Gene N. Herbek, MD
January 2014—The landscape for physician payment is changing and all of medicine is feeling a persistent downward pressure on reimbursement, so this month’s column is a reality check and a call to arms.
The reality check piece is that we’re not just talking about the shift from volume to value, the growing influence of coordinated care, or a new approach to Medicare physician payment updates. The white papers and pilots have put enough flesh to the bone to make it plain that a lot of the new ideas can work. Some can work well, and if we stay engaged, we can help to make them work better—in terms of the quality of care they enable and the financial stability they permit.
The call-to-arms piece is that we have a terrific advocacy team and our members have done four-star work—as individual pathologists and as members of the greater physician coalition. But advocacy in times like these cannot be outsourced. Each of us needs to be stirring the soup.
Policymakers within the Department of Health and Human Services have been working to implement a planned paradigm shift in payment strategy. The unofficial slogan “from volume to value” describes a basket of programs designed to move the system away from measures of activity and instead reward physicians who demonstrate quality, efficiency, and optimal resource utilization. The vision has merit, but it’s complicated.
The elephant in the room continues to be the long-loathed, formulaic sustainable growth rate approach to physician reimbursement updates under Medicare. By the time you read this, it may or may not still be in play, but there’s a better-than-even chance that Congress will repeal and replace the sustainable growth rate sometime this year. And I think we should anticipate, as a global contextual point, that reforms in this SGR repeal effort could alter the way physicians provide input to the CMS on its pricing determinations.
Congressional proposals to reform the SGR are navigating toward a Value-Based Purchasing program (VBP) that combines measures from several current Medicare incentives and pay-for-performance programs. An aggregate score based on the combined measures will be used to determine future payment updates. We are concerned that metrics designed for direct patient care practices cannot accurately assess the quality of pathology practices. CAP advocates are focusing on the best ways to enable the full and fair participation of pathologists in VBP programs. We have found that some legislators are willing to listen, to consider the important and unique contributions of pathology, and to look for ways to incorporate these in the new payment models.
The grassroots grows. In the summer and fall of 2013, a grassroots push across medicine generated thousands of comments to the CMS on the proposed rule laying out plans to implement the 2014 Medicare physician fee schedule. CAP members held dozens of meetings with their representatives, in Washington and at home. Your robust response to CAP action alerts prompted strong commitments of support in the House and Senate.
The CMS on Nov. 27 released its final rule to implement the 2014 physician fee schedule and Hospital Outpatient Prospective Payment System (HOPPS), in which the agency halted its plan to cap 2014 Medicare physician fee schedule payments at Hospital Outpatient Ambulatory Payment Classification rates. This was a win for pathology (although it could be a short-term win).
However, we were disappointed to find that the CMS had also reduced payment rates for certain anatomic pathology codes in the final 2014 fee schedule and discouraged to learn of plans for expanded bundling of payments for clinical laboratory tests performed on hospital outpatients.
So we have much to do.
EHR donation and self-referral. On Dec. 23, the Office of Inspector General for the DHHS and the CMS released their final rulings regarding electronic health record donations under the anti-kickback statute safe harbor and Stark exception. The rules extend the safe harbor/exception until the end of 2021 but exclude “laboratory companies” from the types of entities that can donate EHR items and services, eliminating the abuses associated with these donations and representing a victory for laboratories and pathologists. The OIG and the CMS also clarified the existing prohibition on any action that limits or restricts the use, compatibility, or interoperability of donated items or services. The rule came into effect Jan. 1 without the usual 30-day delay.
In a related note, we continue to advocate for an end to the legal loophole under which the in-office ancillary services exception to Stark has been used to enable inappropriate self-referral of anatomic pathology services. The Government Accountability Office has estimated that this practice cost the Medicare program $69 million in 2010 alone.
Policy Meeting. The 2014 CAP Policy Meeting will take place May 5–7 at the Fairmont Hotel in Washington, DC. If you have attended a Policy Meeting in the past, I’m sure you’re planning to attend this year. If you have not joined us before, please make this your first. Two days of education from the experts will strengthen your effectiveness for the third day, when you’ll meet with legislators and their staff members to do some educating of your own. This is a members-only meeting; please register on the CAP Web site.
Role modeling. Nelson Mandela’s passing was at the top of the news when I was beginning to think about this column. Mandela had a renowned ability to work effectively with the most unlikely partners, people he should have resented but did not. Focus, discipline, and persistent goodwill enabled him to achieve his goals.
One pathologist who understands what Mandela sought to teach, I believe, is Kathryn T. Knight, MD, who chairs the CAP Federal and State Affairs Committee. I’m told that one legislator finally threw up his hands and told Dr. Knight he would come for a tour of her laboratory in Dalton, Ga., if she would then stop inviting him to come. He did, it went well, and he understands, now, why a quality laboratory, properly staffed and equipped, is so important to population health. Kathy believes in the kind of one-on-one, consistent relationship building that creates real partners.
When more of us are relentlessly diligent about advocacy, the influence of pathology will be greater than the sum of its parts. We have busy months and years ahead. Please step up, and persuade your partners to do the same.
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Dr. Herbek welcomes communication from CAP members. Send your letters to him at [email protected].