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ePolicy News November 2013

Wednesday, October 30, 2013



Unprecedented Movement in Congress Toward Permanent Repeal of the SGR

For the past decade, Congress has passed legislation each year approving short-term payment “patches” to prevent the negative adjustments to physician reimbursement resulting from the Physician Fee Schedule (PFS)’s Sustainable Growth Rate formula (SGR). However, recently there has been unprecedented movement in Congress toward permanent repeal of the SGR. Perhaps this is because money spent over the last decade by Congress on payment patches ($146 billion) now exceeds the Congressional Budget Office’s recently lowered estimate of the cost of repeal ($138 billion).

Movement on this issue in the U.S. House of Representatives has been promising, with the introduction and support of H.R. 2810 in July and a recent letter signed by a coalition of 18 members of Congress communicating the urgency for SGR repeal to House leadership. However, it is the recent release of a bipartisan, bicameral framework for SGR reform that makes the possibility of SGR repeal this year a potential reality. On Oct. 31 the HouseWays and Means Committee and the U.S. Senate Finance Committee released a Discussion Draft outlining the framework for repeal of the SGR payment update mechanism. The proposed framework includes zero percent updates through 2023, with annual positive updates beginning in 2024. Key initiatives behind the proposed framework include:

Improved Fee-for-Service Payment System that rewards value over volume: The Value-based Performance Payment (VBP) program would combine the Physician Quality Reporting System, the Electronic Health Record (EHR) Incentive program, and the existing Value-based Payment Modifier program into one compulsory, budget-neutral program. Beginning in 2017, the VBP program would assess provider performance based on quality, resource use, clinical practice improvement activities, and EHR Meaningful Use. Payments could be increased or decreased significantly, depending on comparative performance on a composite score.

Encouraged Participation in Alternative Payment Models (APM), including ACOs, PCMHs, and bundled payment models: Providers who receive a significant portion of their revenue from an “advanced” APM(s), that involves two-sided financial risk and a quality measurement component, would be exempted from the VBP program and would instead receive a five percent bonus payment in 2016-2021.

Encouraged care management for individual with complex chronic care needs: Beginning in 2015, new payment codes specifically for complex chronic care management would be available for billing, which could be paid to both physicians and select non-physician practitioners.

Improved accuracy of the PFS: For 2016 through 2018, the annual target for identifying and reviewing misvalued services would be set at one percent of total annual PFS expenditures. If the annual target is met, the one percent would be redistributed in a budget neutral-manner within the PFS. If it is not met, the PFS payments would be reduced by the difference between the target and the amount of misvaled services identified. In support of this effort, the Secretary would collect resource use data from individual providers. Those that submit requested data may be compensated while those that fail to do so would face a ten percent reduction on PFS payments.

Promoting Appropriate Use Criteria: Ordering professionals would be required to consult with appropriate use criteria for advanced imaging and electrocardiogram services.

Expanded use of quality and resource use data: Qualified entities would be allowed to provide or sell non-public data analyses to providers to assist them in their quality improvement activities.

Enhanced Transparency of Physician Medicare Data: HHS would be required to publish utilization and payment data for providers on the Physician Compare website.

ASCP is currently reviewing the drafted framework and will submit comments by the established deadline of Nov. 12.

While we remain supportive of permanent SGR repeal, we have potential concerns regarding how some of the detailed proposals in this framework would affect pathologists and we will be seeking further clarification accordingly.



U.S. Support is Key to Reaching the HIV/AIDS Tipping Point

ASCP joined fellow organizations of the Global Aids Policy Partnership (GAPP) in applauding the chairs and ranking members of both the U.S. Senate and the U.S. House State, Foreign Operations, and Related Programs Appropriations subcommittees for their unwavering bipartisan support of sustained funding levels for global HIV/AIDS programs for FY 2014. GAPP is a coalition of advocacy and implementing organizations committed to ending AIDS for the next generation by expanding and improving global HIV and AIDS programming.

ASCP and the GAPP also urged the leadership, as they develop FY 2014 funding legislation, to maintain the appropriated levels included in their committee markups for the Global Health Programs–State account that funds the President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) at $4.02 billion and $1.65 billion, respectively. The coalition also requested funding for the USAID HIV/AIDS program be maintained at $330 million.

In addition, ASCP and GAPP urged lawmakers to take steps to protect these important investments in PEPFAR and the Global Fund from any sequestration provisions approved by Congress. Any reduction of financial support by the United States at this juncture could signal retreat from our progress and would likely have implications on assistance from other international donors as well. The coalition feels strongly that sustained U.S. investment has the potential to enable an important “tipping point” in the fight against HIV/AIDS, in which the annual growth in the number of available treatments exceeds the number of new HIV infections. This would be a critical step on the path toward an AIDS-free generation.



