Securing Pathology's Future: Payment, Visas, and the Next Generation

Dr. Carmen Gomez-Fernandez:
Hello, everybody. Welcome. My name is Dr. Carmen Gomez. I am a surgical pathologist at the University of Miami and a member of CAP and I'm joined by Dr. Joe Saad who serves as director of the Council on Government and Professional Affairs. Dr. Saad, welcome.

Dr. A. Joe Saad:
Thank you, Dr. Gomez. Nice to be here.

Dr. Carmen Gomez-Fernandez:
Wonderful. So with your involvement in the CAP, I wanted to ask you, what do you see as the priorities right now for the CAP at the federal level and their role in advocacy?

Dr. A. Joe Saad:
So there's no lack of issues that we're dealing with at the federal level. In my 20 years of dealing with advocacy at the CAP, it's never been busier than it is now around payment, around workforce, including visas and around scope of practice at the state issue around payment for PCCP at the state issue, at the state level. But at the federal level, it's payment and we have a lot of challenges around Medicare payment right now. And of course, PAMA and the New Results Act in getting paid not just on the physician's fee schedule, but also on the clinical laboratory fee schedule.

Dr. Carmen Gomez-Fernandez:
And what do you see? What is CAP doing currently about this?

Dr. A. Joe Saad:
So CAP is working actively with our members, with our staff here. In the DC office, we have over 30 staff members that are committed to our advocacy agenda. And we're working very closely with our lobbyists, working on legislation, working on responding to requests for information, comments, responding about issues. The CAP responds sometimes individually, sometimes in collaboration with other medical societies, such as the AMA and other pathology societies as well.

Dr. Carmen Gomez-Fernandez:
Thank you. So it's very important. You would say it's very important for members to be actively involved and participate and advocate for their profession?

Dr. A. Joe Saad:
Absolutely. It's our profession and we're also advocating for our patients. That's the most important thing we need to keep in mind is our advocacy first and foremost is for our patients to be able to receive the highest quality medical care, including pathology and laboratory services that they can possibly receive. In many areas, it becomes an access issue. We talk about reimbursement, but reimbursement is the way that we keep our practices viable and are able to provide that care to the patients. And particularly in some rural and underserved areas, small decreases in reimbursement can have significant effects on patient access.

Dr. Carmen Gomez-Fernandez:
Absolutely. We know that there is a shortage of pathologists in the workforce, and you mentioned immigration as being an important issue that the CAP is grappling with. Can you talk a little bit about that?

Dr. A. Joe Saad:
For sure. About 25% of physicians overall in the US are international medical graduates. In pathology, it's higher. It's close to a third of all pathologists are international medical graduates. So many of these people, many of these pathologists have gone to medical school overseas, and then they come to the US to do the residency and fellowship, and they usually come on a J1 visa. A J1 visa is a visitor exchange visa, which allows you to come, typically it's for the duration of the program up to seven or so years, but there's a number of issues that these IMGs face when they're on a J1 visa. One of them is a requirement to go back to their home country for two years after they finish the training, unless they get a waiver to be able to have that requirement waived and to be able to stay in this country.

Dr. A. Joe Saad:
So that's one of the hurdles. There's certainly other hurdles as well, but the J1 visa is a mechanism by which they train here. And so once we train them and we spend, Medicare spends 160, $170,000 per resident per year training them. So over a course of four years, 600, $650,000 to train a resident. Once they finish their training, if they'd like to stay in this country and practice pathology, we need for them to have a pathway to stay here to practice. One of the pathways is the Conrad 30, which allows them to get a waiver for the two year home requirement if they agree to serve in an underserved area for six years. So that's the pathway for them to serve. Now, that's only one of the issues we're having with the J1 visa. The other issue is that last year, the Department of Homeland Security floated an idea, it hasn't been implemented yet, that they were going to limit the J1 visa to four years.

Dr. A. Joe Saad:
And that would be enough to get a residency and APCP done in the US, but that wouldn't allow for them to do a fellowship and do additional training. Now it can be extended on a year to year basis, but it injects uncertainty both for the programs that are trying to recruit fellows and for the residents that are applying for a fellowship on whether or not they'll be able to stay here once they finish their residency in pathology. There's more issues on immigration. I'm happy to talk about it.

Dr. Carmen Gomez-Fernandez:
Well, just to continue on the Conrad 30, I think the Conrad 30, for those that may not be familiar, gives out 30 such waivers. And it's not just for pathology, right? It's across the state of Florida, but it also includes surgery and pediatrics. So it's difficult to achieve a waiver, would you say?

