July 2009
Feature Story

John Scott

Health care reform legislation is expected to embrace a coordinated care model with primary care physicians at the center. The CAP is pressing for policy changes to ensure that pathologists remain integral members of the care team, and it announced on June 9 how it plans to achieve this. John Scott, vice president of the CAP Division of Advocacy in Washington, DC, described for various audiences last month what lawmakers and others are aiming for and what the CAP is asking for and why. Following is an edited transcript of his remarks.

I will begin with a brief note about the state of play on health care reform in Washington. The White House has been letting Capitol Hill take the lead in drafting the legislation. That’s very intentional on the part of the administration: The aim is to shift the focus of attention away from Obama himself to the Hill and the legislators.

Most of the focus and activity started in the U.S. Senate. This makes a lot of sense because in the Senate 60 votes are needed to move legislation. The Senate’s effort and its concentration have been on ensuring that it has that 60-vote majority nailed down. Longtime Republican senator Arlen Specter’s (D-Pa.) recent party switch essentially guarantees that the Senate has those 60 votes and is able to move anything to the floor.

This puts the Republicans in a precarious position. They have to decide: Are they going to try to have influence on this legislation, or are they going to sit outside and shoot at it and just try to poke holes in it?

They don’t have a workable majority or enough votes to do that successfully, so we suspect they will try to modify the legislation as it’s being developed. That works to the favor of the Democrats and the president, and it’s an indication of how things are moving.

The draft proposals have been worked on for months, and the College has analyzed them and commented. They’re now in committee markups, where votes are taken and amendments are considered. Next, the committee with jurisdiction will write the legislation. [The 852-page House bill was introduced June 19.] The goal is to get reform passed in the Senate and the House by August, and to move the bill to the president’s desk by October. This is an extraordinarily ambitious and aggressive legislative schedule. You could only possibly do this—even consider doing it—if you were in a commanding position, as they are, with 60 votes and a very strong majority in the House. Otherwise, this is not even feasible.

Even with that, though, this is not at all easy to do. But they are moving at a pace that suggests they are serious about maintaining this schedule. Markups were to take place in June. Senate floor time is blocked for late July. The aim is to pass a bill before the August recess and have it to Obama by October.

There are two parts to the proposals that are coming forward. First, there’s the delivery system redesign, and the focus of this is moving to a coordinated care model, using enhanced health information technology systems so that coordinated care teams can talk among themselves and share information. There is a strong bias toward primary care, and the proposals include shifting money to primary care, to give primary care physicians higher payments, to make them more central players in this system. That will have an impact on pathologists because money may be shifted from specialists to primary care. Also part of the delivery system redesign is more pay for performance. For the most part, the proposals so far have been pay for reporting. Over time with these proposals, they are moving to pay for performance, with penalties and so on. Those things potentially affect pathologists negatively because they have unique issues related to developing pathology measures.

Another piece of the redesign is the use of comparative effectiveness research. They’ve already put a lot of money in place for this, as they have for health IT.

The other, more widely debated part of the proposal calls for expanding health coverage. The question is how to cover everyone, and I assure you they intend to do this. I suspect it’s going to be a system in which there are a number of different players in the market. And they’re trying to equalize the market and make sure everybody is covered. It looks like they will propose using a public health insurance option—allowing people to essentially buy into a publicly run plan. The publicly run plan could be like Medicare or potentially administered by the government, a third-party payer, or the states. They also intend to expand Medicaid. And they’ll have a pay or play requirement for employers, by which employers can decide to cover their employees or pay into the plan. We suspect, too, there will be an individual mandate, much like there is for auto insurance. And they will have insurance reforms to equalize coverage across these different plans. They will choose from among these options. They’re trying not to disturb the employer-based system.

As for the CAP health care reform agenda, the first thing the CAP needs to do is to mitigate any proposals that potentially reduce payments to its members in the next 18 months to two years. That’s job No. 1. Our second job is to begin to establish the future role of pathology in a coordinated, personalized health care model.

Right now, we see four major threats to pathology payments. The sustainable growth rate, or SGR, is the formula by which they update what Medicare pays all physicians. Pathology faces a potential 21 percent cut in 2010, but we think they are going to fix that. They’re also talking about shifting money to primary care through bonuses, up to five percent over the fee-schedule amount, and possibly offsetting them by across-the-board cuts in other physician services. Primary care goes up; pathology goes down.