ASCP, Laboratory Community Anxiously Awaiting PFS/OPPS Final Rules

ASCP and the rest of the laboratory community are anxiously awaiting the release of the CY 2014 Physician Fee Schedule (PFS)/Clinical Laboratory Fee Schedule (CLFS) and Outpatient Prospective Payment System (OPPS) Final Rules. By statute, these rules are supposed to be published 60 days before their Jan.1, 2014 implementation date. However, the shutdown of the federal government complicated the Centers for Medicare and Medicaid Services’ (CMS) ability to roll-out these rules on time.

CMS anticipates publishing these rules and several others delayed by the government shutdown by Nov. 27.The implementation date of Jan. 1 still applies. Given the extensive changes outlined in the Proposed Rule in July, ASCP is concerned that the reduced implementation window may complicate the Agency’s ability to ensure that all policy changes are fully implemented before Jan. 1.

Among the policy changes CMS proposed in July are a cap on the PFS non-facility payment rates at OPPS rates, re-pricing of the entire CLFS, and bundling most outpatient laboratory services currently reimbursed under the CLFS into the OPPS. For more detail on these proposals, click here for ASCP’s analysis of the Proposed Rule. In a letter to CMS on the July Proposed Rule, ASCP and the American Pathology Foundation outlined strong opposition to these three policy changes.

Specifically, ASCP launched several grassroots action alerts in response to the OPPS cap proposal in this year’s PFS. ASCP members sent approximately 10,000 messages to Congress and CMS, urging them to eliminate the OPPS cap proposal in the PFS Final Rule. ASCP also worked with other organization members of the Alliance for Integrity in Medicine (AIM) to rally more than 150 members of Congress to sign off on two letters to CMS in opposition to this same proposal. One letter was signed by almost 115 members of the U.S. House of Representatives and another was signed by 40 members of the U.S. Senate.

ASCP e-Policy will provide an analysis of the PFS Final Rule once it is published by CMS.



GME Support Essential to Thwart Physician Shortage

The number of medical school applicants grew by 6.1 percent to 48, 014, surpassing the record set in 1996, according to data just released by the Association of American Medical Colleges (AAMC). The AAMC findings on the 2013 medical school applicants and enrollees indicate that while medical schools increased their slots to accommodate more students, residency training positions continue to be limited due to the 1997 cap on Medicare Graduate Medical Education (GME) support. Currently, there is a projected shortage of 91,500 physicians by 2020, and its potential impact on patients and the physician workforce may yield negative outcomes.

During a briefing on Capitol Hill, the AAMC invited three speakers to share their perspectives on federal policies that support physician workforce development. Atul Grover, MD, PhD, AAMC Chief Public Policy Officer, stated that “residency training remains the bottleneck in increasing the physician workforce.” Changes in caps on GME support should be implemented to fulfill the increasing demand for more physicians. ASCP supports graduate medical education in pathology by developing and offering policies, programs, and products that address the full range of resident and fellow competencies. ASCP also acknowledges the importance of research in GME, and supports it through programs and advocacy. Payments for GME should recognize all components of costs, including residents’ stipends and benefits, salaries and benefits related to faculty supervision, and allocated overhead expenses.



ASCP Honors Two Global Physicians/Humanitarians

The ASCP Patients’ Advocate Award acknowledges distinguished contributions by members, organizations, or public servants whose actions through advocacy have improved patient care. This year, ASCP honored the contributions of two practitioners whose dedication and innovative approaches to patient care have made remarkable differences in the health status of entire communities. Outgoing ASCP President, Joel Shilling, MD, FASCP, presented the award in September at the ASCP 2013 Chicago Annual Meeting.

The first recipient, Thomas Frieden, MD, is currently the Director of the U.S. Centers for Disease Control and Prevention (CDC). A physician with training in internal medicine, infectious diseases, public health, and epidemiology, Dr. Frieden is especially known for his expertise in tuberculosis control. Dr. Frieden worked for CDC from 1990 until 2002. He began his career at CDC as an Epidemic Intelligence Service (EIS) Officer at the New York City Health Department. From 1992 to 1996, he led New York City’s program to control and reduce cases of tuberculosis. The city’s program became a model for tuberculosis control. It fostered public awareness, helped to garner public funding, and reduced overall incidence of the disease by nearly half. Dr. Friedan continued the fight against tuberculosis on the global stage, assisting the government of India implement a nationwide control program that resulted in 8 million patients treated and 1.4 million lives saved. He returned to serve as New York City’s health commissioner in 2002, and spearheaded tobacco control programs that reduced the number of smokers by 350,000. He was appointed as CDC Director in 2009, and led the nation’s response to the H1N1 influenza pandemic, recognizing and supporting the essential role of the laboratory. Dr. Frieden received the ASCP Patients’ Advocate Award in recognition for his distinguished service and the contributions he has made to advance patient care nationally and internationally.

