Current Payment Challenges and New Payment Models

2. Current Payment Challenges and New Payment Models

3. Jonathan L. Myles, MD Chair, Economic Affairs Committee Current Payment Challenges and New Payment Models May 7, 2012

4. Session Objectives • Discuss macro and micro payment policy pressures on physicians and pathologists specifically • Examine CAP efforts exploring new payment options • Identify federal and state economic payment policy initiatives

5. Payment Threat for Physicians • AMA working to prevent looming payment cuts • CAP, other groups reinforce AMA efforts • Thanks to AMA for preventing 2012 SGR cuts • Working to prevent further cuts • SGR – 2013 • IPAB – 2014 and beyond

6. Revaluation of AP Services • Congress increased Medicare’s authority to review services • Stems from concerns that specialists are overpaid and primary care is undervalued • Primary care built case for increases • Shifting of funds results in budget neutral environment • CAP is engaged in strategy to best protect pathology services • Review is underway with CMS implementation starting in 2013

7. TC “Grandfather” • Congress discontinued TC Grandfather effective July 1 • Argument on double payment accepted by Congress • CAP supports permanent extension to preserve access in rural and small hospital settings • Congress not expected to revisit in 2012

8. Self-Referral: Close the Loophole • Competition from other physicians creates economic strain on pathology practices • Georgetown study demonstrates financial incentives increased utilization with lower cancer detection • Self-referral results in increased use, increased costs, with little to no patient benefit • CAP’s message to CMS, MedPAC and Congress: Close the loophole

9. Direct Billing for Pathology Services • CAP and State Societies together deter use of pathology as a profit center • Successfully enacted direct billing in 15 states since 2003 • Latest successes: Colorado, Washington and Indiana • States in the pipeline: Illinois • Over $1.3 million spent since 2003 • CAP - $632,252 • State Pathology Societies - $691,500

10. Exploring New Payment Options • Case for Change: Better position specialty given economic pressures on pathologists and changing payment models • Effort identified priority services based on impact and payment potential • Areas examined: • Estimated market size • Payment potential/feasibility • Value to pathology • Ease of implementation

11. Exploring New Payment Options • Three themes emerged in review: • Genomics is important going forward • New technologies provide opportunities to bring pathologists closer to patient • Getting “closer to the patient” will be important for pathologists in the changing landscape

12. Exploring New Payment Options • Services prioritized across two scenarios based on payment • Fee for service environment • Coordinated care environment • New services related to policy on ACOs, personalized medicine and health information technology • Additional speakers will explore opportunities in these areas

13. Exploring New Payment Options • Actions to advance adoption were reviewed for identified prioritized services • Example – In Vivo Microscopy • Identified Action - enable payment through code development and valuation • Advocacy efforts • Securing unique pathology code • Valuation activities planned

14. How You Can Help • Tell Congress to: • Repeal the SGR to ensure stable payment system • Remove the in-office exception to the Stark self-referral law

15. Panel Discussion • Cecil B. Wilson, MD,Immediate Past President, American Medical Association • Jonathan L. Myles, MD, FCAP, Chair, Economic Affairs Committee