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As the Centers for Medicare & Medicaid Services (CMS) seeks guidance from stakeholders, the CAP continues to directly engage with the agency on how to implement new Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) programs.

The CAP recently submitted formal comment letters on CMS' draft measure development plan and an agency request for information on establishing episode groups for the purposes of MIPS and APMs. The CAP responded to the CMS with letters on March 1.

In the Spring of 2016, the CMS is expected publish a proposed rule on the implementation of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which eliminated Medicare's broken sustainable growth rate payment formula and created the MIPS and APM programs.

The overall impact of MIPS to the pathology specialty is estimated to be $1.5 billion over a period of seven years beginning in 2019. The MIPS bonuses and incentives will increase yearly beginning at +/- 4% of Medicare Part B payments in 2019 to +/- 9% in 2022. Physicians participating in eligible APMs receive a 5% bonus from 2019-2024 and are not subject to MIPS requirements.

Quality Measure Development for Pathologists

Regarding the measure development plan, the CAP encouraged the CMS to use the plan to provide a strategic framework for the future of measure development for clinician quality reporting to support MIPS and APMs. "Pathologists' activities support the infrastructure and provide essential elements that are an important part of the patient's health care delivery team," the CAP stated. "Pathologists, by virtue of their varied roles actively coordinate care and facilitate achievement of many of the objectives of MACRA and the draft MDP, in addition to other efforts that increase integration and improve patient care and the patient care experience overall."

The CAP urged the CMS to take non-patient facing physicians, such as pathologists, into account as it finalizes the plan. The draft plan emphasized outcomes measures, but it does not address such measures for diagnostic specialties. The communication of a timely and accurate diagnosis is an essential “outcome,” the CAP stated.

Read the CAP letter on the draft measure development plan.

Acknowledge Pathology's Contributions in Episode Groups

The CMS requested information on the MACRA provision, which the CAP secured in the legislation, requiring the agency to give consideration to the circumstances of physicians who provide Medicare services that do not involve face-to-face interaction with a patient. In the letter on episode groups, the CAP stated it is looking forward to working with the CMS to determine how to design the MIPS and APMs to measure these physicians appropriately. "The CAP believes considerable accommodations or alternate measures will be necessary to meet this clause in MACRA," the CAP stated. "In addition to offering these comments, the CAP looks forward to further conversations with CMS prior to release of the proposed regulations for the implementation of MACRA."

The CMS also sought comment on episode groups specifically and on the future role of episode groups in resource use measurement. Resource use measurement is a component of MIPS that factors into incentives and penalties once they apply in 2019. The APM quality measures also are required to be comparable to those set forth under MIPS.

The CAP advocated for the unique contributions to quality healthcare provided by pathologists and other hospital-based physicians that may require a unique mechanism to measure resource under MIPS and APMs. While pathology spending alone does not represent a large portion of episode or alternative payment model spending, the extensive influence of pathology diagnosis and laboratory testing on clinical decision making uniquely positions pathologists to advance achievement of the goals of these models. Pathologists, for example, minimize inefficiencies through adaptation of evidence-based pathways to diagnosis.

Read the CAP letter on episode groups.

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The 2016 CAP Policy Meeting will feature Harold D. Miller, the president and CEO of the Center for Healthcare Quality and Payment Reform, as a keynote speaker to discuss how physicians can provide leadership in future health care payment and delivery reforms.

Mr. Miller leads a national policy center that develops and encourages implementation of national, state, and local strategies for improving the quality and reducing the cost of health care. In addition, Mr. Miller is one of 11 appointed members on the federal Physician-Focused Payment Model Technical Advisory Committee. Created by Congress in 2015, the committee advises the Secretary of Health and Human Services on the creation of alternative payment models (APMs).

Registration is open for you to join your colleagues at the 2016 CAP Policy Meeting May 2-4 in Washington, DC. The annual event is the pathology specialty's opportunity to focus on the federal issues most important to pathologists now and in the future.

In addition to Miller, the 2016 Policy Meeting will feature other policymakers and distinguished speakers from Washington and pathology leaders from across the country. On May 4, pathologists will visit with their elected officials during the CAP's annual Hill Day. Meeting with your representative or senator is your chance to discuss the issues affecting pathology and the patients you care for every day.

Speakers and participants include:

  • Renowned journalist David Gregory provides a firsthand analysis and running narrative of the Obama Administration, Congress and politics in America. Mr. Gregory, former moderator of NBC News' Meet the Press, will share his insights on the latest Washington headlines, the current events facing our country and the upcoming 2016 race for the White House.
  • Leading public opinion expert and NBC and Wall Street Journal pollster Peter Hart and Ed Goeas, who is president and CEO of The Tarrance Group, one of the most respected and successful Republican survey research and strategy teams in American politics today.
  • Alberto Gutierrez, PhD, Director of the Food and Drug Administration (FDA) Office of In Vitro Diagnostics in the Radiological Health Center for Devices and Radiological Health, who will be part of a panel discussion on oversight of laboratory-developed tests (LDTs).
  • Marc Hartstein, the director of the Centers for Medicare & Medicaid Services (CMS) Hospital Ambulatory Payment Group, and Medicare law and policy authority Paul Radensky, MD, JD, of the law firm McDermott Will & Emery. Mr. Hartstein and Dr. Radensky will speak during a panel discussion titled: "Getting Ready for the New Protecting Access to Medicare Act (PAMA) Requirements for Laboratories."

