Read the Latest Issue of STATLINE

June 20, 2017

In This Issue:

Daniel Zedek, MD, FCAP; Barbara McAneny, MD, FASCO; James Caruso, MD, FCAP; Jean Forsberg, MD, FCAP; Melissa Stegun, CAP Advocacy Staff

The American Medical Association (AMA) is working with physician organizations like the CAP to tackle issues from health care reform to the network adequacy. A delegation of pathologists, led by the CAP, participated during the June 10–14 AMA House of Delegates meeting, and advocated on behalf of laboratory medicine. During the meeting physicians voted Barbara L. Mc McAneny, MD, an oncologist from Albuquerque, N.M., as the new president-elect of the AMA. Following a year-long term as president-elect, Dr. McAneny will assume the office of AMA president in June 2018.

Health Reform

The CAP and the AMA oppose the current health care reform legislation. The CAP’s policy principle framework for changes to the ACA are:

  • Ensuring that individuals can access affordable insurance without interruption and take steps toward coverage for all Americans
  • Maintain key insurance reforms (eg, pre-existing conditions)
  • Protect prevention and screening services
  • Stabilize and strengthen the individual insurance market
  • Reduce regulatory burdens on physicians

Building on existing AMA policy supporting the sale of health insurance products across state lines, the AMA adopted new policy to ensure products have patient and provider protection consistent with and enforceable under the laws of the state where the patient lives.

Easing patient burdens for out-of-network care

During the meeting, the HOD discussed policies related to Continuing Patient Care despite changes in their health care plans, and adopted policy seeking to prevent disruptions in care after patients switch health plans while a course of treatment is in progress.

The policy came out of a Council on Medical Service report, which wanted to ensure the continuity of care and underscored that new measures were needed to prevent disruptions in care for patients in active courses of treatment, especially for new enrollees in a health plan. The council stressed that patients who change health plans while in an active course of treatment "should also have the opportunity to receive continued transitional care from their treating out-of-network physicians and hospitals at in-network cost-sharing levels."

The AMA also highlighted ongoing work with the American Board of Medical Specialties about the need for improvements to the Maintenance of Certification (MOC) process. AMA advocacy has focused on educating state medical associations about activity around the country, as well as the risks and benefits of legislating the use of MOC.

The CAP is a part of the AMA House of Medicine and encourages our members to renew their AMA membership and work together with the AMA to help shape a health care system that best utilizes pathologists to deliver high-quality care and meets the evolving demands of patient care.

Back to the top

The Massachusetts Society of Pathologists (MSP) and the CAP are urging state lawmakers to remove provisions of the Senate budget that addresses out-of-network (OON) billing, arguing the measure does nothing to address network adequacy, which is at the heart of the OON problem.

Included in the Senate budget is an amendment addressing OON or "surprise" billing that would base reimbursement to OON physicians at nontransparent contracted rates, giving health insurers the upper hand in contract negotiations. It would also empower the Health Policy Commission to set rates for non-contracted physician services every five years. The Senate and House are now working to reconcile their different budget bills.

In a June 14 letter to leaders of the House and Senate Committees on Ways and Means, the MSP says it supports a policy that ends the problem of patients receiving OON bills. Such a policy must do three things to be successful:

  1. Enhance health plan network adequacy for hospital-based physician services by requiring health plan compliance with stringent network adequacy standards for these services;
  2. Hold health plans financially accountable for their network failures and gaps, by ensuring an equitable and sustainable formula for payment directly to physicians providing out-of-network services to their enrollees;
  3. Reduce the financial risk to patients who are unable to access in-network services at in-network hospital and facilities by limiting their financial responsibility for unavoidable OON bills to in-network costs while maintaining incentives for patients to use in-network physicians when available to them.

"Many out-of-network scenarios are clearly the fault of health plans with inadequate networks," the MSP writes. "In these cases, we favor both appropriate market-based payment for out-of-network physician services and clear regulatory obligations on health plans to induce contracting for hospital-based physician services."

The Senate's budget on this topic fails to meet the first and second criteria, says the MSP. Specifically, the proposed default payment could have dramatic effects on the sustainability of many physician practices and health care institutions, ultimately jeopardizing access to care in many underserved areas. The Health Policy Commission would have nearly unfettered power to set rates that would be in effect for five years, with no meaningful protections for physicians against artificially low rates and no penalties on insurers that would have a financial incentive to develop highly limited networks because the OON rate is to their advantage, argues the MSP.

