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With federal officials working to implement new Medicare law impacting how physicians are reimbursed for services provided to Medicare beneficiaries, the CAP advocated for several changes to proposed regulations that reflect the value pathologists have on patient care and ensure pathologists can participate in the new payment programs. The CAP's comments were submitted to the Centers for Medicare & Medicaid Services (CMS) in a letter on June 27.

The CMS published the proposed regulation implementing Medicare payment reform under the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) on April 27. The CAP is engaged on behalf of pathologists on the proposed regulation.

MACRA creates two new payment pathways for physicians. The Merit-based Incentive Payment System (MIPS) is the default pay program under MACRA and is expected to have a $1.5 billion impact over several years on Medicare payments to pathologists beginning in 2019. The CAP is working to ensure pathologists can comply with MIPS when the program starts impacting Medicare reimbursements in 2019. The CMS has proposed to use the 2017 calendar year as its first year for measurement for MIPS.

For the other MACRA pathway, a small percentage of physicians will be able to participate in advanced alternative payment models (APMs), and will not be subject to MIPS requirements. Advanced APM participants will receive a 5% Medicare bonus from 2019-2024. The CAP also provided several comments calling for changes to the APM section of the proposed MACRA regulation.

Read the CAP's full comment letter to the CMS on MACRA. A few examples of the CAP’s comments are captured below.

CAP Advocacy on the Default Pathway: MIPS

MIPS will combine the current Medicare quality programs—the Physician Quality Reporting System, Electronic Health Record Meaningful Use (which will be known as Advancing Care Information), the Value-Based Modifier (which will be known as Resource Use)—as well as a new performance category termed "Clinical Practice Improvement Activities." MIPS payment adjustments, which are based on scores in the system's performance categories, range from +/- 4% starting in 2019 to +/- 9% in 2022 and beyond.

A MIPS eligible clinician would receive no payment adjustment if the score is at the performance threshold, a negative pay adjustment if the score falls below the performance threshold, and a positive pay adjustment if the score is above the performance threshold.

The CMS has proposed to reweight the Resource Use and Advancing Care Information performance categories to zero for non-patient-facing clinicians and to redistribute the weight of these categories either entirely to the quality reporting performance category or between the quality reporting and clinical practice improvement activities categories. The CAP prefers that eligible clinicians who cannot be scored for resource use or the advancing care information performance category receive a median score in those categories until such time that the CAP can develop viable alternatives for pathologists to be able to participate in these categories. The CAP does not believe that scores that are weighted differently across specialties can be fairly compared.

The CAP also recommended that pathologists, as designated in the CMS' provider enrollment system, be automatically identified as non-patient-facing eligible clinicians at the beginning of each year. The CMS proposed that non-patient-facing clinicians be defined as those who bill less than 25 patient-facing encounters during the performance year.

CAP Advocacy on APMs

Between 2019-2024, physicians participating in advanced alternative payment models (APMs) will receive lump-sum incentive payments. These advanced APMs under the proposed rule are relatively few in number. Some examples that might apply to a limited number of pathologists include the next generation ACO model and tracks 2 and 3 of the Medicare Shared Savings Program. The proposed rule also defines a new category of APM, the physician-focused payment model (PFPM) that was mentioned, but not defined in statute. While the CAP included comments on advanced APMs overall, its focus was on this newly defined model type.

While the CAP did not object to the definition of PFPMs, the CAP stated not all the underlying criteria and subcategories apply to pathology. The CMS will not achieve its goal of providing openings to physicians who are currently unable to participate in new payment models if precisely requiring all criteria including subcategories that may not apply, the CAP said. The CAP advocated for greater flexibility in order to achieve this agency goal.

The CMS requires three fundamental pieces of information for physician-focused payment models to submit to a reviewing body. In its comment letter, the CAP sought to clarify what supplemental information mentioned in the proposed rule might entail and object to criteria used to assess a payment model that would negatively impact the review. Furthermore, the CAP recommended an increased commitment to test physician-focused payment models where the CMS underscored in the proposed rule that it is under no obligation to test models.

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The CMS published its proposed regulation to implement Medicare payment reform under the MACRA. CAP leaders will review the proposed MACRA rule and discuss how it affects pathologists during a 60-minute webinar presentation on July 7 at 2 PM ET.

The MACRA regulation would set two payment pathways for physicians beginning in 2019: the MIPS and APMs. MIPS is expected to have an estimated $1.5 billion impact on payments to pathologists. Physicians participating in eligible APMs would not be subject to MIPS and would receive 5% Medicare payment bonuses.

The CMS is proposing to use 2017 as its first year to start measuring physician performance under the new payment system. Learn more about MACRA, MIPS, and APMs during this complementary presentation for CAP members. At the end of the presentation, our expert panel will answer your questions.

