Read the Latest Issue of STATLINE

April 30, 2019

In This Issue:

Emily E Volk, MD, FCAP Leads a discussion on health care reform with William E. Kobler, MD, AMA Board of Trustees and Matthew Fiedler, PhD, Fellow, USC-Brookings Schaeffer Initiative on Health Policy.

CAP members traveled to Washington, DC, to advocate for patients and the pathology specialty during the 2019 Policy Meeting from April 29 through May 1. During the meeting, CAP members discussed the continuing national health care reform debate, how Medicare should reimburse clinical laboratory tests, surprise medical bills, and the oversight of laboratory-developed tests (LDTs).

On May 1, CAP members will ask legislators to amend the Protecting Access to Medicare Act of 2014 (PAMA) to reflect an accurate, market-based payment system for laboratories paid through the clinical laboratory fee schedule. Moreover, CAP members will also discuss how the CAP can help protect patients from surprise medical billing disputes, ensure network adequacy, and if an out-of-network physician provides services to a patient, fairly compensate that physician for the services provided.

Council on Government and Professional Affairs (CGPA) Chair Donald S. Karcher, MD, FCAP, opened the meeting on April 29 by reviewing the challenges facing the pathology specialty. Emily E. Volk, Vice-Chair of the CGPA, then led a panel discussion on the changing landscape on health care reform and how it will impact the practice of pathology. The discussion has shifted from repealing the Affordable Care Act to protecting and improving it. The group discussed the “Medicare for All” and other health care legislative proposals as well as the CAP’s health care reform principles.

Robust Discussion on Reimbursement and Oversight Policies

The next panel reviewed the surprise out-of-network billing issue that has captured the attention of lawmakers at the state and federal levels. The session, led by Dr. Volk and panelists Loren Adler, associate director, Brookings Center for Health Policy; and Rita Habib, PharmD, MPH, health policy advisor, Sen. Michael Bennet (D- CO) discussed the different perspectives of various groups on reimbursement of services and holding patients financially harmless. During this session, attendees learned about the CAP’s advocacy on the issue of insurance network adequacy and what remedies lawmakers have proposed.

PAMA data collection continues to be an issue for laboratories as the data collected does not accurately reflect all sectors of the clinical laboratory market. During this session, Stephen Black-Schaffer, MD, FCAP, chair of the Economic Affairs Committee, thoroughly explained the much-needed PAMA improvements to ensure that the data collected by the Centers for Medicare & Medicaid Services (CMS) accurately reflect all sectors of the clinical laboratory market. Moreover, Marc Hartstein, principal at Health Policy Alternatives, helped to explain why the validation of data collected by the CMS is important and the impact of burdensome reporting requirements on laboratories.

Dr. Karcher then led a panel discussion on LDTs and the new congressional legislation. The release of the Food and Drug Administration (FDA)’s technical assistance late last year on the Diagnostic Accuracy and Improvement Act (DAIA) spurred a flurry of activity. In response, the Congress released the Verifying Accurate Leading-edge IVCT Development Act (VALID Act), as a new starting point for the debate. In this session, attendees learned some of the CAP’s concerns with the VALID Act.

On May 1, nearly 75 CAP members will discuss these advocacy priorities during 150 meetings with the offices of Senate and House members. Since 2012, CAP members have participated in over 800 meetings with congressional offices and achieved several victories.

Former Senator Baucus Discussed the Future of Health Care Reform

During his luncheon keynote address, former ambassador to China and former senior US senator from Montana Max Baucus discussed the ever-changing health care reform debate. As one of the principal architects of the Affordable Care Act, Senator Baucus answered CAP member questions regarding the impact of health care reform on pathology.

On April 30, Policy Meeting attendees will receive additional political analysis from John Zogby, a leading public opinion pollster and founder of the Zogby International poll, and current FOX News anchor Chris Wallace, who will provide an objective overview on the current news and political environment as well the Trump Administration’s role in the press.

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On May 1, pathologists will be in Washington, DC, meeting with congressional offices and advocating for pathology during the CAP’s annual Hill Day. CAP members in Washington will ask their elected officials to hold patients financially harmless in out-of-network billing disputes and set network adequacy standards. They will also urge legislators to amend the PAMA law to reflect an accurate, market-based payment system for laboratories paid through the clinical laboratory fee schedule.