Join your colleagues at the 2016 CAP Policy Meeting in Washington, DC. Focus on the issues most important to pathologists now and in the future. The CAP's Annual Hill Day will take place on May 4.

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The CAP is fielding the 2016 Practice Leader Survey to gather data from individual pathology practices regarding their economics, demographics, and market trends. Data from the new survey will help CAP leaders determine which advocacy issues are most important to pathology practices and further assist the CAP on advocating on behalf of the pathology specialty.

The survey is targeted to practice leaders who can answer the questions for the whole practice. For some practices this will be one individual, while for others it will be multiple individuals. Practices with more than one practice leader should coordinate about how to best complete one survey for their practice. For a listing of the specific questions on the survey, please email

All responses are kept strictly confidential. Responses will be reported in aggregate form only. No individual practice information will be uniquely identified or shared.

Watch for a Link to Take the Survey

Pathology practice leaders will begin receiving invitations to complete the survey on March 21. CAP members who complete the survey, which should take about 20 minutes to complete, will later receive an invitation to attend an exclusive webinar reviewing the survey results. A report on the survey will then be available for all CAP members.

Those completing the survey will receive early access to the results. The CAP will publish more details about this and other benefits for completing the survey.

Learn more about the 2016 Practice Leader Survey.

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Sen. Warner and Dr. Foster

CAP member Matthew Foster, MD, FCAP, a pathologist with Pathology Consultants of Central Virginia (Lynchburg), recently had the opportunity to discuss challenges facing the specialty during a meeting with Sen. Mark Warner (D-VA) in Richmond.

Dr. Foster was one of 12 people attending the March 7 breakfast meeting and was able to engage the senator on issues important to pathologists, including the narrowing of provider networks and Medicare local coverage determinations. According to Dr. Foster, they also discussed cybersecurity, financial regulation and opioid abuse—issues that Sen. Warner raised.

Dr. Foster says the meeting was a positive one that allowed him to raise awareness of the critical issues important to the specialty of pathology. "I believe when you have an opportunity to have meaningful face time with an elected official, you should take advantage of it."

"Overall, my time spent with Sen. Warner and his staff was a very positive experience," he adds. "I decided to use my time with him as a platform to help build a long-term relationship with the senator and his office. I'm looking forward to continuing our dialogue on the important role pathologists have in our health care system, as well as touch on specific issues affecting our profession."

Register for the 2016 CAP Policy Meeting

To talk with Dr. Foster about his experience in raising awareness of the critical importance of the specialty of pathology, be sure to connect with him during the 2016 CAP Policy Meeting, May 2-4 in Washington, DC. This year's meeting will provide you with a deep understanding of the changing health care landscape and what you can do to benefit the practice of pathology.

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At the close of its annual legislative session, the Florida State Legislature on March 11 passed an out-of-network physician services bill that does not allow physicians to continue to balance bill patients in all cases. Under the legislation: "An insurer is solely liable for payment of fees to a nonparticipating provider of covered nonemergency services provided to an insured in accordance with the coverage terms of the health insurance policy, and such insured is not liable for payment of fees to a nonparticipating provider, other than applicable copayments, coinsurance, and deductibles, for covered nonemergency services."

The Out-of Network Health Insurance Coverage (HB 221) legislation was unanimously approved by the state Senate and was largely the result of negotiations. In addition to balance billing, the legislation seeks to address facilities to comply with licensure requirements and provide information on hospital websites about providers under contract with health plans. The balance billing prohibition occurs when the insured "does not have the ability and opportunity to choose a participating provider at the facility who is available to treat the insured."

The Florida Society of Pathologists engaged with lawmakers and other key medical society stakeholders on the bill. If signed into law, the bill will take effect in July. The CAP will report more information about the legislation in a future edition of STATLINE.

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Six national pathology organizations, and the New York chapters of the AARP and the American College of Radiology (ACR) have urged the New York State Department of Health (DOH) to repeal the regulation prohibiting pathologist-patient conferral on laboratory and pathology test results.

The CAP and New York State Society of Pathologists (NYSSPATH) have continued to strongly advocate for the DOH to remove an outdated prohibition on discussions between patients and pathologists. The CAP and NYSSPATH state regulatory impediments to patient discussions with pathologists should be removed as pathologists are legally and ethically obligated to communicate with their patients.

In addition to the CAP, the national pathology organizations calling for repeal of the regulation are: Association for Molecular Pathology, American Pathology Foundation, American Society for Cytopathology, American Society for Clinical Pathology, and National Association of Medical Examiners. The six national pathology organizations in a joint statement asserted that: "No other state has any such regulation constraining pathologists from conferring with patients. Moreover, no other physician medical specialty in New York, or in the Nation, is prohibited from answering patient questions. Thus, the legal impediment presented by the New York regulation is an unjustifiable and grossly improper intrusion of the State into the physician practice of medicine by pathologists."

The state DOH has been conducting calls with external stakeholders to determine their respective positions on the issue. A DOH stakeholder call with CAP in February included Emily Volk, MD, FCAP, Chair of the CAP Council on Government and Professional Affairs (CGPA), and Patrick Godbey, MD, FCAP, Vice Chair of the CGPA.

Following conclusion of the stakeholder discussions, the DOH will decide whether to take any action to repeal or change the regulation. The NY Public Health Planning Council, following testimony by pathologists, set a deadline of July 2016 for the DOH to make a determination.

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