College of American Pathologists
Printable Version

  STATLINE — CAP’s Bi–Weekly Federal and
  State Advocacy E–Newsletter

September 13, 2012  •  Volume 28, Number 19
Next Issue: September 27, 2012
© 2012 College of American Pathologists

In This Issue:

Georgia Recognizes CAP Accreditation Program

Georgia’s Department of Community Health has afforded the College’s Laboratory Accreditation Program (LAP) “deemed status” recognition, after legislation was enacted earlier this year and in 2010 that cleared statutory and regulatory impediments to formal state recognition. The decision was based upon determining that the College’s LAP standards are “substantially equivalent” to those of the Department.

The College sought this status intermittently over the past 10 years so that CAP-accredited laboratories would not have to submit to redundant routine state inspection to satisfy Georgia laboratory licensure requirements. The CAP worked closely with the Georgia Association of Pathologists to facilitate legislative and regulatory action in support of this recognition. With this decision, Georgia becomes the 12th state to formally recognize CAP accreditation for purposes of state laboratory licensure compliance.

CAP Physician Fee Schedule Comments Center on Molecular Code Placement, Quality Initiatives

The new molecular pathology CPT codes demand professional interpretation of test results, therefore the College continues to advocate for their placement on the Medicare physician fee schedule, outlined the CAP in comments to CMS on the proposed 2013 Physician Fee Schedule (PFS).

CMS Proposes Payment Changes for 2013

CMS’s proposed PFS included other payment policies that impact pathology:

  • Cost of 7% family physician increase spread across all specialists with 1% cut to pathology (part of multiple year strategy to encourage care coordination services)
  • Additional 1% cut to pathology due to practice expense methodology change phase-in
  • Projected 27% cut due to SGR (Congress expected to avert cut)
  • Expected 88305 TC cut for 2013 – (announcement in final rule)
  • TC Grandfather termination confirmed

The September 4 comments also focused on CAP’s concerns with the agency’s further expansion of the Multiple Procedure Payment Reduction (MPPR) policies. The College’s comments addressed the challenges pathologists face in complying with CMS’s quality reporting initiatives, including the Physician Quality Report System (PQRS) and Value-Based Payment (VBP) Modifier. CMS is expected to release the final fee schedule in November.

In addition to these initiatives, CMS included a number of other payment reforms as further evidence of the agency’s continued focus on spending cuts. This includes a 1% cut to pathology, which in part—along with cuts to other specialties—will cover a 7% increase to family physicians as part of a multiple year strategy to encourage care coordination (see box for more details).

Molecular Code Placement

In comments related to molecular code placement, CAP responded to several issues on which the agency was seeking feedback, including batch size and the utilization of these tests that may inhibit accurate PFS pricing. The College reiterated its position on placing these codes on the PFS, arguing that the data generated by these procedures cannot be released to the ordering clinician prior to professional interpretation into a clinically meaningful result. “The Physician Fee Schedule (PFS) provides for the true resources to be continuously reviewed and scrutinized through the relative value update processes, taking into account changing technology and increased efficiencies as technology is adopted and becomes more widespread,” stated the comments.

Register for CAP Members-Only Webinar

Anticipating Reimbursement Adjustments: Hear CAP Experts Discuss Expected Payment Changes in 2013

Tuesday, September 18, 1:00–2:00 PM Eastern Time

Register online

In addition to seeking feedback on code placement, CMS also proposed expanding the MPPR policies in light of continued growth in ancillary services subject to the in-office ancillary services exception. The College is concerned about the validity of the MPPR as a mechanism to value services when performed on the same date of service. Evaluating potentially duplicative work in services performed on the same date should be conducted at the individual code level, rather than through across-the-board payment policy modifications proposed by CMS, asserted the CAP.

It’s important to note that while the College commented on the expansion of MPPR, pathology was not included in this year’s reduction under this mechanism. CMS has concluded that they would expand the MPPR to cardiovascular and ophthalmology services based on identified duplicative services.

The MPPR is distinct from CMS’s plans announced in the 2012 final rule to revalue the technical component (TC) of the anatomic pathology (88300-88309) code family. Reductions are expected in the TC of the 88300-88305 code family next year. For the 88305 code, the CAP was able to mitigate the impact by limiting the review to the TC, after successfully arguing that the PC had been reviewed as recently as April 2010. CAP continued to advocate through the AMA/Specialty Society Relative Value Scale Update Committee (RUC) process. However, scrutiny of the costs associated with the TC has increased since it was originally valued in 2000.

