ePolicy News March 2013
Friday, March 1, 2013
Ready … Set … Sequester …
As almost everyone knows by now, the Sequester—the $85 billion in across-the-board automatic spending cuts in federal spending—went into effect on March 1. These cuts will affect every sector of the economy, and health care is no exception. While many elected officials in Washington, D.C., have stated publicly they do not support the cuts, Congress does not appear to be poised to reverse these cuts at this time. Many U.S. House Republicans have indicated they are reluctant to reverse the cuts, even if they impose harsh cuts in defense spending.
That said, downstream events, such as the economy sliding back into recession or key industries being crippled by the furloughs of federal staff, could prompt a full or partial lifting of the Sequester’s mandated cuts. For example, many food producers are required to have food inspectors on site daily. With food inspectors anticipated to be on the list of furloughed federal employees, businesses not served by an inspector may be forced to suspend operations.
While Medicaid, the Children’s’ Health Insurance Program, and veterans’ health programs are exempt, almost every other federal healthcare program will be affected by the cuts. On the Sequester list are Medicare provider rates, National Institutes of Health (NIH) research grants, Center for Disease Control and Prevention (CDC) public health activities, and Food and Drug Administration (FDA) programs, among others. Exact details of how each program will be affected, however, are elusive as the federal agencies have not yet announced their plans for implementing the cuts.
At the CDC, reports suggested that the CDC’s $6 billion budget would be cut by about $350 million, with staff layoffs and/or furloughs paying for much of the cuts. Health and Human Services Secretary Kathleen Sibelius told Congress recently that cuts in the agency’s budget could result in 424,000 fewer HIV tests by state and local health programs. Thomas Frieden, Director of the CDC, indicated that there could be 2,000 fewer disease control specialists working to prevent disease outbreaks and other critical health problems.
The FDA will see its budget cut about 8 percent. Because most of the agency’s budget pays for staff rather than programs, the agency will also have to either layoff or furlough staff. This may slow the agency’s approval of new laboratory tests, medical devices, and drugs. It could also result in the suspension of many food inspections.
NIH, whose budget funds many research programs across the United States, is expected to lose $1.6 billion in funds. Academic research laboratories are already reported to have started laying off or furloughing researchers in anticipation of the sequestration and other cuts in federal research spending.
Comparatively speaking, Medicare provider rates have escaped relatively unscathed. The Physician Fee and Clinical Laboratory Fee Schedules (CLFS) will be cut 2 percent. Given the size of Medicare spending relative to the overall budget, that 2 percent cut is expected to result in $11 billion—or about two-thirds of the $15.5 billion in spending cuts coming from the healthcare sector. Overall, health care’s share of the Sequester cuts is almost 20 percent.
That said the 2 percent cut on Medicare CLFS cuts could be problematic for clinical laboratories as this fee schedule has regularly been the target of spending cuts.
While the cuts technically went into effect on March 1, it may be a few weeks before furloughs are put in place. Federal law requires federal employees to be given 30 days advanced written notice before a furlough takes place. As a result, federal furloughs may not kick in till April.
ASCP Joins Choosing Wisely Campaign
ASCP has joined the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation to promote appropriate test utilization. ASCP is one of 37 major medical societies in the Choosing Wisely campaign and is the only one representing pathology and laboratory medicine.
Pathologists and laboratory professionals are uniquely positioned to play a key role in promoting and managing the delivery and use of healthcare resources—and creating awareness about appropriate care with clinicians and patients. The mission of Choosing Wisely is to do the right thing for patients and avoid care that is unnecessary and possibly harmful. ASCP is a major proponent of patient-centered care and evidence-based medicine.
Inappropriate or over-utilized medical tests account for $250 to $300 billion in medical expenditures in the United States each year. Furthermore, many healthcare experts believe that these tests result in compromised quality and safety for patients. The Choosing Wisely campaign aims to “help physicians and patients engage in conversations about the overuse of medical tests and procedures and support physician efforts to help patients make smart and effective care choices.”