Third, there is pay for performance. If our members are not able to participate in this program sufficiently, they could face penalties. There have been logistical and procedural problems in our trying to get pathology measures approved. We think it’s premature to be talking about penalties.

Fourth, and while all this is going on, we’re working through the AMA system on the potential reevaluation of anatomic pathology codes. The reevaluation could become a significant problem. Our codes haven’t been evaluated for decades. This could potentially lead to reductions in payments to CAP members that are independent of anything that happens related to reform.

Our future agenda reflects in policy terms the transformation of the specialty, which CAP president Jared Schwartz, MD, PhD, has spoken and written about for some time now. Our ‘ask’ translates the transform­ation into something policymakers can understand, that taps into our members’ unique training and expertise and provides better service to patients.

Our analytical framework for our future agenda focused on test selection, therapy management, clinical consultation, clinical epidemiology, and population disease management. We focused on new services to patients and clinicians—that is, what we can do that’s going to enhance our services and make them and the patients better. After deliberating all of the information uncovered in our research, we concluded patient care will improve if pathologists provide direct care through diagnostic test selection, performance, interpretation, and direction on optimal therapy options to patients and clinicians.

It’s certainly not new that pathologists perform diagnostic tests or that they interpret them. But what about diagnostic test selection on the front end, where pathologists are actively involved in helping clinicians and patients choose? What about directing optimal therapy on the back end, where pathologists are actively working with clinicians to guide therapy options? Primary care physicians may have individual experiences of having had that kind of interaction on an ad hoc basis with their pathologists, but they have not experienced that on an organized specialtywide basis, and that’s what we’re talking about.

We’re also talking about being more proactive in using the patient data that reside in the laboratory to benefit patients and patient populations. This, too, is new.

If the pathologist is to perform these roles, we need policy changes. The system as it is set up now doesn’t encourage this at all. In fact, it discourages pathologists from performing these services. What we need are new payments for consults. Pathologists need to be initiating consults. Right now, the consultation payment policy of the government is: ‘We’ll call you if we need you.’ What we want is to be able to respond: ‘No. We’ll call you if the patient needs us.’ That’s where we want to be. To do that, we’re going to need access to the patients’ electronic health records. And pathology practices need to be able to access that information economically. It’s great to have access, but if the cost is excessive, no one can afford to do it. We need to help pathologists with that by finding incentive money to help them navigate that.

So we have three transformation ‘asks,’ all high-level for now. First, we want Medicare payment policy to be modified to pay for diagnostic consultations initiated by pathologists, with clinicians and patients, on test selection and therapy management. If we get this changed, there is no doubt this specialty will be in a different place than it has been.

Second, Medicare should adopt policies that provide incentives for pathologists, and enable them, to secure full access via electronic health records to the patient care history and information. They’re designing an entire system to make patient electronic health record information portable and accessible. Shouldn’t pathologists have access to that, so they can bring their skills, on behalf of the patient, to the table?

Third, to achieve the first two, we must demonstrate the cost saving and improved care we envision. We are proposing a pathology demonstration project to do just that.

The time is right. We need to make this case now. They’re redesigning the system, and pathology must have a central role. Pathology is the bridge that enables the patient-centered medical home model, which the primary care professional organizations developed in 2007, to embrace and deliver personalized medicine. There needs to be a bridge between those two concepts, and pathologists have the expertise to be that bridge.

Redefining the pathology profession will take a long time. Thirty days from now when Congress adjourns for the summer recess, whether we’re successful or not, is not the end. It’s still only the beginning of this conversation. That’s how big things get done. The medical home model was developed over a period of years. It may take years for pathologists to achieve our goals for the ­pathologists’ role in patient care, but we are committed to doing it. The models under consideration today, the things they’re redesigning, were all vetted. They were incubated through demonstration projects hatched by the private sector and supported by health care policy research. We will follow that pathway as well. That’s why this initiative will happen on multiple levels over multiple years. The one we’re kicking off now is just the start.

Still, time is of the essence and we’ve already launched our agenda on Capitol Hill. Dozens of CAP members and staff have met with key congressional committee members and staff. We’ve already told them what we think. We’ve told them of real case examples of the roles we envision. Now is the time to turn those visions into reality.