Self-Referral Opponents Secure Cuomo Veto
In a major victory for pathologists, New York Governor Andrew Cuomo (D) vetoed legislation on Oct. 3 that would have weakened the state’s current self-referral law, citing concerns about the potential impact on patient referrals and health care providers with financial self-interests.
“Given the concern with real and apparent conflicts of interest that this change would engender, I see no reason to upset New York’s rules for determining the propriety of practitioner referrals,” wrote Gov. Cuomo in the veto letter. “The bill is disapproved.”
The CAP and the New York State Society of Pathologists (NYSSPATH) joined with other laboratory groups as well as the New York-based Center for Medical Consumers (CMC) to urge Gov. Cuomo to veto the legislation. Other opponents of the legislation (Assembly Bill 3551)/Senate Bill 4660), which was approved by New York lawmakers in June, included New York Blue Cross Blue Shield plans, as well as the Alliance for Integrity in Medicare (AIM), whose members include the American College of Radiology (ACR), the American Physical Therapy Association (APTA), and the American Society for Radiation Oncology (ASTRO).
NYSSPATH President Rana Samuel, MD, FCAP explained that the veto is a result of this unified coalition of pathology and consumer groups communicating the potential negative impact of this bill to the Governor and his staff. “Concerned pathologists advocated evidence-based medical policy,” she told Statline. “We made the Governor’s staff aware of peer-reviewed published medical literature—including CAP-funded research by Dr. Jean Mitchell published earlier this year in Health Affairs and Medicare and Medicaid Research Review—documenting overutilization and abuse of in-office ancillary services, exposing patients to the risk of unnecessary procedures and treatments if this bill was not vetoed.”
CAP’s Chair of the Council of Government and Professional Affairs, Richard C. Friedberg, MD, PhD, concurred with Dr. Samuel on the importance of showing evidence of the link between financial self-interest and increased utilization. “It’s heartening that the Gov. Cuomo and his staff recognized our position on the impact of self-referral, given that it continues to be a challenging issue on both the federal and state levels,” he told Statline.
CAP Leaders Urge Providers to Prepare for 2013 PQRS Expansion
CMS’s Physician Quality Reporting System (PQRS) program is expanding next year, and pathologists need to start preparing now to participate in 2013, or prepare for the penalties of not participating next year that will be felt in 2015, according to CAP Economic Affairs Committee member, Emily E. Volk, MD, FCAP.
CMS’s PQRS website contains additional details on reporting and related information.
“By participating successfully in 2013, you will receive a 0.5% bonus of total Part B allowed charges in 2014,” she explained to Statline. “More importantly, providers will avoid a 1.5% deduction in overall Part B Medicare payments in 2015.”
Pathologists will continue to qualify for incentives for reporting on three quality measures. There are five CAP-developed quality measures that pathologists may choose to report.
Other changes beginning next year that CMS detailed in the proposed 2013 Physician Fee Schedule (PFS) include new group reporting options. Providers in group practices of 25 or more will be subject to a value-based payment modifier adjustment in 2015 determined by their 2013 PQRS participation.
CMS Distributing 2011 PQRS Incentive Payments
CMS began distributing provider incentive payments and feedback reports for the 2011 PQRS program the week of Oct. 3. Incentive payments amount to 1% of total estimated 2011 Medicare Part B PFS allowed charges for covered professional services furnished during reporting period.
Incentive payments for the program will continue through the first week of November. More information on how to access 2011 PQRS reports is available on the CMS Quality Net portal
The expansion of the PQRS program is further evidence of the government’s commitment to shifting from the current fee-for-service (FFS) reimbursement model to pay-for-performance in a coordinated care environment, explained CAP’s Chair of the Council of Government and Professional Affairs, Richard C. Friedberg, MD, PhD.
“Against the backdrop of the current health care and economic environment, the longer term pressures on reimbursement are going to continue to be downward,” he told Statline. “With the continued focus on quality-based reimbursement, it’s likely that the current PQRS quality measures could be used as quality measures in emerging private or public Accountable Care Organizations.”
More information on pathology-related aspects of PQRS is available on the CAP Advocacy website. Watch for further analysis on PQRS and other payment changes embedded in the final 2013 Medicare Physician Fee Schedule (PFS) (due out by Nov. 1) in a forthcoming CAP Today/Statline special report, future Statline issues, as well as Webinar events in November. More details to come.
CMS Postpones Model One of Bundled Pay Initiative
CMS’s Center for Medicare and Medicaid Innovation (CMMI) is suspending model 1 of the bundled payment initiative that involved retrospective reimbursement for acute hospital stays. While the industry interest in the program’s other models (2-4) has been positive and robust, model 1 has fewer prospective participants and less diversity than originally anticipated when the model was designed, an agency spokesperson explained to Statline.
Bundled Payment Models
Model 1: Retrospective Acute Care Hospital Stay Only (now suspended)
Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute Care
Model 3: Retrospective Post-Acute Care Only
Model 4: Acute Care Hospital Stay Only (prospective payment)
As a result, further implementation of model 1 will be postponed and the agency will review how the prospective participants might fit into the other three models, added the spokesperson. (See box for more details on the models.)
Viewed as the beginning of CMS’s definitive move away from fee-for-service (FFS), this initiative is designed to transition hospitals and providers to bundled payments centered around episodes of care. Three of the models involve acute care hospital says, while one involves post-acute care only.
More information is available on CMMI’s Bundled Payment Initiative website.
Hospitals Could Save Millions with Appropriate Blood Use
Hospitals could realize millions in savings through appropriate blood product transfusions, found a recent study in Economic Outlook, a publication of the hospital purchasing organization, Premier Inc.
