January 2012
Feature Story

Anne Paxton

Pathologists’ participation in Medicare’s Physician Quality Reporting System (PQRS) moves to the next level this year with the addition of three new pathology-related measures, making a total of five ways pathologists can benefit from the bonus program. The PQRS program provides incentives to eligible professionals and group practices who satisfactorily report data on PQRS quality measures—and it will eventually impose penalties on those who don’t participate.

The new PQRS measures, developed by the College and accepted by the Centers for Medicare and Medicaid Services, are Barrett’s Esophagus, Radical Prostatectomy Pathology Reporting, and Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor 2 Testing (HER2) for Breast Cancer Patients. They join the breast cancer and colorectal cancer measures that were pathology’s initial measures in the 2008 Physician Quality Reporting Initiative.

The expansion of the PQRS to include these new measures will allow significantly more pathologists to participate in the program, says Emily Volk, MD, chair of the CAP Public Health Policy Committee and medical director, Department of Pathology and Laboratory Medicine, Baptist Health System, San Antonio. To date, pathologists have not participated to the same degree as the other specialties. “We have sort of been on the fringes with this. Until 2012, we’ve only had the two measures in play with CMS; we had just dipped our toe in the water. With the addition of three new measures, we now have the ability to participate in a more substantive manner.”

In this latest round, there were nine measures that made the final cut as far as the College is concerned, and the prostatectomy, HER2, and Barrett’s esophagus measures were the ones the CMS accepted, Dr. Volk says. “They were the measures recognized from both a medical and layperson standpoint as representing the most ‘value added.’”

When it was established in 2007, PQRS was referred to as a pay-for-performance program, but it is really pay for reporting, she adds. “The PQRS program comes out of the recognition that paying physicians for individual services without demanding some kind of performance metrics isn’t cost-effective.”

The PQRS program is the beginning of a shift of Medicare from traditional pay-for-service to value-based purchasing, says Jonathan L. Myles, MD, chairman of the CAP Economic Affairs Committee and pathology advisor to the AMA Relative Value Update Committee. “Value-based purchasing will mean that Medicare will compensate individuals who are providing more value to Medicare beneficiaries than those who provide less value. The analogy is if you go to the store to buy a lawnmower, instead of every product being the same price, you pay a different price for a different product.” Private payers, he adds, are likely to adopt some type of similar system, as physician quality and value will increasingly be subject to measurement.

It was the house of medicine that initiated the quality improvement program in the form of the Physician Consortium on Performance Improvement, says David Witte, MD, PhD, former chair of the CAP Public Health Policy Committee. But it later became obvious to the government that quality improvement could be married to value-based purchasing. “The critics will say it’s an enormous amount of cost for a small benefit on the quality curve, and to an extent, that’s true. The proponents of this program will say this is an attempt to use quality medicine and value-based purchasing to try to reduce the cost of medicine.”

The program was voluntary to begin with, and it’s still voluntary as it’s structured now, says Dr. Myles, who is in the Department of Anatomic Pathology, Cleveland Clinic Foundation. As it evolves, “it will just mean that you receive a penalty for not participating in it instead of a bonus for participating.” The dollar amount of the incentives, which started at two percent but for the next three years will be 0.5 percent, is not great, he concedes. But he urges pathologists to participate. “It’s worthwhile to avoid penalties in the future in addition to ensuring the best possible care to patients.”

Some pathologists will participate in the PQRS for the first time this year, “and that was the goal with these new measures,” says Fay Shamanski, PhD, assistant director of public health and scientific affairs in the CAP’s Division of Advocacy, Washington, DC. Dr. Shamanski has been the key CAP person in charge of the CAP measures development program and steering the measures through the various levels of CAP committee reviews and external reviews.

Specifically, the new clinical performance measures are: No. 249, the percentage of patients with esophageal biopsy reports for Barrett’s esophagus that contain a statement about dysplasia; No. 250, the percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score, and a statement about margin status; and No. 251, the percentage of patients with quantitative breast tumor HER2 IHC evaluation using the American Society of Clinical Oncology/CAP-recommended manual system or a computer-assisted system consistent with the optimal algorithm for HER2 testing. From 2012 through 2014, pathologists can receive incentive bonuses of 0.5 percent for reporting on these measures.