Dr. A. Joe Saad:
Correct. It's not specific for pathology. It's for all physicians, including pathologists. And so if there's a critical shortage in pathology in a certain area and you're able to demonstrate that, you have to put it in an application. And it's certainly a process. We know of many pathologists that have gotten Conrad 30 waivers as their way to stay here and practice in the US. The legislation that we're promoting would actually increase it from 30 to 35 per year, which is still not a whole lot. But since the inception of the program a little over 30 years ago, about 20,000 physicians have used this in order to be able to obtain permission to stay and work in the US. Many of those, they all start out in underserved areas. Many of them remain in those underserved areas. Currently, about 60% of physicians overall working in underserved areas are probably international medical graduates.

Dr. Carmen Gomez-Fernandez:
Yeah, I'm sure you're right. And these international medical graduates tend to be the creme de la creme of their group. So they tend to be, at least in our experience at Miami, they're very good and very qualified.

Dr. A. Joe Saad:
I would agree with that. They're self-selected to come here and very motivated and committed. And just to add many of those that actually get the Conrad 30 waiver and go for six years, many of them end up staying in those communities and provide care for patients in those communities.

Dr. Carmen Gomez-Fernandez:
So I want to just pivot a second to state societies. You've served as president of the Texas Society of Pathologists. I currently serve as president of the Florida Society of Pathologists. How can these state societies help with these advocacy initiatives and getting people excited about joining advocacy?

Dr. A. Joe Saad:
So it's very important to have a strong state pathology society, but that provides our grassroots. It provides our booths on the ground if you want, both at the state level when state issues arise, but also to be our foot soldiers for the federal issues when there's a federal issue that comes up. So it's very important for us to motivate our pathologists in our states to join their state pathology society, also join their state medical society and the AMA, put in a plug for both of those. Very important to be members, because we can't do this alone, and we need a collective effort and wisdom of all our members. We're a small specialty. There's just under 21,000 pathologists practicing in the US, and we need every one of those that we can involve advocating for the federal issues and also advocating for state issues.

Dr. Carmen Gomez-Fernandez:
Yes. I'm going to put in a plug for our state society a moment. We're here at the CAP Pathology Leadership Summit, as you know, and we will be discussing these issues like Conrad 30 and PAMA tomorrow and then going to the Hill Day on Tuesday. And just to engage the younger members of our faculty and of our society, the FSP is actually providing stipends for them to attend this meeting this weekend. So it's a way of helping them and sort of getting them to come. And once we get them here, then they get excited about the issues and they learn the workings, the inner workings of government, which for them may be a brand new experience.

Dr. A. Joe Saad:
Yeah. No, absolutely. I'm so glad that Florida is doing this. I know it's not the first year you've done it for two or three years, I think. That's right. That's right. And you've provided up to 10 stipends, I think, which is really, really great. There are a couple of other state pathologist societies that are starting to imitate Florida. I hope it becomes contagious and there are more state pathologist societies that follow suit and do the same. So thank you for leading the way.

Dr. Carmen Gomez-Fernandez:
Dr. Saad, what do you see as some of the roadblocks in our younger pathologists, the pipeline that's coming up and getting involved in advocacy and in government?

Dr. A. Joe Saad:
Well, if we're talking about trainees, it starts at the program level, I think. And there needs to be encouragement, enthusiasm, a pathway for them to, number one, become aware of the CAP, become aware of the issues that we're dealing with, and number two, a mechanism for them to be able to participate. So the first is knowledge, and the second, they need to take that second step and be able to participate. Oftentimes, it's a mentor. It's a one-on-one conversation that ignites the spark within these trainees. Someone who suggests that they come to the Pathologist Leadership Summit, for example, and helps them to come, encourages them to come, mentors them about the issues. And it's not uncommon for, I wouldn't say 100%, but it's not uncommon for if you know about the issues, if you get involved with the issues, if you appreciate the importance of the issues for our patients and for our practices, that you'll get that bug and want to be active in your state pathology society, CAP, your medical association, et cetera. And once they come to DC, a lot of them get the bug and want to come back to DC. And I will tell you, it is a privilege for us to be able to petition our government. There are many countries in the world where you can't do that. It's a right and a privilege for us to be able to petition our government and we must encourage that.

Dr. Carmen Gomez-Fernandez:
Well stated. Thank you.

Dr. A. Joe Saad:
Thank you.