The second recipient, Doreen Ramogola-Masire, MD, is the Country Director at the Botswana-UPenn Partnership and a lead physician for women’s health in Botswana. Dr. Ramogola-Masire has also been a leader on issues affecting HIV infected pregnant women. She co-directed the first Prevention of Mother-to-Child Transmission (PMTCT) of HIV Clinic in South Africa and assisted in the development of national HIV guidelines in Botswana. She is also currently spearheading an effort to strengthen anatomic pathology services in Botswana.Dr. Ramogola-Masire attended the School of Medicine of the University of Nottingham in the United Kingdom, where she graduated with honors. She continued her training in obstetrics and gynecology, first in the United Kingdom and then in the Republic of South Africa at the University of Cape Town where she also pursued subspecialties in perinatal medicine and cervical cancer prevention. During her training, she helped develop the See and Treat, an approach for the diagnosis and management of precervical cancer lesions. This method ultimately proved to be a very effective approach in resource-limited settings as it allows women to be tested and treated in a single visit. See and Treat is currently recommended by the World Health Organization for use in resource-limited settings. At least six countries have adopted See and Treat as part of their public healthcare systems, and it has also been implemented in Thailand and parts of Asia.

Past recipients of the ASCP Patients’ Advocate Award include Former First Lady Laura Bush, Barbara Bush, Dr. Paul Farmer, the late U.S. Sen. Edward Kennedy(D-Mass.) and U.S. Sen. Barbara Mikulski.(D-Md.).



Why Pathologists are the “Have Nots” of CMS-developed Quality Reporting Programs

There’s something about a damned, predestined fate that paralyzes its victims in place. Such is the case for the pathology community when it comes to the multiple, CMS-developed quality reporting programs in existence. Currently, all pathologists are essentially barred from participating in both the Medicare and the Medicaid Electronic Health Record (EHR) incentive programs, nearly all pathologists do not qualify for the e-prescribing (eRx) incentive program, and the majority of pathologists do not have one applicable measure under the Physician Quality Reporting System (PQRS). Additionally, failure to successfully participate in PQRS is directly correlated with failure to receive the bonus PQRS: Maintenance of Certification (MOC) program incentive and now failure to meet the requirements for a positive, rather than negative, Value-based Payment Modifier (VPM).

Perhaps it is most discouraging that pathologists are unable to successfully participate in these programs through no fault of their own. Instead, they are incapable of successfully participating as a result of various reasons that all seem to be directly tied to the innate uniqueness of their specialty. Examples include: lack of face-to-face patient encounters; lack of prescribing medications; frequent billing with Place of Service code 81 in the independent laboratory setting; historic utilization of laboratory information systems (LISs); and difficulty in tracing tangible health outcomes back to the point of accurate diagnosis—even if the proper and effective patient care protocol relies on the accuracy of diagnosis.

As a result of failure to successfully participate in these quality reporting programs from 2007 through 2014, an ASCP internal analysis indicates that the average individual pathologist is estimated to incur a total cost of 8 percent (approximately $65,000) of his or her total Medicare Part B allowed charges by 2015. Aggregated across the pathology community participating in Medicare, this cost is estimated at approximately $630 million. This includes both the opportunity cost and the actual cost incurred by pathologists unable to successfully participate in these quality reporting programs since the introduction of PQRS in 2007.

While these estimates are alarming, unfortunately they do not even begin to take into account additional potential stressors on Medicare Part B reimbursement. Such stressors may include sequestration (-2 percent), future payment adjustments if CMS does not extend the five-year hardship exemption for the EHR Incentive program (up to -5 percent), and the negative adjustments that could result from partial application of the Sustainable Growth Rate (SGR) (up to -24.4 percent), among others. Worse yet, while pathologists continue to feel the wrath of their inability to participate in these programs, laboratories are increasingly expected to gift EHRs to clinicians that are eligible to participate in the EHR incentive program in exchange for referrals. The Secretary of the U.S. Department of Health and Human Services estimates the cost of an EHR at approximately $54,000 for the first year and $20,610 for subsequent years. In response to more than just this added cost burden, ASCP has repeatedly encouraged CMS to reconsider this harmful practice as a direct violation of the Stark Act.

Initially, the pathology community was relatively silenced by its inability to successfully participate in these quality reporting programs, which resulted merely in failure to receive incentive payments. Pathologists gratefully accepted hardship exemptions from payment adjustments under the eRx and the EHR Incentive programs and simply advocated for additional applicable measures under PQRS. However, as CMS introduces more permanent payment adjustments, develops more programs that fail to effectively target pathologists, enhances program requirements, and places more dollars at risk based on performance within each program, the pathology community is called to look at the bigger problem and generate a solution accordingly. In an effort to break through this sort of “program paralysis,” ASCP’s Institute for Public Policy, Science, and Technology has begun to explore alternate ways that CMS can begin to acknowledge the pathology community’s quality improvement and reporting efforts already in existence. Stay tuned for more updates on this in next month’s e-Policy!

Kaitlin Cooke, Senior Manager, Advocacy & Public Policy, ASCP


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