If you couldn’t make it to Washington this year, you can still make a difference from your home or office! Visit our Action Center to help support our advocacy on surprise billing. It’s easy and takes little time to advocate on the issues impacting how you practice and your ability to provide patients with quality care.

Join PathNET and visit the Action Center today.

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Because of the CAP’s as well as other stakeholders’ advocacy, the CMS proposed to increase reimbursements for chimeric antigen receptor (CAR) T-cell therapies for fiscal year 2020. According to proposed regulation released on April 23, the treatment’s new technology add-on payment will increase to 65%, up from the current 50%, which would translate to a maximum add-on of $242,450, up from the current $186,500 payment for the therapy.

CAR-T is the first-ever gene therapy used to treat certain forms of cancer for which no other treatment options exist, which is why the CMS highlighted the unique challenges associated with paying for CAR-T technology in particular.

In March, the CMS announced that the final coverage policy is flexible for new technologies and will create clear guidance for reimbursements for all CAR T-cell therapy care-team physicians, including pathologists. This recent decision by the CMS is a response to stakeholders, including the CAP, who requested that the new procedures involving CAR T- cell therapies needed increased reimbursements.

The CMS also seeks input from stakeholders on payment alternatives for CAR-T cell therapies that could increase the payment for these services. The CAP will continue discussions with the CMS regarding alternative payment methodologies for these services.

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After four years advocacy, in which both the CAP and the Washington State Society of Pathologists (WSSP) were extensively involved, the Washington State legislature passed legislation that prohibits balance billing of patients for out of network (OON) services at in-network facilities. The conceptual origins of the bill, to require network adequacy and to avoid a strictly prescribed payment formula, evolved from an initial proposal made by CAP-WSSP early in the legislative process.

Notably, as urged by the CAP and the WSSP, a strong network adequacy provision is included, requiring the Commissioner of Insurance to determine “whether the carrier's proposed provider network… includes a sufficient number of contracted providers of emergency and surgical or ancillary services … to reasonably ensure enrollees have in-network access to covered benefits delivered at that facility.” Ancillary services is defined in the bill to include pathology and laboratory services. The final passage of the bill was led by the Washington State Medical Association and a coalition of medical specialties, that included the CAP and the WSSP. Key highlights of the legislation include:

  • No adverse payment formula tied to in-network rates or Medicare; instead of a statutory reimbursement rate or mechanism for OON payment, requiring carriers to reimburse OON physicians at a “commercially reasonable rate.”
  • Physician-friendly dispute resolution process with no reference to Medicare rates as an arbitration criterion, and claims bundling allowed over a two-month timeframe.
  • Direct payment from carriers to physicians (prohibiting carriers routing the payment through patients).
  • Workable requirements for physician groups pertaining to transparency and enforcement of the law.

The legislation is expected to be signed into law by the Governor soon. If enacted, Washington State would be the 15th state to enact a law protecting patients from the additional costs of out-of-network physician services at in-network facilities. Washington state would also become the third state, in addition to New Hampshire and Louisiana, to enact a statutory requirement for holding health plans accountable for hospital-based physician network adequacy.

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The CAP is fielding the 2019 Practice Characteristics Survey to gather data from individual pathology practices regarding their economics, demographics, and market trends in the evolving business environment. The survey is open from April 29 through May 17.

On April 29, pathologists received an email from with a link that is unique to the pathologist receiving the invitation. Respondents are eligible for a drawing for either one of three Amazon gift cards or Apple Watch® Series 4 wrist-wearable device. Pathologists who respond to the survey will have early access to survey results via an exclusive webinar.

If you have not received your invitation, please contact us at This survey is available to board-certified pathologists who are currently practicing in the US. The survey excludes full-time retirees, pathologists practicing in different countries, and junior members of the CAP.

The survey should not take more than 15 minutes to complete. The CAP will share the survey findings with its members in a full report and provide early access to the data to those who finish the survey. If you have not received your invitation, you can take the survey.

All responses are kept strictly confidential.

The CAP will use the data in its advocacy efforts with policy influencers, health care leaders, and other stakeholders to increase understanding of the significant role and value of the pathologist in the delivery of patient care.

Survey participants are helping the CAP to serve its members better. The survey will capture:

  • Vital practice member characteristic data
  • Information on the concerns and challenges of the CAP member
  • Compensation data, including salary and benefits
  • Practice-related data

Complete your survey soon before it closes on May 17.

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