Massachusetts S

April 2009
Inside this Issue
1 / Comments from the President
1 / Cytology Proficiency Testing
2 / “The Blues” Discourage
Use of Hospital Labs
3 / The “Medical Home”
Mass. Society of Pathologists
22 Hutchins Road
Medford, MA 02155


Comments from the President

Donald G. Ross, MD, PhD

With mixed feelings of satisfaction, relief, and regret at what has not yet been finished, I write my last newsletter as President of the MSP. Dean Pappas, MD, will be taking over later this month. I thank you all for the confidence you showed in me, and the many expressions of support I’ve received from you over the last two years. I hope that you will give Dean the same kind of backing and assistance I have received.

The speaker for our April meeting is our own Rebecca Johnson, MD, of Berkshire Medical Center. Becky’s presentation is on the topic of Maintenance of Certification. Many specialty boards already require periodic recertification. The American Board of Pathology has had this requirement for a few years for new diplomates, but people who passed their boards in earlier years do not (yet) have to do this. This issue may be forced upon us, however, by insurors and/or state medical boards, which are increasingly reluctant to recognize lifetime board certification.

Your Massachusetts Society of Pathologists is the only organization which advocates for the practice of pathology at the state level. NESP, ASCP and CAP do not do this. CAP advocates for pathologists on the national level, but many issues must be tackled at the state level, and even the national issues require local advocacy; our state representatives in Congress want to hear from their own constituents, not from strangers.

Our advocacy activity requires the assitance of professional lobbyists and attorneys. All of this does not come cheap; in fact, we have been fortunate to date that we do not have a major battle to fight every year, so we have time to replenish the “war chest.” Our principal source of revenue is your membership dues. I appeal to all of you, once again, if there are pathologists in your practice or of your aquaintance who live and/or work in Massachusetts, who are not MSP members, approach them and see if you can bring them in. Remember, it is now possible to join and register for events online at http://masspath.org.

Thanks.

Don Ross

Cytology Proficiency Testing

Donald G. Ross, MD, PhD

And the beat goes on…

The CAP-endorsed Cytology Proficiency Improvement Act of 2007 (HR1237) was passed by the House last summer. The Senate version of the bill (S2510) was moving long nicely until the present financial crisis hit us. Understandably, Congress is preoccupied at the moment with the very pressing economic issues, and fixing cytology proficiency testing has moved to the back burner.

So, we are still using the existing, flawed proficiency testing system. Into the “vacuum” came CMS, with a

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proposed improvement to the system, a 20-slide test every two years instead of a 10-slide test every year – not much of a change!

The following is the text of a letter authored by CAP and signed by me as your President, sent to CMS regarding this issue:

To Whom It May Concern:

I am writing to express my concern with the content of the Centers for Medicare and Medicaid Services’ (CMS) proposed regulation concerning cytology proficiency testing, CMS-2252-P. I urge you to withdraw the regulation and develop an alternative proficiency testing model that will be more meaningful and effective in improving quality and women’s health. The Cytology Proficiency Improvement Act, passed by the House of Representatives last year, provides such an alternative.

I have repeatedly taken the proficiency test in its current form and find that it neither represents normal practice nor is an effective measure of competency. Experts in the field have concluded that CMS would have to administer a program consisting of at least 100 Pap test slides to ensure that this testing model is statistically valid. Simply increasing the number of slides from 10 to 20, as the new regulation proposes, still results in a test that lacks validity. In addition, the proposed regulation maintains a very limited set of diagnostic categories. These categories, similar to those in the current program, are not representative of the slides we see in real practice and don’t reflect complex, ambiguous cases, such as ASCUS, that we seen the laboratory every day. The proposed regulation also provides no evidence that either the current or revised testing model can enhance skills and produce better patient outcomes.

CLIA mandates extensive Pap test quality standards which the laboratory director must use to assess the performance of laboratory personnel. For example, laboratory directors (pathologists) conduct monthly assessments of cytotechnologists screening Pap tests, on a daily basis assess cytotechnologist’s screening totals and monitor daily workload, rescreen at least 10% of negative cases, as well as any negative cases from the previous five years on any current HGSIL case. However, the proposed regulation fails to consider a proficiency testing approach that would take into account these existing performance requirements.

Both the current and proposed proficiency tests suffer from the same scientific and statistical deficiencies. Yet, a test of 100 slides is neither cost effective nor practical. CMS should consider the alternative approach provided in the Cytology Proficiency Improvement Act of 2007. The alternative provides for proficiency testing and documented assessment of skills in the context of an educational framework. It also has significant advantages over the test proposed in the regulation in that it would incorporate complex, difficult Pap tests, keep contemporary with best practices and new technologies and ensure on the ground oversight through lab directors, accrediting agencies as well as CMS.