The study, “Best Practices in Blood Utilization” looked at 464 hospitals, determining a top-performer quartile of hospitals with low blood utilization and better-than-expected outcomes. Other hospitals in the study were then compared to those in this quartile. Researchers concluded that if all of hospitals studied were able to achieve utilization rates similar to those in the top quartile, they would save over 800,000 blood product units at a savings of over $165 million a year.
The study’s authors also noted that unnecessary blood product use is not only costly, but is a patient safety issue, as there is evidence that inappropriate utilization can increase complication rates and length of hospitalization.
Blood utilization was also one of the issues focused on at the Sept. 24 National Summit on Overuse, co-sponsored by The Joint Commission and the AMA-convened Physician Consortium for Performance Improvement. Workgroups met prior to the meeting to discuss appropriate use of blood products, as well as heart vessel stents, ear tubes, antibiotics for common colds, and early scheduled births without medical need.
The blood product workgroup found a significant variability among clinicians regarding transfusion rates, explained participant and CAP member Emily E. Volk, MD, FCAP, to Statline. “We studied literature that found 90% of patients at some hospitals were getting blood transfusions compared to 10% at another hospital under the same DRG,” she said. “Clearly, there is inappropriate utilization going on. Fortunately, there is a growing literature of evidence-based blood utilization guidelines now available to practitioners.”
Workgroup members are urging the continued development of guidelines for a variety of clinical settings. Dr. Volk insisted that pathologists must be part of this discussion, particularly since they get a richer residency education on transfusions compared to other specialty providers. “Pathologists must have a key role in establishing these clinical guidelines, which could then be incorporated into standing order sets and computerized physician order entry [CPOE] modules,” she stated. “This will help hospital blood utilization committees flag outliers and develop just-in-time CPOE education. With these tools, we can really impact utilization.”
Support Building for House Bill to Exempt Pathologists from HIT Penalties
Legislation (H.R. 4066) excluding pathologists from penalties under the current federal electronic health record incentive (EHR) program is quickly gaining favor in the House, with 57 House members now signed on as co-sponsors.
Introduced last year by Rep. Tom Price, MD (R-GA), the most recent co-sponsors include members of the House Energy & Commerce Committee: Charles Bass (R-NH), Sue Myrick (R-NC), Bill Cassidy, MD (R-LA), John Barrow (D-GA), and Brian Bilbray (R-CA). Adding cosponsors from this committee is critical, since this committee has jurisdiction over the bill, and will determine whether or not it proceeds to the full House for final consideration.
The College is supporting this bill, as pathologists are unable to comply with the federal EHR Meaningful Use requirements. These standards—used to measure EHR implementation—fail to recognize the various goals and structures within the U.S. health care system, particularly for pathologists, explained Rep. Price to Statline in a statement.
“This bill, the ’Health Information Technology Reform Act’ will prevent pathologists from being penalized for what they are not able to realistically do as they practice their profession,” he added. “Meaningful use standards currently in law are clearly not applicable to the nature of their practice. Physicians and other medical practitioners should not be penalized when the law is inflexible or inapplicable.”
CMS Delays POS Transmittal to April 2013, Pathology Clarification Forthcoming
CMS has delayed implementation of the Place of Service (POS) policy change until April 2013, although clarification of specific pathology-related changes are forthcoming through another agency change request (CR). The effective and implementation dates were revised to allow additional time to implement and clarify the POS instructions.
This policy change involves the POS designation for physician practices and attempts to clarify Medicare’s policy to facilitate the correct facility and non-facility payment rates for services paid under the Medicare Physician Fee Schedule. As the original transmittal (2407) released by the agency in February caused some confusion, CMS released CR 7631 on Sept. 28 to provide clarification on certain aspects of the policy change. Specifically, CMS explained when physicians and supplier entities may bill for a global diagnostic service code, as well as the appropriate address to report for determining the payment locality assignment of global diagnostic service codes and professional diagnostic test interpretation service codes (as identified by modifier -26) when billed separately from the technical component (TC).
The transmittal also included the appropriate address for determining the payment locality of professional diagnostic test interpretation service codes billed separately from the TC that are furnished at an unusual and infrequent location. In addition, the transmittal clarified the appropriate POS code for services furnished to a registered inpatient and for outpatient hospital departments. “Clarification on the POS for pathology services will be provided through another CR,” stated the transmittal. CMS did not indicate a date for this CR.
CAP, Dermatology Leaders Approach BCBSA With New Policy-Related Concerns
Leaders from the CAP and the American Academy of Dermatology Association (AADA) have reached out to Blue Cross and Blue Shield (BCBS) Association officials about concerns regarding the insurer’s recent policy clarification requiring Blue Card claims for laboratory services.
According to the clarification, all independent clinical laboratories must submit claims to the local Blue plan in the state where the biopsy was taken (ultimately where the ordering provider is)—not where the laboratory is located, as was frequently the case prior to the clarification. While the compliance date is Oct. 14, Blues plans in some states implemented the change earlier, including at least one in July.
The CAP and the AADA are concerned that this policy change prevents ordering physicians from having specimens on their BCBS patients interpreted by their chosen pathologist or dermatopathologist, often with whom he or she has had a longstanding relationship.
“As we relayed to the Association...the AAD and CAP are concerned not only about network disruption, but also negative impact on access to and continuity of care, and increased beneficiary financial responsibility that will arise from the Clarification,” wrote CAP President Stanley J. Robboy, MD, FCAP and AADA President Daniel M. Siegel, MD, FAAD, in a Sept. 28 letter to BCBSA’s Senior Vice President and Chief Medical Officer, Allan M. Korn, MD, FACP. “As such, we urge the Association to revise the Clarification as it applies to independent clinical laboratories, prior to the currently required compliance date of no later than October 14, 2012.”
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