Quality Reporting Initiatives

While pleased that this proposed PFS retains the current PQRS measures for use in 2013, the CAP notes that there are still many pathologists who will not be able to participate due to lack of applicable measures. As CMS begins to impose penalties on non-participants in the program in 2015, the CAP is requesting that eligible providers (EPs) who cannot report in 2013 not be penalized due to lack of applicable measures.

The 2013 proposed rule also initiates the use of a value-based payment (VBP) modifier in 2015 for group practices with 25 or greater EPs. Under this proposal, CMS sets the VBP modifier at -1.0% for all physicians in these groups who do not satisfactorily report on PQRS measures through the group reporting option.

Again, CAP’s concern with this proposal centers on the lack of applicable measures for many pathologists. “As with the PQRS penalty, we request that eligible professionals who cannot report on PQRS measures in 2013 due to lack of measures have the VBP modifier set at 0.0 percent in 2015,” stated the CAP’s comments, adding that the agency should continue accepting satisfactory PQRS reporting by individual EPs. “If CMS finalizes the proposal to only count satisfactory reporting through the group practice reporting option, it is essentially forcing EPs who reported as individuals to switch reporting processes with very little lead time, in a year that will affect both PQRS penalties and the VBP modifier for the first time.”

House Subcommittee Marks Up PT Referral Legislation

A bill ending severe mandatory sanctions against labs that inadvertently violate CLIA’s proficiency testing (PT) referral rules moved forward in Congress this week, passing with bipartisan support and without amendment from the House Energy and Commerce (E&C) Subcommittee on Health to the full committee for consideration.

The CAP urged support for the bill, H.R. 6118, the Taking Essential Steps for Testing (TEST) Act, which grants CMS discretion in determining sanctions against laboratories violating CLIA rules on referral of PT samples to other labs for analysis.

The College has long been concerned about imposing severe sanctions—which include revocation of a lab’s CLIA certificate as well as a two-year ban on operating or owning a laboratory for laboratory directors and owners—even for inadvertent violations. CMS has maintained it has little enforcement discretion under CLIA, and as a result, a growing number of laboratories across the country have been sanctioned for inadvertent PT referrals, facing potential shut down, disruption in patient care, and substantial settlement costs. In the future, further modification may be needed to make sure that PT keeps pace with evolving laboratory practice. In the meantime, this legislation is an important and necessary first step.

“The TEST Act would give the Centers for Medicare and Medicaid Services (CMS) much needed flexibility to match sanctions to the level of noncompliance,” said CAP President Stanley J. Robboy, MD, FCAP in a letter of support sent to the E&C Subcommittee this week. “The bill would still forbid the practice of PT referral. CMS would still be able to hold ‘bad actors’ accountable to the fullest extent of the law. However, the agency could impose lesser sanctions, if at all, for inadvertent PT referrals.”

“The TEST Act marked up this week by the Health Subcommittee gives the Centers for Medicare and Medicaid Services much needed flexibility in regard to lab sanctions,” said Representative Joseph Pitts (R-PA), E&C Subcommittee Chairman.

“Congress properly wanted the Clinical Laboratory Improvement Amendments to hold labs to a high standard. However, we don’t want to unduly punish labs that are doing their best to comply and even self-reporting mistakes. CMS should have more leeway to consider sanctions on a case-by-case basis and make sure that we keep quality labs up and running,” the Chairman added.

The companion Senate bill, S.3391, was introduced on July 17. Sens. John Boozman (R-AR), Amy Klobuchar (D-MN), and Jeanne Shaheen (D-NH) sponsored this bill. Supporters in the House and Senate want to move this bipartisan legislation as soon as possible, with the goal of enactment before year’s end.

AMA Calls on Congress to Avert SGR, Sequestration Cuts

Congress must reach a bi-partisan agreement to nullify the Medicare physician payment cuts currently set to take effect by the end of the year—the 2% cut called for under the Budget Control Act’s sequestration provision and the 27% under SGR formula—stated the AMA in a Sept. 12 letter to House Democratic Leader Nancy Pelosi (D-CA) and Speaker John A. Boehner (R-OH) that was signed by the College.

These looming cuts come at a particularly challenging time, as Medicare physician payments have been nearly frozen for 10 years, while the cost of caring for patients has increased by more than 20%. “While these cuts alone will be devastating to physician practices and patient access to care, physicians are also facing present and future financial penalties if they do not successfully participate in multiple Medicare programs, including the e-prescribing program, the electronic health record meaningful use program, and the Physician Quality Reporting System, as well as the value-based modifier,” noted the letter.