As a part of the Choosing Wisely program, ASCP developed a list of the “Five Things Physicians and Patients Should Question” for the pathology specialty. This list was developed under the leadership of the 2011–2012 Chair of the ASCP Institute Advisory Committee and the Past President of ASCP, Lee H. Hilborne, MD, MPH, FASCP, DLM(ASCP)CM, and members of the Institute Advisory Committee. Subject matter and test utilization experts across the fields of pathology and laboratory medicine were included in this process for their expertise and guidance. The recommendations, based on an extensive review of pathology practice and literature, were developed to result in higher quality care, lower costs, and more effective use of laboratory resources and personnel.
ASCP has had a long history of education and advocacy on the appropriate use of laboratory services. At the 2012 ASCP Annual Meeting, Donald M. Berwick, MD, the United States’ leading advocate for high quality health care, shared his vision for change through well-applied information technology, new methods of healthcare delivery, and effective legislation. In addition, ASCP supports Accountable Care Organizations (ACOs) as an opportunity to improve patient care, control patient health care costs, and improve the patient care experience for Medicare and Medicaid beneficiaries. ASCP’s policy on ACOs states, “to improve cost savings, quality of care, and the patient care experience, these delivery models should fully utilize and incorporate into their administrative structure pathologists and advanced certified laboratory professionals to identify inappropriate, unnecessary, and/r duplicative testing.”
As a partner in the Choosing Wisely campaign, ASCP will release additional recommendations in the coming months. Click here to view a video of ASCP Executive Vice President E. Blair Holladay, Ph.D., SCT(ASCP)CM, discussing ASCP's Choosing Wisely recommendations.
ASCP Organizes Coalition to Change California Draft Regulations
In 2010, the California Department of Public Health (CDPH) released a proposed regulation to change the way the state would regulate laboratory professionals working in California. Ultimately, the effort was unsuccessful as numerous groups, including ASCP, raised concerns about some of the proposals. Since then, the Department, or rather the Office of Laboratory Field Services, has been working to address these concerns. Recently, the Department released a “draft” proposed rule allowing interested stakeholders to offer comments before the Department publicly releases a proposed rule later this year.
In commenting on the draft proposed rule, ASCP partnered with six other stakeholders interested in the rule, including the California Society of Pathologists, California Association of Cytotechnologists, California Society for Histotechnology, American Society of Cytopathology, American Society for Cytotechnology, and National Society for Histotechnology. The coalition noted that the draft rule was a substantial improvement over the 2010 rule, but it also suggested that CDPH make several changes to the draft. The group urged the Department not to mandate that all clinical training programs, including those accredited by the National Accrediting Agency for Clinical Laboratory Personnel and those approved by the Department, provide 52 full weeks of clinical training.
In addition, the coalition raised concerns about the scope of practice of cytotechnologists, histotechnologists, and histotechnicians and urged the Department to allow these individuals to perform molecular testing. The group also expressed concern about a proposal requiring at least one supervisor for every four “unlicensed laboratory personnel,” a grouping that includes ASCP certified histotechnologists. Additionally, the coalition welcomed a proposal allowing licensure applicants to satisfy the training requirement with acceptable practical (on-the-job) experience. The change would be a significant shift, as current policy mandates that licensees graduate from an approved training program. This policy, combined with others, has made it very difficult for individuals not trained in California to get licensed there.
To obtain a copy of the coalition letter, please click here.
California Senate Bill Would Require ACOs to Establish Laboratory Testing Panels
On Feb. 13, California State Sen. Fran Pavley (D-Calabasas) introduced legislation, SB 264, requiring Accountable Care Organizations (ACOs) operating within the state to establish clinical laboratory testing advisory boards to recommend testing guidelines for ACOs to adopt. The bill’s intent is to ensure safe and cost-effective laboratory testing and guidelines for diagnostic procedures. On Feb. 21, SB 264 was referred to the California Senate Health Committee, of which Sen. Pavley is a member.
Among its many tasks, the federal Patient Protection and Affordable Care Act (PPACA) was designed to promote the formation of provider-based ACOs to encourage accountability for a specific patient population and to coordinate patient care. Currently, there are 24 ACOs operating in California, including those formed by Cedar Sinai, University of California in Los Angeles, and others in Southern California.
