February 2011

Stephen N. Bauer, MD

In the zone

I’m not a serious fan, but sports has its place. There are better stories about teamwork in sports than anyplace else, for one thing.

Water polo was my sport, and we often used a zone defense. The strategy is all about players working hard to work together, staying flexible, thinking strategy over tactics, keeping an eye on the ball. A zone defense is useful in a lot of situations.

Most of us are on several teams, personal and professional. Although many of the CAP’s important partners are not visible to us day-to-day, our members need to know about them. Whether contributing to clinical guidelines development or sound public policy, many groups outside the CAP bring inestimable value to our team.

Outside groups play an important role in the work of the CAP Pathology and Laboratory Quality Center. The American Society of Clinical Oncology has been critical in the development of HER2 and ER/PgR testing guidelines. The International Association for the Study of Lung Cancer and Association for Molecular Pathology are working with us, through the Center, to develop guidelines for evaluation of key biomarkers that will help to guide treatment and clinical management of lung cancer.

Many pathologists attend both the CAP annual meeting and the annual meeting of the United States and Canadian Academy of Pathology, which focuses on pathology research and education. USCAP participates in the AMA Pathology Section Council and Pathology Coding Caucus.

Research and education are core elements of the zone that our public policy work protects. Pathologists can no longer limit their professional participation to strictly scientific groups, which is why subspecialists meet their advocacy responsibilities by working with the CAP. Pathology subspecialty groups rarely engage in extensive public policy work because of the legal limits on what an organization can do without a 501(c) (6) tax status. The 501(c) (6) allows the CAP to spend unlimited dollars on lobbying and to operate a political action committee. This is one reason why the many benefits of subspecialty involvement are no substitute for active participation in the CAP—and why it is so important that all CAP members support PathPAC.

Member involvement is essential for effective advocacy. The CAP Division of Advocacy is second to none, but our staff cannot do it alone. They coordinate our collaboration with a network of pathology and nonpathology physician groups on national issues of common interest. These personal and organizational ties enable the College to speak with authority for pathology and to influence public policy on matters of importance to the specialty.

I have served as a CAP representative to American Medical Association committees, where I learned how recommendations to the federal Department of Health and Human Services on CPT coding and the resource-based relative value scale are established. These are complex, technical, time-consuming, and sometimes tedious evaluations that then must be defended. Advocacy is serious work that calls for a good memory, a flexible attitude, and a strong commitment to collective purpose—an ability, in other words, to cover the zone.

A few more examples:

• In December, the Clinical Laboratory Coalition asked administrators within the Centers for Medicare and Medicaid Services to reconsider a proposed rule that would require the signature of a physician or a qualified nonphysician practitioner on all requisitions for clinical diagnostic laboratory tests whose payment is tied to the Medicare clinical laboratory fee schedule. We do a lot with the Clinical Laboratory Coalition, whose diverse membership includes, among others, the Mayo Clinic and the Medical Group Management Association.
• We work with other members of the In-Office Ancillary Services (IOAS) Coalition to eliminate self-referral of anatomic pathology from the IOAS exception.
• The American Society for Clinical Pathology is a member of the Clinical Laboratory Coalition and the IOAS Coalition. The ASCP is an integral participant in the Pathology Section Council and the Pathology Coding Caucus, and it has supported direct billing initiatives at the state level for years.
• We have been working with the National Association of Medical Examiners to support replacement of coroner systems with medical examiner systems.
• We have collaborated with the American Society of Cytopathology around proficiency testing and with the Association for Molecular Pathology around gene patents and direct-to-consumer genetic testing.
• We have partnered with the American Medical Association and all of medicine to protect the profession from a looming 21 percent Medicare cut. When all specialties and affiliated groups speak with one voice, we are far more likely to be heard.
• The College chairs and coordinates the Pathology Coding Caucus, a partnership of the AMA and other pathology and laboratory groups, which develops consensus recommendations on new CPT codes for consideration by the CPT Editorial Panel.
• The Association of Pathology Chairs always steps up in any way it can. Its work (with the Accreditation Council on Graduate Medical Education) to refine the Common Program Requirements in ways that will empower new pathologists is a huge boost to the specialty.
• The CAP meets annually with the national pathology societies to talk about public policy priorities and coordinate our advocacy work.
• We chair and underwrite the Pathology Section Council in the AMA, which enables the member pathology societies to coordinate their advocacy within the AMA.
• The hospital-based specialists with whom we work most closely as cofounders of the AMA Hospital-Based Caucus (emergency medicine physicians, radiologists, and anesthesiologists) enable us to work more effectively within the AMA.
• The state pathology society presidents meet annually and keep us posted on local initiatives. Most recently, they carried the ball on direct billing, preventing inappropriate attempts to allow other specialists to mark up and bill for pathology services. The importance of our state pathology societies will grow substantially as health care reform is implemented because important decisions will be made at the state level. This is a good time to verify that your state pathology society membership is current and that your contact information is up to date. Your state society may need to call upon you to testify before committees making decisions that will affect your practice.

Powerful forces are driving change in health care, forces that will roll right over isolated smaller groups. Within the CAP, the qualities of a strong professional team—working hard to work together, staying flexible, putting strategy before tactics, keeping an eye on the ball—are already in place. Pathologists who volunteer energy and expertise are leaders on that team. As a small specialty, pathology must unite many voices to have an impact. We must have a team that can stay in the zone.

Just as all politics is local, all advocacy is personal. When we follow up to make sure that the implications of test results are fully understood, when we volunteer on medical staff committees, when we work to bring innovative tests to our hospitals, partnerships are made. We have a deep bench, as the saying goes, and with the help of many partners and a focus on our patients, we will never run out of new strategies to cover our zone.