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March 14, 2017

In This Issue:

The House Energy and Commerce and Ways and Means committees approved legislation to repeal and replace portions of the Affordable Care Act (ACA).

On March 8, the legislation was voted out of the committees on a party line vote. The American Health Care Act (AHCA), which repeals and replaces portions of the ACA now heads to the House Budget Committee where a vote is expected this week with a possible vote in the House next week.

On March 13, the nonpartisan Congressional Budget Office (CBO) published a report that showed the AHCA would reduce federal deficits by $337 billion over 10 years. However, the report estimated that the number of uninsured Americans would increase by 24 million by 2026, and premiums would by increase 15 percent to 20 percent for the first year of implementation (2018-2019) for single policyholders in the non-group market, but then premiums would lower to 10 percent below the current ACA standards by 2026.

The CBO report estimates that the largest savings would come from reductions in Medicaid and from the elimination of the ACA's subsidies for non-group health insurance. The largest costs would come from repealing many of the alterations the ACA made to the Internal Revenue Code. These include an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, annual fees imposed on health insurers, and from the establishment of a new tax credit for health insurance.

Physicians, Hospitals Oppose AHCA

The decline in health insurance coverage under the House bill had drawn concern from physician associations and hospitals representing physicians even before the CBO score was released. In a statement, the American Medical Association (AMA) said it’s unable to support the repeal and replace bill in its current form. "As drafted, the AHCA would result in millions of Americans losing coverage and benefits," said AMA President Andrew W. Gurman, MD. "By replacing income-based premium subsidies with age-based tax credits, the AHCA will also make coverage more expensive—if not out of reach—for poor and sick Americans. For these reasons, the AMA cannot support the AHCA as it is currently written."

The American Hospital Association and AARP also stated they oppose the bill.

The CAP's positon is to not support the AHCA in its current form. The legislation does not address the majority of the CAP's overarching principles for health care reform. The bill also would leave intact ACA provisions that have been harmful to pathologists. 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

More updates on this issue will be published in future editions STATLINE.

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The CAP and the Texas Society of Pathologists (TSP) are actively opposing efforts by UnitedHealthcare (UHC) to expand its laboratory benefits management program to Texas. The program, administered by Beacon LBS in Florida, was slated for mandatory participation in Texas on March 1 but has been delayed until further notice.

The CAP has been active in its opposition to the program, which it believes negatively affects patient access to services, delays results, and creates inconsistencies with current clinical practice, professional judgment, and laboratory operations. The program administered by Beacon LBS, a wholly owned subsidiary of LabCorp, went into full effect in Florida in April 2015.

In Florida, the program affects about 80 laboratory services ordered by network providers in the state for patients insured by most UHC commercial plans. Providers are required to use the Beacon LBS Physician Decision Support tool to order tests for UHC patients covered by the program.

Voluntary participation in the program in Texas began on January 1, 2017, but UHC delayed the claims denial component of the program, which was scheduled to begin March 1. UHC has indicated it would provide 90 days' notice prior to any full implementation. The CAP has long urged UHC not to move forward with the program and is actively engaged with UHC.

Bill Introduced in Texas

Both the CAP and the TSP are backing a bill (SB 1375) introduced in the Texas State Legislature that would prohibit a health plan from directing or limiting the decision making of an enrollee’s physician or health care provider relating to the use of clinical laboratory services or referral of a patient specimen to a laboratory in the health benefit plan network. It also would prohibit a health plan from denying payment for clinical laboratory services based on whether the ordering physician or health care provider uses clinical decision support software or a laboratory benefits management program.

The language in this bill is modeled after language the CAP worked on in Florida with the Florida Society of Pathologists and the Florida Medical Association that was considered by the state legislature in 2015 and 2016. The CAP has been involved with opposing Beacon LBS prior to its inception in Florida.

In addition to arguing that the program negatively affects patient access to services, the CAP also objects strongly to the program's uniform secondary review requirements that are inconsistent with an evidence-based guideline developed by the CAP and the Association of Directors of Anatomic and Surgical Pathology in May 2015 on timely second reviews to improve patient care.

The CAP will remain actively engaged with both UHC and the Texas legislature on this critical issue. Watch future issues of STATLINE for further updates.

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President Trump has nominated Scott Gottlieb, MD, as commissioner of the Food and Drug Administration (FDA), the White House announced on March 10.

As FDA commissioner, Dr. Gottlieb would oversee an agency with regulatory influence over pharmaceuticals and medical devices, in addition to food safety and other areas of human health.

Dr. Gottlieb is a physician and resident fellow at the American Enterprise Institute and has also served as an FDA deputy commissioner under former President George W. Bush's administration, including serving as the deputy commissioner for medical and scientific affairs under former FDA Commissioner Mark McClellan, MD.

Dr. Gottlieb was also a senior policy advisor at the Centers for Medicare & Medicaid Services (CMS) during the implementation of the Part D drug benefit for Medicare beneficiaries.

Dr. Gottlieb's appointment to the FDA is subject to Senate confirmation.

Read future editions of STATLINE for more updates on the Trump administration's appointments.

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The Connecticut Society of Pathologists (CSP), with the support of the College of American Pathologists (CAP), is urging state lawmakers to pass legislation that would ensure parity in the payment formula for all out-of-network hospital-based physicians, including pathologists. The effort is being led by the Connecticut State Medical Societyand is also supported by the state chapters of the Coalition of Hospital Based Physicians (ACEP, ASA, ACR, CAP).

The legislation, SB 876, is needed to correct an error in current Connecticut law, enacted in 2015, that provides out-of-network emergency medicine with payment established at 80% of the FAIR Health Inc. rates and all other physicians at the in-network rate of the health insurance carrier payment. The formula, which went into effect in July 2016, is a disincentive to health plan contracting and does not serve the patient's health care interest, testified William Frederick, PhD, MD, CSP president, in March.