Congress Once Again Tackles Workforce Training
Reintroduces Workforce Investment Act
U.S. Reps. John Tierney (D-Mass.), George Miller (D-Calif.), and Ruben Hinojosa (D-Texas) reintroduced Workforce Investment Act (WIA) as the Workforce Investment Act of 2013 (HR798). The bill is, in essence, the same as last year's version of the legislation, HR4227. The legislation is supported in large measure by adult education and workforce skills development leaders. ASCP has been a long-time proponent of WIA, believing it to be the catalyst to broaden the training of laboratory professionals. The full bill is available from www.thomas.gov.
The U.S. House Republican version of WIA—also virtually the same as last year's bill—is likely to be reintroduced soon by U.S. Rep. Virginia Foxx, R-N.C., and to go to mark up in early March. Senate intentions with regard to WIA are currently unclear at this time.
ASCP Joins Friends of HRSA in Supporting Health Funding
ASCP has lent its support to a Congressional letter urging strong discretionary support for health funding for fiscal year 2014.
Each year, the Coalition for Health Funding leads the health community in securing increased funding for health agencies and programs, including the National Institutes of Health, Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services, Health Resources and Services Administration, Agency for Health Research and Quality, and the Food and Drug Administration, and the Indian Health Service, among others. The Coalition, which was originally founded by Jeff Jacobs, ASCP Senior Vice President for the Institute of Science, Technology and Policy, works collaboratively to secure a strong discretionary health funding allocation in the budget resolution, which then increases the funds available for agency appropriations. This, in turn, directly affects ASCP members’ specific federal funding priorities.
Early this year, the Coalition convened a Health Summit with leaders of the health agency coalitions to develop a funding recommendation for FY 2014. Summit participants recommend $65 billion be allocated for health funding, a $7 billion increase over the Congressional Budget Office's estimated FY 2013 budget authority level of $58 billion.
With sequestration on the horizon and President Obama yet to release an FY 2014 budget, it is unclear if the healthcare community will be able to get the necessary funds to sustain programs. Given these fiscally challenging times, proponents are, at best, hoping for no additional cuts and a balanced budget.
HPNEC Outlines Prospects for Health Funding in Pending Budget Negotiations
In recent discussions, the Health Professions Nursing Education Coalition (HPNEC) outlined possible scenarios for funding healthcare programs, given the current climate on Capitol Hill. For example, regarding FY 2013 Appropriations/Sequestration, it remains unclear whether Congress will resolve FY 2013 appropriations with an omnibus bill, including the Labor-Health and Human Services-Education spending bill, or extend the current continuing resolution for the remainder of FY 2013.
Last month, President Obama called on Congress to avoid sequestration with a “balanced approach.” The White House and U.S. House Democrats recently released reports on sequestration’s impact on families, federal agencies, and the economy. The U.S. Senate Appropriations Committee also held a hearing on sequestration’s impact on federal agencies. U.S. Senate Democrats are expected to present a plan to avoid sequestration; it is expected to contain $120 billion in new revenue and spending cuts.
The Nondefense Discretionary (NDD) United letter was sent to all members of Congress and the White House on Feb. 11. The letter, which included ASCP and nearly 3,200 other national state and local organizations, called for taking a balanced approach to deficit reduction that does not include further cuts to discretionary programs. In addition, the President’s budget is not expected to be released until the middle of this month, with the Congressional Justification following later in the month. This time frame will further delay decisions to agency appropriations.
HPNEC had a broader, thematic discussion about HPNEC’s FY 2014 recommendations, hoping that understanding the budget climate and potential funding scenarios will foster an informed recommendation process. For example, if sequestration goes into effect, how will it affect the requests that individual organizations and HPNEC, as a whole, make to legislators. Secondly, what does it mean for the appropriations process? Are there elements of the coalition’s requests that would preclude organization’s support for and participation in HPNEC activities and materials?
Only time will provide answers to these questions, as well as funding for health programs. ePolicy News will continue to monitor these developments.
