Case Examples

 

Effective Advocacy Requires Grassroots Engagement

Jonathan L. Myles, MD, FCAP
Jonathan L. Myles, MD, FCAP

Newton-Wellesley The most persuasive arguments for the value of pathology will be direct, concrete, and evidence based.

At the critically important practice level, this can mean one-on-one conversations about what pathologists do, how their work benefits patient well being, and why support for pathology will boost the institutional bottom line—all of which are equally relevant at the national level, where a bigger sandbox offers its own challenges and opportunities.

Advocacy around valuation of pathology services is a responsibility of the CAP Economic Affairs Committee (EAC). Jonathan L. Myles, MD, FCAP, chairs the EAC and holds joint appointments in the departments of anatomic and molecular pathology at the ClevelandClinic Foundation.

These are interesting times for the valuation of physician services; so much is in flux. As disruption in the marketplace increases, the federal Centers for Medicare & Medicaid Services (CMS) continues to pursue value-based purchasing (reimbursement structured around the value—rather than the volume—of professional services performed).

"As we move toward a more value-based system," Dr. Myles said, "activities that have not been reimbursed will become important in helping us demonstrate our value."

Dr. Myles is persistent by nature; it is always too soon to give up and never too late to try again. When a policymaker says no, he hears: Maybe you can educate me. Let's talk later.

For example, consider his work with the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC). The RUC is a panel of experts comprising both primary and specialty care physicians representing national medical specialty societies. Its members make relative value recommendations to CMS after reviewing specialty society recommendations. The purpose of the RUC process is to provide recommendations to CMS for use in annual updates to the new Medicare relative value scale, with the agency making all final decisions under the Medicare program.

At RUC meetings, specialty advisors present statistical and technical evidence supporting the valuations that are recommended. While representatives are committed to collegiality, the process can be stressful: Medicare dollars are limited, and it's a zero-sum game.

In his capacity as pathology advisor to the RUC, Dr. Myles presented evidence- supporting placement of the new Tier 1 and Tier 2 molecular pathology codes on the physician fee schedule. In late 2013, however, CMS announced that it was not to be. This was disappointing, Dr. Myles said, but there was an upside. CMS also provided a G code that would capture the pathologist's work. The evidence gathered could be used next time around.

"We can appreciate the opportunity to use the G code to recognize our role in molecular diagnostics as physicians," he said, and pathologists certainly should if the requirements of the code use are met.

In other words, maybe we can educate....

Action/Solution

Beyond one-on-one education, how can individual pathologists promote the value of their specialty?

When AMA Current Procedural Terminology (CPT) codes are created or updated, individuals who perform the service are surveyed and their responses help specialty societies like the CAP develop recommendations submitted to the RUC for their review in developing recommended values. "Two important factors in physician code valuation are the time it takes to perform a service and the intensity of that service relative to other services," Dr. Myles said. So the first way to help is to positively respond to any requests from the CAP and RUC for evidence or expertise. And the second is to assist the CAP when asked for practice expense inputs used in the valuation of the technical component of a service.

Finally, he said, recognize that when it comes to highly technical services, the CAP advocacy team and the pathologists involved in the RUC predominantly act as process experts. They know what types of data they need to formulate a recommendation but rely upon subspecialty experts to assist in the formulation of recommendations presented to the RUC.

"When a code is being revalued, we typically bring in a specialty pathologist to assist in the presentation and elaborate on any technical details of the procedure," he said. "So the third way to advocate for your specialty is to respond positively to any requests for help with a presentation for the RUC."

Summary

Individuals do not make decisions on the basis of what they do not know. The value that others attach to pathology services will be defined by what individual pathologists do—and do not—communicate about their work. For this reason, pathologists should embrace a responsibility for advocacy.

"Everything is interrelated," Dr. Myles said. "Remember, CMS has a boss too, and its actions are limited by the statutes Congress has legislated."

For example, grassroots advocacy released a wellspring of support for pathologists in late 2013, when CMS floated a proposal to cap reimbursement for 39 pathology codes at the hospital outpatient rate. The CAP circulated an all-member action alert; other pathology groups did the same.

We had thousands of people write to their representatives in Congress," Dr. Myles recalled, and by the end of November, 113 members of Congress and 40 senators had signed a letter to CMS opposing the change. "CMS withdrew that proposal, (at least) for now," he said."Grassroots advocacy does work."


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