economic impacts on academic surgical pathology

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Economic Impacts on Academic Surgical Pathology

Stanley Robboy, MD, CAP PresidentRichard Friedberg, MD, PhD, Chair, Council on Gov’t & Professional Affairs

Notice of Faculty Disclosure The individual below has disclosed the

following financial relationship with a commercial interest:Richard Friedberg, Consultant, EmpiraMed Inc.

The individual below has no relevant financial relationship to disclose:Stanley Robboy, MD

© 2013 College of American Pathologists. All rights reserved.

Payment & Advocacy

3


Key Pathology Issues in 2013 PFS

• SGR & Physician Payment• 100+ New Molecular Codes • LDT Oversight• Physician Quality Reporting

System • HIT/Meaningful Use• GME funding• Future payments: ACO, New

paths 4


Payment Changes

5

88305 PC$43 in 1992$36 in 2012$30 by 2014 if MedPac 17.7% cuts enacted

88309 PC23% RVU increase with 2009 revaluation


Payment Changes in 2013 PFS

Code PC TC• 88300 0 -

57%• 88302 +5% -

51%• 88304 +3% -

35%• 88305 +2% -

52%• 88307 +4%

+39%• 88309 +4%

+41%

6


PFS Payment Changes for 2013

• 7% Family Doc Increase• Overall Pathology Cut -6%

7


Congress and SGR fix• Decision pushed to 12/31; ~

30% cut• 10-year freeze now $138

billion, due to reduced spending

• Previous proposals: MedPAC to cut specialists’ pay by 5.9% for 3 yrs (~18% total), then freeze for 7 years 8


AMA’s SGR Stance• Eliminate SGR• For next 5 years, provide PFS

updates to pace practice costs, while developing new approaches

• Let physicians choose from various payment options best fitting their practice

• Reward reducing duplicated services, adverse events, ER visits/hospitalizations 9


100+ New Molecular CPT Codes• New CPT molecular codes

placed on 2013 CLFS• CAP helped create codes and

urged placement on PFS• New CMS HCPCS II G-code for

physician interpretation and reporting.

10


Lab Developed Tests• Thousands in use…Increased

government oversight likely• Jurisdiction: CMS or FDA?• Companion diagnostics• CAP proposed oversight

needing minimum administration and time.

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Future Genomic Leadership• Leadership: Positioning• Payment: Leading on NGS• Regulatory Framework: LDTs• Gene Patents: Myriad Case• Infrastructure Needs: Clinical

Variant Database

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Pathology PQRS – Part I• 62% of eligible pathologists

participated. Better than 26% of total eligible MDs

• Average pathologist bonus: $1564 in 2010

• 5 measures in place now; 3 new for 2014

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© 2013 College of American Pathologists. All rights reserved. 14

Included in CMS 2012 and 2013 PQRS:

• Breast Cancer Resection -- #99• Colorectal Cancer Resection -- #100 • Barrett’s Esophagus -- #249• Radical Prostatectomy -- #250• IHC Evaluation of HER2 for Breast Ca --

#251 Proposed for 2014:• Lung cancer (biopsy/cytology

specimens)• Lung cancer (resection specimens)• Melanoma

Pathology PQRS – Part II


Value-Based Payment Modifier• In 2013, applies only to

groups of >100+ members• Must cover all physicians by

2018• Relies on PQRS reporting• 1% penalty for failure to

participate15


Health Information Technology• 2009 Recovery Act catalyzed HIT

and Meaningful Use • Program targets PCPs; • Nearly all pathologists eligible

& some academic centers successful

• Most groups unable to participate, and vulnerable to penalties

• CAP advocated relief from penalties. Success! ….temporarily.

• CAP seeks permanent fix in H.R. 4066

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HIT issues for AP• Integrated reports• EMR• ONC changes

• Laboratory Orders/Results Interfaces

• Electronic Delivery of Services• Laboratory Results Reporting

• Key influencers of federal HIT standards

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• Policy Developmento Align Specialty for Joint

Advocacyo PRT White Papero GME Panel at Policy Meeting

• Legislative activityo HR 6562, HR 6352, S. 1627 o +15,000 Medicare Supported

Residency Slots over 5 years18

Graduate Medical Education


Workforce & Models of Care

19


Demographics, big changes…• Pathologist shortages:

oRetirement cliffoChanging skills in demand

• Aging Population:o% >65 to double in next 15 yrs

20


Net Changes to Pathology Workforce

2010 2014E 2019E 2024E 2030E

-500-400-300-200-100

0100200300400500

88151

30 23

-139

-284-206-204

-329-346-329-296-222

-144-140-146-180-93 -123-114 -75

Pathologist Demographics:Retirement Cliff Approaching

Path

olog

ist

s


Pathology= a Report

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for 85%How Other MDs See Us


Transformation of Pathology

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What is it? Why is it important?• Emerge from shadow• Affirm value• Show new value• Secure future


• Focus on value, not volume• Reassert our role as

physician• Diversify and expand

services• Prepare for new payment and

delivery models

We must change


Beyond Fee for Service

• Medicare Shared Savings• Private Sector Coordinated

Care /Clinical Integration Programs

• CAP ACO White Paper, Resource Center, & ACO Network

• CAP’s Promising Practice Pathways

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• Value = clinical quality/ cost• System transitioning to …

o Value vs Fee For Serviceo Delivery models – coordinated care,

population management• Consumer health care

o Employees now pay > employerso Consumer-directed high deductibles

58% of employers in 201170% of large companies by 2013

Value Transformation


Public Policy DevelopmentPolicy Roundtable

oPathologists Value in ACOs oGraduate Medical Education oValue Based Pricing of Diagnostics

CAP Policy MeetingoNew Payment Models, Bundled

PaymentsoP4P, Value-based Pathology oPRT: Graduate Medical Educationo Lab Regulation: LDTs, Digital

Pathology


Promising Practice Pathways™Describes new pathologist-driven services and programs

Adds clinical value outside of the lab by improving downstream clinical quality and outcomesGenerate downstream clinical cost savings

28

TM


www.YourPathYourChoice.org


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Threats Opportunities

Population informatics

Molecular and genomics Dx

Value-based market

Others snatch our ‘golden era’

Dx as vendor to be cut

Why Promising Practice Pathways?


High-Performance Diagnostic Services

Coordinated Population Care

Services

Patient Diagnostic

Services Center

High-Performance Pathology for

High Value Oncology

The Practice Pathways

© 2013 College of American Pathologists. All rights reserved. 32Source: Community Oncology Practice Impact Report, April 2012

1,254 practice

s impacted over past 4 yrs.

Community Oncology Practices Under Financial Pressure


High Accuracy DiagnosisValue Impact:

Better outcomes, less unnecessary RxHow:

Digital path reviewsCollaborate with radiology

imaging

Oncology Pathway Model


Pathology-Driven Care DecisionsValue Impact:

Rx better matched for tumor & patientLower hospital & ER costs Better outcomes How: Personalized medicine + informaticsKnowledge services and tools

Oncology Pathway, Part II


Later Stage: Clinical Trials & PalliationValue Impact: Improved outcomes if trial effectiveBetter patient options and

preferencesAvoiding unnecessary end-of-life

chemoHow: Molecular tumor profiling(Next gen sequencing & informatics)

Oncology Pathway, Part III

economic impacts on academic surgical pathology

Documents

eligible pathologists

pfs payment changes

new paths4

breast cancer resection

colorectal cancer resection

pfs updates

pfs codepctc88300

pathology pqrs