ASCP Continues Support for Graduate Medical Education Funding (GME)
The Association of American Medical Colleges (AAMC) held a graduate medical education (GME) discussion on the future of Medicare GME funding, the challenges in the deficit reduction debate, and the potential impact on physician training. Atul Grover, MD, PhD, Chief Public Policy Officer of AAMC, provided an update on GME discussions from the Hill and presented the AAMC physician workforce policy recommendations. With the country’s aging population and life expectancy now at 78.5 years, there will be an anticipated increase in insurance coverage and healthcare utilization not only among patients but physicians as well. According to AAMC reports, “the passage of healthcare reform, while setting in motion long-overdue efforts to insure an additional 32 million Americans, will increase the need for doctors and exacerbate a physician shortage driven by the rapid expansion of the number of Americans over age 65.” The proposed GME cuts will not only contribute to physician shortage of more than 90,000 doctors in 10 years, but also force teaching hospitals to lay-off staff, close training programs, and eliminate services that operate at a loss.
Recently, ASCP and the Association of Pathology Chairs (APC) collaborated with the Cooperating Societies of the American Board of Pathology to request that the Institute of Medicine (IOM) consider adding pathology to the list of specialties that are recommended for targeted increases in Medicare funding for graduate medical education. The growing demand for medical care due to an aging population is driving the fast-paced advances in medical technology and explosion of higher laboratory test volume. Pathology and laboratory medicine will play a key role in the future of healthcare utilization in the nation. Therefore, ASCP will continue to support initiatives that will increase GME funding.
View "ASCP, APC Lead Effort to Inform IOM about Pathologist Workforce" here.
The AAMC, joined by 46 physician groups, Feb. 26 launched an advertisement that urges Congress to preserve funding for physician training through Medicare graduate medical education (GME).
IOM Lauds PEPFAR's Successes
The highly anticipated Institute of Medicine (IOM) evaluation of the President's Emergency Plan For AIDS Relief (PEPFAR)—the U.S. government's 10-year-old effort to help 31 partner countries treat HIV-infected individuals and slow the spread of the virus—described the program as “transformative.” The 680-page report, released last month, took a 20-person committee four years to complete, following visits to 13 partner countries and more than 400 interviews. “PEPFAR was described as a lifeline, and people credit PEPFAR for restoring hope,” the report states. Through PEPFAR programs, the U.S. government disbursed $21.8 billion in aid between 2004 and 2010.
The IOM evaluation was conducted under a Congressional mandate, following a similar report released in 2007. While the mandate did not ask the IOM to compare PEPFAR's activities in different countries, the committee clearly had concerns that “in some countries there are still challenges related to governance and management capacity for the maintenance and sustainability of the HIV/AIDS response.” The report did note some disparities in how much money PEPFAR spends per HIV-infected person in partner countries.
Overall, however, the Committee gave PEPFAR high marks, stating that it “has saved and improved millions of lives worldwide and offered proof that HIV/AIDS services can be effectively delivered on a large scale even in countries with high rates of disease and resource constraints.”
The report also highlighted the tremendous strides that PEPFAR has made in strengthening laboratory infrastructure, recognized as an absolutely essential component of an effective AIDS/HIV response. Since 2005, ASCP staff and consultants have facilitated over 120 trainings, workshops, and mentorships as well as trained more than 2,200 laboratory professionals and medical laboratory instructors worldwide through a PEPFAR-funded cooperative agreement with the U.S. Centers for Disease Control and Prevention (CDC). ASCP’s latest PEPFAR initiative with CDC and other partners focuses on laboratory management and practices necessary to gain accreditation.
PEPFAR currently has funding through 2013, and many HIV/AIDS advocates worry that Congress will cut its support. While the authors of the IOM report operated independently and did not set out to influence this debate, global health advocates are hopeful that the report will serve to educate new members of Congress who were not in office during the first two PEPFAR authorizations.
This past month, ASCP joined fellow members of the Global AIDS Policy Partnership (GAPP) on sign-on letters to U.S. Secretary of State John Kerry, Global AIDS Coordinator, Ambassador Eric Goosby, and the Chairs and Ranking Members of the House and Senate State and Foreign Operations Appropriations Subcommittees, seeking the higher of the proposed FY2013 funding levels for PEPFAR and the Global Fund.
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