The College hopes these measures will broaden the ability of its members to participate in the PQRS. When the program was in its formative stages, “There were some concerns,” Dr. Volk says. “The College was taking an eyes-wide-open approach to this. We didn’t want to create performance metrics that would be too onerous, that wouldn’t necessarily be relevant to the practice of pathology, or that would make practice too difficult.”

The CMS set up the program based on existing infrastructure, Dr. Volk adds. “It was built on the ICD-9 and existing CPT code structure, so in order to find cases that would qualify, they had to use a combination of the two codes. Because pathology has so few CPT codes compared to the other specialties, this became trickier. The risk was that we’d capture things that are not really appropriate in the denominator. So CAP was very cautious—I think appropriately so—in engaging in this program and wanting to make sure the measures were both appropriate and achievable by the CAP membership.”

To participate in the PQRS program, pathologists will not have to change the billing codes on claims, Dr. Shamanski says. “However, to participate, pathologists will have to add reporting codes to their claims. It is definitely extra work that somebody has to do. And it may require some systems changes that pathologists will have to implement in their own laboratory or administrative setting.”

The measures have resulted from the combined input of various stakeholders, Dr. Myles says. These include the CAP resource committees, the Performance Measures Committee that Dr. Volk leads, the Economic Affairs Committee, and the Physician Consortium for Performance Improvement, which includes surgeons, oncologists, and a representative of the Centers for Disease Control and Prevention. “The first two measures, breast and colorectal cancer, were selected, first, because they applied to the largest number of pathologists possible,” Dr. Myles says. “Second, the performance measure could be coded using a claims-based process. The third thing is we had to be able to document a gap in care.”

But there has been a period of adjustment along the way. “The biggest concern that pathologists have had is how to properly code a case, and that’s a matter of experience,” Dr. Myles says, noting that the CAP has given webinars and presentations at national meetings to help pathologists and billing services not initially familiar with the codes to get in step with the PQRS program.

To report correctly, Dr. Shamanski says, “it’s very important for physicians to have a conversation with their billing and coding people, so that everybody knows how to do this.” There tends to be a lot of confusion about how to use the CPT2 codes in the PQRS program, Dr. Volk says. “These kinds of codes are new to many pathologists, practice managers, and billers and coders, so I’ve steered them to the CMS website [www.cms.gov/PQRS/] for final answers to their many questions.”

A second issue in transitioning into the program is that independent laboratories, including privately owned non-hospital pathology practice sites, are not part of the PQRS. In the enabling legislation they were excluded because they are classified as contractors. “CMS is continuing to work to resolve that issue, and it will take a legislative fix,” Dr. Myles says. The College has worked to address this exclusion and has advocated that independent labs be included.

Most of the work on performance measures goes back at least 10 years, says Dr. Witte. “It really started with the College’s relationship with the AMA’s Physician Consortium on Performance Improvement,” on which Dr. Witte was the CAP’s representative. The first performance measure the consortium developed was for diabetes in the late 1990s. “Then these performance improvement measures were viewed as very positive things by payers, when they started thinking about paying for value instead of volume, so they got appended onto the quality improvement initiative that the AMA and CAP were involved in.”

The concept of measures depends heavily on data about gaps in care, Dr. Shamanski explains. “When we were developing the measures years ago, that was one of the criteria that the organizations endorsed, that there be data showing gaps in care. The point is to improve care, and if there is no gap in care, then what are you really doing with the measure? It’s just an exercise in reporting, not quality improvement.” The new prostate measure relied on a 2006 Q-Probes study, and both the breast and colon cancer measures were also supported by data showing gaps in care.