Pathologists Participating in ACOs Focus of Sept. 25 CAP Policy Roundtable Webinar

The CAP Policy Roundtable is hosting a special Member-Only Webinar event, “Thriving in an ACO: How Pathologists Can Confront Challenges and Maximize Opportunities,” on Tuesday, September 25, from 2:00pm-3:00pm. The Webinar will highlight how pathologists are confronting challenges related to participating in ACOs, as outlined in the White Paper, Contributions of Pathologists in ACOs: A Case Study, recently released by the Policy Roundtable. Register online for this special event.

One of the CAP members featured in the White Paper, David Scamurra, MD, FCAP, of Catholic Health in western New York, will discuss how his team is developing pathology-related performance measures to improve quality and cost efficiency. White Paper author David J. Gross, PhD, CAP’s Policy Roundtable Director, will also discuss his research findings. Registrants are invited to participate in the question and answer session following the presentations.

Shared Savings Study Finds Interest Among Payers to Absorb Start-Up Costs

Many private payers are willing to absorb costs associated with launching a shared savings delivery model, as well as sharing tools for measuring health care performance and cost savings, according to a recent study by The Commonwealth Fund.

AdvocateCare Profiled on CAP ACO Resource Center

Learn more about how pathologists are participating in the Blue Cross Blue Shield of Illinois and Advocate Health Care ACO, called AdvocateCare, on the CAP ACO Resource Center.

The study, Shared-Savings Payment Arrangements in Health Care: Six Case Studies, found that most payers in this coordinated care analysis viewed these efforts either as pilots in which they needed to invest or as necessary steps to get providers to move away from fee-for-service (FFS), one of the authors, Michael Bailit, told Statline. The paper looked at a variety of models, specifically the Maryland Multi-Payer Patient-Centered Medical Home Program, Medica and Fairview Health Services, Health Care Incentives Improvement Institute (Prometheus Payment), Blue Cross Blue Shield of Illinois and Advocate Health Care (AdvocateCare), HealthPartners, and Harvard Pilgrim Health Care.

The researchers found that most payers in these entities believed that even when the pilot programs failed to achieve savings, they were moving in the right direction, considering the challenge of shifting away from FFS, explained Bailit, a health care consultant. “The payers felt that FFS was not a viable option, but also recognized that they and their contracted providers had some learning and adaptation to do before the parties would be fully successful using a shared savings model,” he added. “In addition, I think that they were being realistic that change isn't easy and can take time.”

New CAP Policy Agenda Toolkit Now Online

CAP Advocacy recently released a Policy Agenda Toolkit featuring resources on how pathologists are key to transforming health care. Resources on CAP’s Now and Future Policy Agenda are included, plus information on preserving fair payment and equitable business practices; seeking new roles, services, and payment opportunities; getting to the ACO table and demonstrating pathology’s value; becoming leaders in genomic medicine; and defining pathologists’ role and value as stewards on health information.

The Toolkit also has links to updated Advocacy Issue Briefs on ACOs, pathology code revaluation, direct billing of pathology services, HIT/Meaningful Use, laboratory developed tests, physician self-referral, as well as other CAP policy priorities.

In Brief: USPSTF Reaffirms Recommendation Against Ovarian Cancer Screening; New IOM Report Estimates $750 Billion in Unnecessary Health Spending in ’09

In Brief: USPSTF Reaffirms Recommendation Against Ovarian Cancer Screening

The United States Preventative Services Task Force (USPSTF) recently reaffirmed its recommendation against screening for ovarian cancer in women. The recommendations state that there was adequate evidence that annual screening using two methods—transvaginal ultrasonography and a blood test for cancer antigen (CA)-125—does not reduce the number of ovarian cancer deaths. Furthermore, the 16-member panel of medical experts asserted that screening can result in unnecessary surgeries with high complication rates, leading them to conclude that the harms for screening outweigh the benefits.

In Brief: New IOM Report Estimates $750 Billion in Unnecessary Health Spending in ’09

About 30% of health care spending in 2009—an estimated $750 billion—went to unnecessary services, excessive administrative costs, fraud, and other problems, according to a new report by the Institute of Medicine called Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. The Sept. 6 report goes on to conclude that while the U.S. health care system has become too costly and complex to continue operating in its current form, the knowledge and tools exist to put it on the right course to achieve continuous improvement and better quality care at lower cost.

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.


202-354-7100  •  202-354-7155 (fax)  •  800-392-9994


Related Links Related Links

Customize CAP Ads with your laboratory’s logo