The proposed regulation mandates a proficiency test that is of no value to my profession or the fight against cervical cancer. Again, I urge you to withdraw this proposed regulation and allow alternatives to be considered.

Sincerely,

Donald G. Ross, MD, PhD, FCAP

President, Massachusetts Society of Pathologists

Chief Pathologist, Holy Family Hospital

70 East Street

Methuen, MA 01844

Please visit www.cap.org to see what the status is and what you can do to help promote reform of this proficiency testing requirement.

“The Blues” Discourage Use of Hospital Labs

Donald G. Ross, MD, PhD

Early this year, Blue Cross/Blue Shield of Massachusetts (BCBSMA) sent a communication to their primary care docs offering an unspecified incentive for using office labs or commercial labs in preference to hospital labs. As many of us are hospital-based, we were puzzled and alarmed by this policy. I wrote to John Fallon, MD, the Chief Medical Officer of BCBSMA, about this issue:

March 2, 2009

John Fallon, MD

Blue Cross/Blue Shield of Massachusetts, Inc.

The Landmark Center

401 Park Drive

Boston, MA 02215-3326

Dear Dr. Fallon:

I am the current President of the

Massachusetts Society of Pathologists.

Many of our members are dismayed

with the recent policy change at

BCBSMA which would attempt to direct

laboratory testing away from hospital-

based labs and pathologists to commer-

cial labs or physician office labs. I

refer to a recently-communicated

(November 2008):

Lab Efficiency Measure. This measure

will reward physicians at three levels of

performance for the percentage of

outpatient lab tests performed for their

members at freestanding labs or in

physician offices.

This measure would adversely affect

hospitals and hospital-based patholo-

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gists at a time when many hospitals

are already under severe financial stress. We are upset that BCBSMA would institute such a policy, and at a loss to understand why this measure would be adopted. There is no evidence that physician office labs or commercial labs provide higher quality than hospital labs. Patient care is adversely affected when outpatient laboratory results are not available in the

hospital setting, and costs are increased

when tests are unnecessarily repeated

due to this problem.

Thank you for your attention. Could we

make an appointment to discuss this

policy and the possibility of altering it?

Sincerely,

Donald G. Ross, MD, PhD

President, MSP

Dr. Fallon has yet to respond to my

letter.

The “Medical Home”

Donald G. Ross, MD, PhD

CMS, AMA, Mass. Medical Society and a host of insurors are interested in the concept of the “medical home” as a means to make patient care more efficient and cost-effective. Briefly, the concept is to place the patient’s primary care physician in charge of organizing all of his/her specialty care and testing. The PCP would be compensated for this management role, and would be financially incentivized to provide cost efficiency.

How does this affect us as pathologists? Sounds a lot like capitation, where primary cares are incentivized to avoid use of specialists, or seek the cheapest provider.

CAP has provided the following summary of the concept:

The Medical Home: At a Glance

Introduction

Seeking ways to slow the growth of Medicare spending and to better coordinate the health care it finances, the federal government is preparing to test the concept of the "medical home" in the Medicare program. Congress has directed the agency to use the program to "redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations." The federal demonstration program will operate for three years in rural, urban, and underserved areas in up to eight states. The demonstration is intended to inform future reforms related to physician payment and health care delivery.

Lapses in patient safety and quality, attributed to a fragmented health care delivery system and misaligned incentives in how care is paid for has lead payers in the public and private sectors to propose the medical home as a mechanism to better organize how care delivered and paid for.

Within a medical home, physicians provide closer management of patient care, averting unnecessary treatments and hospitalizations.

What is a medical home?

A medical home is not a place but a process of care in which a physician-led team provides comprehensive primary care. A medical home allows a physician to provide, and to be remunerated for, serving as a single point of care coordination for all health care services, including specialist care, community services, hospitalizations, and post-acute care. In a medical home, a physician acts as the facilitator and manager of all the care a patient receives.

According to principles endorsed by the American Medical Association, care is coordinated across all elements of the complex health care system, facilitated by registries and information technology, to ensure that patients get the indicated care when and where they need and want it in a culturally appropriate manner.

A medical home incentivizes physicians to have regular contact with patients, as well as to be meaningful users of information technology to ensure patients receive appropriate, evidence-based care. In the current demonstrations, providers receive payments and incentives for serving as care coordinators.

In the current research and pilot demonstrations of the medical home, in addition to traditional fee-for-service arrangements for physician services, providers are eligible to receive per patient care management fees and share in savings that can be attributed to the care coordination services provided.

Early research on the medial home model has shown that this care delivery model and alignment of incentives lead to improved patient outcomes with fewer readmissions, more patient-centered care and better coordination of specialty care.

Stay tuned.


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