“Some of the gaps, where we couldn’t necessarily find data, were based on the experience of members of the working group as well,” Dr. Shamanski says. This was the case with two elements in the prostate measure. “Following public comments, we changed the measure significantly. We had originally three elements, and we spoke with the urologists and they really felt it was important to add the Gleason score and the status of margins. A Q-Probes study showed no gap in care there, so we hadn’t included them in the original measure. But the urologists felt that didn’t matter; they still wanted to include these two elements.”

One issue that sets pathology apart is that a lot of measures available to the other specialties aren’t applicable to pathology, Dr. Myles notes. “Various types of physicians take care of patients with hypertension or diabetes, and these just aren’t available to us because we don’t physically see patients in routine practice.”

“All the specialties had the opportunity to build performance measurements,” says Dr. Witte. But from the standpoint of an insurer or the CMS, “pathology is a small proportion of the money they have to pay out,” so it was not the focus of the first efforts. “Because there’s a lot more bang for the buck, from CMS’ perspective, in primary care, the priorities partnership tried to focus on the high dollar volume/high health impact kinds of things, so there was a lot of attention to diabetes, hypertension, prenatal care, and so on.”

The measures to be used for pathology were developed from an initial cadre of about 30 topics. “As with any consensus project, it’s a very lengthy process,” Dr. Witte says. “We ended up with breast and colon cancer because they were the easiest ones to build consensus on. Esophageal cancer, prostatectomy, and HER2 were also not that difficult. The ones coming up in the future will be a little harder to win consensus on,” because there is less evidence of gaps in care or potential impact from adopting performance measures.

The College’s standards programs give it a somewhat unique background, Dr. Witte says. “Pathology has been so heavily involved in performance improvement for 50 years that we have a strong culture of measurement and accountability. That means the impact that was left to be made by these measures was a little less in pathology than it might have been in some other specialties.”

Years of following CLIA regulations and participating in the Laboratory Accreditation Program have kept pathologists under scrutiny for some time, Dr. Volk agrees. “We have done a lot of self-imposed measurement, and we’ve had measurement imposed by outside agencies, that have forced us to standardize our practices much more extensively than any other specialty I know of.”

That’s one of two factors that have complicated the development of the measures in pathology, Dr. Shamanski says. “The first is because we’ve focused on quality for so long, it’s been difficult for us to find gaps in care. What the general stakeholders are looking for are large gaps, with 30 percent to 50 percent of the appropriate care not being given. You don’t see that in pathology. The biggest gap we’ve had was 15 percent. And the areas where you do find gaps can’t be measured through a claims-based process. So the trick or difficulty is finding those gaps in care that can also be measured using CPT and ICD-9 coding.”

The second is that there are a number of subspecialties within pathology, “so the time and energy required for measure development are huge. We’ve been trying to start in areas where we can cover the most pathologists, but we’re also working to bring in measures for the smaller subspecialties as well. So it’s been challenging.”

When this program was first conceived, “folks were primarily thinking of primary care practitioners,” Dr. Volk says. “I don’t think pathology was on anyone’s mind.” Despite that, Dr. Witte says, “Pathology has had pretty good participation when you look at all the specialties.”

“In some ways you have to participate in PQRS to get an understanding of how the program works,” Dr. Shamanski says. “We try to inform pathologists as best we can, but there are some things we just can’t anticipate, that will be unique to any individual pathologist’s billing and coding system.”

Pathologists are getting used to the process, however, as the breast and colon cancer measures have shown that difficulties have been relatively minor, she says.“There was initially some confusion about what to do when you have a breast or colorectal cancer patient who is having a biopsy for something completely different. The history of their breast or colorectal cancer appears in the ICD-9 code on their claim, so they get picked up in the measure.” To address this, the CAP Measures Development Working Group developed a specific code for second-site resections rather than the site of the original tumor. “That’s ironed out the confusion and seems to be working pretty well.”

There is anecdotal evidence that some pathologists find the measures bothersome at times, Dr. Witte says. “I don’t think we ever got much criticism on the medicine side of it. But to get the information that you need was not always as easy as we thought it would be. It’s really an information flow issue, getting the information onto the right piece of paper in the right format so that it looks right. Each practice has its own information flow, and if you’re in the ‘ease and facility’ group, then presumably the extra money is worth it. If you’re in the ‘difficulty and hindrance’ group, it may not feel like it’s worth it.”

