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Tucking pathology incentives into the ACO model

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Anne Ford

June 2013—When David Scamurra, MD, needed a better, more cost-effective platform for C. difficile testing, he did the only thing he could do: He asked hospital administration to purchase it. And he waited. And waited. “And two years later, they bought the equipment,” he says.

End of story, yes? If you belong to an ACO, maybe not. Dr. Scamurra is president of Eastern Great Lakes Pathology, an independent pathology group that provides services to the Buffalo, NY-based three-hospital Catholic Health System. The group’s pathologists are members of Catholic Medical Partners, a network of 975 independent physicians and the Catholic Health System facilities that was selected last year to participate in the CMS shared savings ACO program.

It’s not that Dr. Scamurra had a problem waiting for the new C. diff platform: “I understand the budget constraints.” What he worried about instead was how this inability to complete a project (in this case an equipment purchase) in the new performance-driven reimbursement model may affect future pathology profit-sharing payments.

Dr. Scamurra

“I can suggest this new test, I can ask for it, but if the administrator decides it’s not in the budget this year, does that mean I fail as a pathologist? No,” he says. In other words, it’s hardly fair to penalize someone for not cutting costs when they’re simply not able to get their hands on the scissors (metaphorically speaking).

The question of exactly how pathologists should be incentivized under the ACO model was the central theme of “ACOs: An Independent Pathologist’s Observations of an Evolving Concept,” a talk Dr. Scamurra delivered in March at the American Pathology Foundation’s spring conference in Las Vegas. Dr. Scamurra subsequently shared with CAP TODAY some of the observations from his talk.

From a pathologist’s point of view, the fundamental problem is that “most of the ACO incentives so far have been centered around primary care practices, and the metrics they use to pay, pretty much, are directed toward primary care,” he says. “And in many specialty groups, like dermatology or allergy”—or, of course, pathology—“it’s difficult to figure out how that relates in terms of metrics. How does what we do fit into what the goal of the ACO is, that is, better quality and lower costs?”

Take a routine cholecystectomy, for example. “Absent looking at the slide of a gallbladder,” he says, “what does the pathology laboratory do that makes that a better, more cost-effective experience and therefore earns a share of the year-end ACO surplus? How do you measure that? How much is it worth? And that’s what everybody’s struggling with across the country.”

What Dr. Scamurra has been told by his ACO, he says, is that incentives cannot be paid for “outcomes consistently achieved, as well as for basic competency of practice.” In his view, if that standard is strictly enforced, “much of what we do to contribute to the success of an integrated delivery system are things that would be disqualified.”

Such as? “Understanding and explaining how to use a test. Reviewing the data to see how doctors are actually using it. Doing outcome studies. Those are things we do on a consistent basis that provide a level of quality that’s necessary for the ACO to deliver its clinical side of the equation. But theoretically, those do not qualify for incentive dollars. Instead, we have to have some kind of impact on decreased utilization. And my contention is, we have limitations on our ability to do that.”

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