Register Today

Registration for this complementary presentation is available for CAP members and their staff. If you are unable to attend the live event, those who register will automatically receive an email link to an archived recording of the presentation by July 11.

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The 2017 CAP Policy Meeting will be a week earlier than in previous years—so mark April 24-26, 2017, in your calendar to join your colleagues in Washington, DC. The CAP Policy Meeting is the specialty's opportunity to focus on the issues most important to pathologists now and in the future. The CAP's Annual Hill Day will take place on April 26 and will be a unique time for you to personally meet with your representatives in Congress to advocate for improved patient care and for the practice of pathology.

Registration and program information will be published in future issues of STATLINE and on

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Each month, STATLINE will feature one of the many CAP members who have been champions for pathology in Washington and at the state level through our grassroots and PAC programs. If you would like to get involved, you can join PathNET, contribute to PathPAC, or join your state pathology society.

Name: C. Leilani Valdes, MD, FCAP
Position: Partner, Regional Pathology Associates, Victoria, TX; Laboratory Director for the RPA Anatomic Pathology Laboratory, Cuero Community Hospital, Jackson County Hospital, and Otto Kaiser Memorial Hospital

What advice would you give to someone who wants to be involved in advocacy?

When it comes to advocating for our specialty, every little thing you can contribute helps toward achieving our greater goals. Even if you don't have the time or ability to attend the CAP Policy Meeting (yet), there is something you can do to help. From grassroots efforts in your local community to making a contribution to PathPAC (any amount makes a difference), you can help our efforts to make pathology and pathologists known.

If you want to increase your efforts, the annual CAP Policy Meeting is an excellent way to stay informed, forge relationships with your federal representatives, and network with like-minded pathologists. With all the changes coming to the health care system, the time to start actively participating in advocacy is now!

Do you have a favorite memory or experience that stands out in your advocacy work?

I was eight months pregnant during my first visit to Capitol Hill, and I still remember the surprised looks from the Congress member's office staff when I introduced myself as a physician/pathologist. I thought to myself, now you see me, a female, a patient, and a physician all in one advocating not just for me but for my family and my patients. I’m pretty sure it made for an interesting impression.

What do you find most rewarding and/or most challenging about being an advocate for pathology?

In my opinion, pathology as a specialty has challenges when it comes to our image or lack thereof among our colleagues in medicine as well as in the general public. The politicians and lawmakers often do not even know who we are or what we do, much less how important we are to quality patient care. As a reflection of that lack of understanding, legislation often forgets about our role altogether. Through advocacy, we have the opportunity to educate lawmakers about our role. Little by little we can make a difference for our specialty and for our patients by actively participating in advocacy efforts at the federal, state, and local level. It will take as many voices as we can muster to educate others to the value we provide in the constantly evolving health care environment.

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Rajesh Dash, MD, FCAP has been appointed to serve on a federal committee charged with making recommendations on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information.

The CAP nominated Dr. Dash, an anatomic pathologist and associate professor at Duke University Medical School, in 2015. At that time, Dr. Dash served as chair of the CAP Informatics Committee, which seeks to empower pathologists to drive higher quality and more cost-efficient patient care by improving and promoting tools for information analysis and management, and removing information technology-related barriers to optimal practice.

The Health IT Standards Committee provides its recommendations to the Health and Human Services (HHS) Office of the National Coordinator for Health Information Technology. The 2009 American Recovery and Reinvestment Act further mandates that the committee develop, publish, and update a schedule for assessing policy recommendations annually.

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Throughout this hour-long panel discussion on July 14, CAP experts will explain the changes proposed by the CMS in the draft 2017 Medicare Physician Fee Schedule. The presentation begins at 2 PM ET.

Expected to be published by the CMS in early July, the proposed fee schedule contains reimbursement changes affecting pathologists. Under a new requirement, the CMS will provide additional detail on its intention to revalue certain pathology services targeted as potentially misvalued. During the webinar presentation, the CAP will review proposed changes, discuss how the rule affects Medicare reimbursement for pathology services, and the CAP's advocacy efforts to impact the CMS’ proposal prior to its finalization.

The second part of the webinar will be a question-and-answer session.

Register Today

CAP members are encouraged to register for this complementary presentation. If you are unable to attend the live event, those who register will automatically receive an email link to an archive recording of the presentation by July 18.

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Due to the Fourth of July holiday, the CAP's weekly edition of STATLINE is taking a scheduled break on July 5. The next regular edition of STATLINE will be published on July 12. If major news breaks before July 12, CAP members will receive a STATLINE Special Report with news also published on the CAP's Twitter and Facebook feeds.

Please email STATLINE's editor if you have questions or comments.

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