The three new measures move pathologists’ participation in the PQRS to a new level. “With our first two measures, our committee was certainly pleased we got them accepted,” Dr. Volk says. “But the negative feedback I’m aware of was frustration that the measures weren’t a little more broad-reaching. We recognized right away that we had left out all the folks who didn’t diagnose breast and colon cancer, and all the folks who did just clinical pathology. “

On the face of it, bonuses for performance is a great idea, Dr. Volk says, “but as with anything, the devil is in the details. Eventually I suppose the goal is PQRS will translate into pay for performance. It’s well intentioned, but right now we’re at pay for reporting, and I’m not sure what kind of impact it will have on improving the quality of pathology practice.”

She is already seeing a role for the pathology measures outside the CMS. In San Antonio, where she practices, “we’re in the early stages of developing what I think will become an accountable care organization for our hospitals. Specialty groups have been asked to come up with performance measures. It was really great to have measures to use in this setting that have already been vetted and approved by CMS and say, ‘You know what, these we can do.’”

The ultimate performance measure, she adds, would be “did you get the right diagnosis?”

“But a diagnosis is a medical opinion, and we’re probably nowhere near getting that as a performance measure, so I think we have to use these surrogate measures of quality to try to improve our practices.” The measures are good only for a couple of years, she notes. “The measures process is meant to be a living process, and the measures will be regularly re-evaluated for their appropriateness.”

In 2009, about 50 percent of the pathologists who participated in the PQRS did so successfully and got a bonus, Dr. Shamanski says. The CMS has not issued collected data on the specific reasons for not getting a bonus, but “sometimes the measures’ reporting codes get dropped off the claim by claims processors because they don’t know what they are for. Again, these are coding issues; they’re not issues with performance.”

She expects that 50 percent figure to increase, but in the meantime, “I would say that pathologists’ participation and success rate was fairly comparable to that of physicians in general and even slightly better, so compared to our fellow physicians we are doing well.”

Because it continues to have a small incentive payment, the program is still a carrot, Dr. Volk notes, but “it’s now a carrot in transition to becoming a stick.” That was one reason the CAP decided to encourage a good portion of the membership to begin getting used to this kind of reporting before it became a penalty, she says. And the penalty has gotten the attention of more pathologists. “That’s the psychology of it. I think there were folks who did not participate early because they weren’t sure the bonuses were worth the effort.”

The original law was clear that the bonus was going to dwindle and finally be dropped. “The penalty system, which takes effect in 2015, was only added fairly recently,” Dr. Shamanski says. “But we certainly suspected that’s where they were going to go with it. The intent in the larger payer community is to use this as a way partially to link quality to payment.”

This year, the CMS will publicize the successful participation rates for physicians who participate through the group practice program. “So they won’t be publicizing the individual physicians’ performance but the group as a whole. But eventually, they will be making available information on individual physician performance through the ‘Physician Compare’ site.”

Pathologists have a good opportunity to still collect a bonus—though it’s smaller than last year’s—and become familiar with the pathology measures program as well. The penalty beginning in 2015 will be based on participation in 2013, Dr. Shamanski notes. “So they have a year to practice.” It’s unclear at this point how the CMS will handle cases where individual physicians don’t have any measures that apply to them, but the College is hoping the CMS will clarify that.

The larger context of the PQRS program is the ebb and flow of how medicine is paid for, Dr. Witte says. “Back in the 1990s, there was a big fuss because health care was costing 11 percent to 12 percent of the gross domestic product. Now we’re at 16 percent or 17 percent. So more of these measures are in store, and there are going to be rigorous changes in payment, because there’s no way in the world our society can put 20 percent of its GDP into health care.”

The PQRS pathology measures also square nicely with the goals of the College’s transformation initiative, Dr. Volk believes. “Participating in programs that our colleagues in the primary care and surgical practices have to participate in, which involve all physicians, is simply another way we reinforce our central role in the medical care of patients.”