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January 31, 2017

In This Issue:

The Senate Committee on Health, Education, Labor, and Pensions and the Senate Finance Committee heard testimony from Rep. Tom Price, MD (R-GA) on January 18 and 25 respectfully on his nomination to become the secretary of Health and Human Services (HHS). Repeal and replacement of the Affordable Care Act (ACA) was a top issue at the hearings.

Rep. Price, an orthopedic surgeon from Atlanta, was elected to Congress in 2004. In addition to his opposition to the ACA, Dr. Price has pressed for policy changes in Medicare, and Medicaid, which was challenged by some members during the committee hearings. Rep. Price was also asked during the Finance Committee Hearing about an executive order issued by President Trump on January 20 that directs federal officials to provide relief from costs, penalties, and regulatory burdens imposed on consumers, insurers, and health care providers by the ACA.

When it comes to the ACA, Rep. Price favors policies that stress the need for consumers to have more choice in the types of policies they can buy, which could lower premiums.

Through the years, Dr. Price has supported the CAP on a number of issues. Dr. Price was a lead sponsor on House legislation to repeal outdated cytology proficiency testing requirements, and he orchestrated passage of the bill twice in the House. In addition, Dr. Price supported exempting pathologists and other hospital-based physicians from penalties under Medicare's meaningful use of electronic health record program. He also supported the CAP's efforts to extend the technical component (TC) grandfather. Finally, Dr. Price cosponsored the Local Coverage Determination Clarification Act of 2016.

Dr. Price is a member of the American Medical Association (AMA) House of Delegates representing the Medical Association of Georgia.

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Joseph Gulfo, MD, MBA, is a potential President Donald Trump choice for US Food and Drug Administration (FDA) commissioner, according to several news reports.

Other potential nominees also include Scott Gottlieb, MD, a former FDA deputy director, and Jim O'Neill, managing director at Silicon Valley investment firm Mithril Capital Management.

Currently, Dr. Gulfo is the executive director of the Lewis Center for Healthcare Innovation and Technology at Fairleigh Dickinson University. He also has served as a senior fellow at both the Progressive Policy Institute and the Mercatus Center at George Mason University and has founded several biopharma and medical technology companies.

Dr. Gulfo received his MD from Rutgers New Jersey Medical School (formerly University of Medicine and Dentistry of New Jersey) and his MBA from Seton Hall University.

Read future editions of STATLINE for more updates on the Trump Administration's appointments.

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The Massachusetts Society of Pathologists (MSP) has joined the chorus of state societies calling for network adequacy, a position that the CAP has long supported.

In a January 19 statement submitted to the Massachusetts Special Commission on Provider Price Variation, the MSP noted that there is a fundamental correlation between out-of-network balance billing and health plan network adequacy. The Special Commission was created in 2016 to begin studying variation in prices among health care providers in the state.

"When regulators approve health plans that do not have hospital-based physicians under contract, patients of these facilities are likely to have out-of-network charges," said the MSP in its statement. "It is logical that enrollees with health insurance plans providing robust network adequacy, including hospital-based physicians, have fewer bills for out-of-network services. Thus, the problem of out-of-network billing will only be exacerbated by the failure of regulators and health plans to ensure physician networks at in-network hospitals and facilities."

Another factor contributing to patient reliance on out-of-network physicians at in-network facilities is the deliberate narrowing of insurance networks by health plan payers, notes the MSP. The CAP and the AMA support requiring health plans to document to regulators that they have met requisite standards of network adequacy—including hospital-based physician specialties such as pathology, radiology and emergency medicine—at in-network facilities.

Like the CAP and the AMA, the MSP believes that health insurance plans should be scrutinized by state insurance regulators, prior to approval, to ensure that such plans are capable of providing their enrollees with reasonable and timely access to in-network physician specialties at in-network hospitals and facilities. The MSP also supports state sanctions against health plans that list in-network hospitals and facilities but then fail to contract with physician specialties at these locations.

Ultimately, the CAP and the MSP believe that patients are best served by insurance products that provide in-network services through the continuum of care that an enrollee is likely to need and receive in the hospitals setting. Health policy measures that do not compel health plans to contract for the provision of such services for their enrollees alter the public policy rationale for participating preferred provider organization (PPO) insurance products and should raise fundamental questions about the role of insurance in the value chain of health care delivery, they say.

Waiver of Payment

The MSP also expressed concern about some payers accusing physicians of fraud if they waive co-payment, co-insurance, or deductibles. According to a recent national survey, approximately 22% of individuals who used out-of-network providers negotiated a bill with the insurer or provider, and 58% were successful in reducing their cost for at least one of the bills.

"Health insurance plan efforts to legally assail physician authority to waive charges, on a case-by-case basis based upon a patient's economic condition, creates a hostile legal atmosphere that is designed to deter such benevolent financial actions by physicians for their patients," writes the MSP. "Accordingly, physicians should have an explicit legal safe harbor in state law to conduct such waivers on out-of-network charges on a case-by-case basis so as to financially benefit economically distressed patients."

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Beginning now, the Protecting Access to Medicare Act (PAMA) requires certain laboratories to submit private payor rates for clinical laboratory tests. Private payor data is due to the Centers for Medicare & Medicaid (CMS) by March 31, 2017, which less than 60 days away.

To help you with the submission process, the CMS created a PAMA Data Collection User Guide with step-by-step instructions and screen shots.

The CAP has added this invaluable tool to our pathology-specific PAMA resources , including an informative infographic and podcast, to help laboratories understand regulatory requirements and upcoming deadlines. These resources and additional tools can be found on the CAP's PAMA resources webpage.

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With a new presidential administration, the US government will pursue policies that are yet hard to predict. On February 21, 2017 at 1 PM ET/noon CT the CAP will present the A Seat at the Table—The Impact Only You Can Make on the Future of Pathology webinar.

If you ever had a doubt that your voice matters, this 60 minute webinar will present the facts and figures on the crucial impact you have on members of Congress. Learn how you can make a difference with data presented from Congressional Management Foundation surveys, the National Journal, and other reputable sources illustrating the importance of grassroots advocacy.

Get facts and figures along with down-in the-trenches insight from Joe Saad, MD, FCAP, the CAP Federal and State Affairs Committee Chair, and Michael Giuliani, CAP Advocacy Senior Director and former Hill staffer, on what drives members of Congress: who they listen to, how they make decisions, and the best ways to influence them.

Register now.

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With a theme of Protecting the Practice of Pathology and Our Patients, let your voice be heard at the 2017 CAP Policy Meeting. From April 24–26, CAP members can connect with government leaders and policy experts to discuss the impact of federal regulation on their pathology practices.

Registration is now open. Stay tuned for more updates.

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