"Pathologists, like emergency physicians, are legally and ethically obligated to provide services to patients," said Frederick in his March 2 testimony. "We cannot and do not defer the performance of pathology based upon the insurance status of the patient."

"The Connecticut out-of-network law was modeled after a similar law in New York—with the one glaring exception being that New York correctly provides parity for all hospital-based physicians, with a payment under 80% of the Fair Health Inc.," said Frederick during a hearing before the Insurance and Real Estate Commission. "In addition, no other state adversely differentiates payment of all other physician services from emergency medicine."

The CSP believes this must be corrected for the following reasons:

  1. The current law is not transparent and is highly biased in determining payment because only the payer determines the in-network payment rate;
  2. The current law provides no economic incentive to contracting because the provider is paid exactly the same whether in-network or out of network, thereby inducing the dismantling of physician networks by both plans and providers; and
  3. By granting all rate setting power to the payer, the current law leads to a devaluation and discounting of physician services reflected in both the contracted rates and non-contracted rates, creating an adverse practice environment for physicians in Connecticut.

The use of the FAIR Health Inc. database is the most objective and transparent way to determine "usual and customary" rates for physician services, argues Frederick. "It is for this very reason that the out-of-network New York law uses the Fair Health database for determining all out-of-network payment," he says. "There is simply no logical or sound public policy reason for Connecticut law to establish adverse payment differentiation between hospital-based medical specialties."

The Connecticut State Medical Society (CSMS) concurs, noting that the intent of SB 876 is to ensure that services provided by physicians who are out of network receive the same protections as those who provide emergency services. "It is important to note that network status for many physicians is outside their control," said the CSMS in testimony submitted to lawmakers. "Within a highly concentrated insurance market in our state, it is often the insurers who determine network status or offer contracts that are not viable for physicians…For these reasons, the protections provided within emergency situations…should be extended to all physicians who for various reasons are contractually required to provide services."

Under current Connecticut law, patients are protected from balance billing for out-of-network hospital-based services. SB 876 does not alter the statutory provisions of that protection.

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Claire Murphy, MD, FCAP

STATLINE regularly features one of the many the 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: Claire Murphy, MD, FCAP
Position: Hematopathology Fellow, University of Washington

Why should your colleagues get involved in advocacy?

Advocacy in politics is an influence game, whether you like it or not. We cannot sit back and relax, be absent, and let others speak for us. It is our responsibility to advocate for pathology and ourselves. Our future, especially for those of us just starting our first jobs, is dependent on our involvement with our representatives in government. It can be done ethically—and it can be, dare I say it, fun! It feels so empowering to walk the halls of Congress and be able to influence bills and legislation at the local and national level.

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

There are endless ways to get involved. The process can create some anxiety at first, but pathologists have an innate sense to persevere. Our county, state, and national medical organizations are a great first step and would be overjoyed to hear from you. Learn how to advocate for yourself and for pathology at the department level, hospital level, and local and national government levels. Events like the CAP Policy Meeting and state medical association and American Medical Association meetings and legislative days have sessions that teach the techniques. All have resources available if you are a member, so join! Many of your more seasoned colleagues who are already involved can also help and extend your network of support.

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

My introduction to advocacy started in my first year of residency where I met a lobbyist at the Washington State Medical Association Legislative Summit. Step by step, she taught the group the strategies of influence and made the idea of approaching legislators less formidable. Her book, The Influence Game by Stephanie Vance, taught me many tactics that I use. Later, I met Michael Giuliani, the CAP’s advocacy senior director, as I was preparing for my first day advocating in Washington, DC. I had quite a schedule, complete with a roundtable lunch meeting, Senate and House meetings, including one with a staff member on the Ways and Means Committee. I walked the hallowed grounds of Congress as a citizen that mattered. I sat in rooms with magnificent architecture and the legislative staff's undivided attention. Anxiety and sense of responsibility aside, I found the meetings to be genuine and fun. The legislative staff wanted to learn about pathology and my perspective as a constituent, and they were hungry for ideas for new policy or improvements. I was assisted every step of the way by CAP staff, and together we didn't miss a beat.

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On April 5, 2017, the CAP will present the Essential Tools for Pathologists Engaging in Grassroots Advocacy webinar that will provide a foundational training for members interested in becoming grassroots advocates. The 60-minute webinar will cover the basics of how Congress works, why grassroots matters and the tools and resources the CAP provides for members. We strongly encourage anyone attending the CAP Policy Meeting for the first time to participate, in order to gain a general understanding of grassroots advocacy before you arrive in Washington.

Whether you are DC bound or looking to get involved in your district, you'll want to hear from experienced advocates Joe Saad, MD, FCAP, Federal and State Affairs Committee Chair, Al Campbell, MD, FCAP, Grassroots Subcommittee Chair Federal and State Affairs Committee and moderator Michael Giuliani, CAP Advocacy Senior Director.

Register for the webinar.

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With a theme of Protecting the Practice of Pathology and Our Patients, let your voice be heard at the 2017 CAP Policy Meeting. From April 24–26, CAP members can connect with government leaders and policy experts to discuss the impact of federal regulation on their pathology practices.

New regulations are taking shape that will impact pathology reimbursements for years to come. Beginning in 2017, metrics outlined by a new reimbursement system for Medicare take effect.

At the 2017 CAP Policy Meeting, government leaders and policy experts will discuss how these major changes will impact your practice. You'll learn how to prepare your practice for these changes and how to make an impact on the legislation moving through Congress.

Registration is now open. Stay tuned for more updates.

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