"If a default rate is substantially below market value, insurers would have little incentive to negotiate in good faith with physician practices, knowing that any resulting out-of-network scenario would be reimbursed at a low default out-of-network rate. Having this insufficient reimbursement rate would significantly jeopardize the sustainability of both health plan networks and many physician practices, threatening access to care for patients across the Commonwealth," writes MSP.

The CAP will continue to follow developments in Massachusetts.

Back to the top

The CAP Advocacy team sent a letter to the US Senate Leadership outlining the CAP's health care reform principles and policy recommendations as the latest version of the health reform bill is currently in the Senate.

In the letter the CAP, "ask(s) that (the Senate) prioritize patient access to meaningful insurance coverage, maintain key patient protections and make policy adjustments to reduce the regulatory burden on physicians as the Senate develops its health care reform bill."

The CAP has adopted a set of policy principles as a framework for changes to the Affordable Care Act (ACA) and we urge Congress to consider these key components during deliberations to reform our current health care system. These principles are:

  • Any efforts to reform the health care system at the national, state or local levels should ensure that individuals with healthcare insurance can continue to access affordable insurance without interruption and take steps toward coverage and access for all Americans.
  • Maintain key insurance market reforms, such as pre-existing conditions, parental coverage for young adults, and elimination of annual and lifetime coverage caps.
  • Protect prevention and screening services that are currently covered.
  • Stabilize and strengthen the individual insurance market.
  • Reduce regulatory burdens on physicians implemented as part of the ACA and subsequent Medicare legislation that expanded upon the ACA.

The CAP along with the vast majority of the medical community including the American Medical Association, American College of Physicians, American Hospital Association, Federation of American Hospitals, AARP and patient advocacy organizations, oppose the legislation in its current form.

Stay tuned to STATLINE for further updates on health care reform.

Back to the top

The Centers for Medicare & Medicaid Services (CMS) is expanding its new Quality Payment Program website to include a streamlined system to manage information for practices and providers and is looking for feedback from practices.

CMS is reaching out to organizations like the CAP to join interviews on the new QPP web site. Specifically, CMS is looking for:

  • Clinicians or health care providers who look at Medicare feedback reports
  • Administrative staff and office managers who interact with Medicare systems and complete tasks related to Medicare quality data submission

If your practice would be interested in participating, please email with the subject line "Participation for QPP Feedback Report Research" and someone from CommunicateHealth (a CMS-authorized contractor) will follow up directly. Sessions will be 1 hour and participants will receive $150–$200 per practice for their time. Sessions will take place remotely via phone calls or online meeting platforms. Your practice may be contacted over the next few months to participate in feedback sessions.

In order to qualify as a participant, your practice must:

  • Be part of a small to medium practice (15 or fewer providers)
  • Work for a practice that intends to participate in the Quality Payment Program for 2017
  • Be familiar with Medicare feedback reports (previously known as QRURs) or plan to review Quality Payment Program feedback.

Back to the top

Are the pathologists in your state getting the coverage and payment their services deserve?

Recent trends in Medicare coverage have been to limit payments for the services pathologists provide to Medicare beneficiaries. Medicare Contractor Advisory Committee (CAC) representatives and state pathology leaders can work with the CAP to make a difference.

Hear directly from your colleagues on ways you can impact Medicare payment in your state during this networking forum. This networking forum is exclusively for CAC representatives, State Pathology Society presidents, and State Issue Advisors Only.

Sign up now at:
Course Number: STA007B
Course Title: Medicare Coverage and Networking Forum
Date: Sunday, October 8th, 9:30 – 10:30 AM

If you have any questions or would like additional information, contact Nonda Wilson at

Back to the top

In 2018, most pathologists will need to take action to stop penalties from reducing future Medicare payments for their services.

The CMS soon will issue its latest proposed rulemaking that implements provisions of the MACRA. On June 28 at 1:00 PM ET, the CAP will host a 60-minute webinar to discuss the CMS's proposals for participating in the 2018 Medicare Merit-based Incentive Payment System (MIPS) program, including options for preventing Medicare penalties.

Patrick E. Godbey, MD, FCAP, chair of the CAP's Council on Government and Professional Affairs; Jonathan L. Myles MD, FCAP, chair of the CAP's Economic Affairs Committee; and Diana M. Cardona, MD, FCAP, chair of the CAP's Economic Affairs Measures & Performance Assessment Subcommittee, will discuss how these proposed Medicare pay changes under MACRA will affect pathologists in 2018.

Register today.

By registering you will also receive a link to a recording of the presentation following the live event. Registrants will receive the link to the recording even if they are unable to attend the session on June 28.

Back to the top