdictional space of the consolidated A/B MAC regions.

Keep Up with the Latest CAP Advocacy News on Twitter

CAP Advocacy is now on Twitter. Follow CAP Advocacy’s daily “tweets” to keep pace with regulatory and legislative news affecting pathology. For the latest health care news, be sure to check out what we are following on Twitter.


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