The Impact of Health Care Reform on Pathology Practice and Payment: - - PowerPoint PPT Presentation

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The Impact of Health Care Reform on Pathology Practice and Payment: - - PowerPoint PPT Presentation

Apr 15, 2023 552 likes •1.16k views

The Impact of Health Care Reform on Pathology Practice and Payment: From Volume to Value Donald Karcher, MD Chair, Department of Pathology The George Washington University Medical Center The Impact of Health Care Reform on Pathology Practice

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The Impact of Health Care Reform on Pathology Practice and Payment: From Volume to Value

Donald Karcher, MD Chair, Department of Pathology The George Washington University Medical Center

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The Impact of Health Care Reform on Pathology Practice and Payment: From Volume to Value

Objectives -

  • Briefly review pathology practice and payment
  • Describe the recent history of healthcare delivery and

payment reform

  • Detail the impact of these reforms on pathology

practice and payment

  • Give examples of value-based pathology practice
  • Propose a potential pathology-related project for the

OCPI

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Pathology practice . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties
  • Cytopathology
  • Autopsy pathology

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. Special areas

  • Molecular/genomic pathology
  • Forensic pathology
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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties
  • Cytopathology
  • Autopsy pathology

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. Special areas

  • Molecular/genomic pathology
  • Forensic pathology
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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties FFS
  • Cytopathology FFS
  • Autopsy pathology

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. Special areas

  • Molecular/genomic pathology
  • Forensic pathology
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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties FFS
  • Cytopathology FFS
  • Autopsy pathology Part A

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. Part A Special areas

  • Molecular/genomic pathology
  • Forensic pathology
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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties FFS
  • Cytopathology FFS
  • Autopsy pathology Part A

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. Part A Special areas

  • Molecular/genomic pathology
  • Forensic pathology Government
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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties FFS
  • Cytopathology FFS
  • Autopsy pathology Part A

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. Part A Special areas

  • Molecular/genomic pathology ??
  • Forensic pathology Government
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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties 80%
  • Cytopathology 10%
  • Autopsy pathology

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. 10%? Special areas

  • Molecular/genomic pathology ??
  • Forensic pathology
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Pathology payment . . . in 3 minutes

In the FFS world . . . live or die by CPT 88305 CPT 88342

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Pathology payment . . . in 3 minutes

Anatomic pathology

  • Surgical pathology – General, subspecialties 80%
  • Cytopathology 10%
  • Autopsy pathology

Clinical pathology

  • Clinical chemistry, hematology, transfusion

medicine, microbiology, immunology, etc. 10%? Special areas

  • Molecular/genomic pathology ??
  • Forensic pathology
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The dream . . .

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. . . the challenge

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. . . the challenge

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. . . the challenge

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. . . the challenge

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. . . the challenge

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. . . the challenge

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. . . the challenge

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. . . the challenge

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So what’s wrong with the traditional health care system?

  • No built-in system for coordination of care
  • No real incentive to give high-quality care
  • Little connection between care of individual

patients and the health of the population

  • No effective way to control costs → volume

rewarded over value

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Projected Future Spending on Health Care in the US If Nothing Changes (% of GDP)

Source: Congressional Budget Office

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Modern health care reform: The “triple aim”

  • Better quality care for individuals
  • Improved health for the population
  • Lower cost

Value =

Quality/Outcome Cost

The goal: Value-based health care  value rewarded over volume

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Value-based health care . . . so far

  • Accountable care organizations
  • Patient-centered medical homes
  • Bundled payment/episodes of care

arrangements

  • Pay-for-performance (P4P)
  • Meaningful use of HIT
  • __________________??
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HHS targets for value-based payments

  • By 2016
  • 85% of provider payments  value-based
  • 30% of payments  “alternative” models
  • By 2018
  • 90% of provider payments  value-based
  • 50% of payments  “alternative” models
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Accountable care organizations: What are they?

  • Health care organizations that accept

accountability for the . . .

  • Quality of care
  • Health of the population served
  • Per capita cost of care for a designated

population

  • Formed by combination of providers and/or

hospitals

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Accountable care organizations: What are they?

  • Health care organizations that accept

accountability for the . . .

  • Quality of care
  • Health of the population served
  • Per capita cost of care for a designated

population

  • Formed by combination of providers and/or

hospitals

 group practice, network of individual provider practices, joint venture/partnership of hospital(s) and providers, hospital- employed providers, etc.

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Accountable care organizations: What are they not?

HMOs by another name? HMO ACO

  • 1. Better quality care for individuals* ?? +
  • 2. Improved health for the population* ? +
  • 3. Lower cost*

+ + *HIT can now facilitate all three

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Accountable care organizations

Total Number of ACOs – 1/15

Medicare vs. Non-Medicare

Courtesy of Brookings-Dartmouth ACO Learning Network – January, 2015

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Accountable care organizations

Total Covered Lives in ACOs – 4/14

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Accountable care organizations

% Covered Lives in ACOs by Hospital Region − 4/14

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Accountable care organizations: Different models

  • CMS Medicare Shared Savings Program

(MSSP) ACOs

  • CMS CMMI Pioneer ACOs
  • Medicaid ACOs
  • Private sector ACOs
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Accountable care organizations: Different models as of 1/15

  • CMS Medicare Shared Savings Program

(MSSP) ACOs…………………427

  • CMS CMMI Pioneer ACOs…....23
  • Medicaid ACOs………………......7 states
  • Private sector ACOs………….250+

Total 710+

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Accountable care organizations: Common elements

  • Coordination of care key to success

−Chronic disease management, transitions of care (i.e. handoffs), population health management, etc.

  • Use of EHR and informatics to improve care,

manage utilization, and monitor performance

  • Payment: − Based on meeting quality measures

− Shared FFS savings  capitation, bundled payments, etc.

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Accountable care organizations: Different models

CMS Medicare Shared Savings Program ACO

  • Accountable for the . . .
  • Quality of care – 33 quality measures
  • Cost of providing care (compared to past)
  • Costs and savings based on fee-for-service
  • ACO can share in FFS savings and/or be at

risk for added costs

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Accountable care organizations: Different models

  • CMS Medicare Shared Savings Program

(MSSP) ACOs

  • CMS CMMI Pioneer ACOs
  • Medicaid ACOs
  • Private sector ACOs
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Patient-centered medical home

  • Care delivery model based on “partnership”

between individual patients and their provider (usually primary care, may be specialty care)

  • Team-based care coordinated across the

continuum of care

  • Focused on quality and safety
  • Currently, >8,000 accredited PCMHs
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PCMHs and ACOs

(James Crawford, 2014)

PCMH Practices Hospital(s) Emergency Dept. SNF, Rehab. Laboratory, Imaging, Pharmacy, “Urgent Care” Clinic

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Bundled payment/episodes of care arrangements

  • Single “fixed dollar” global payment to hospital,

provider organization, and/or individual providers for single “episode of care”

  • Similar to Medicare DRGs for hospitals, but . . .

providers may now be included in bundle

  • Distribution of payment is determined internally
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Pay-for-performance (P4P), etc.

  • Started in 2000 with Benefits Improvement and

Protection Act

  • Reinforced with

2009 HITECH Act 2010 Affordable Care Act

  • Applies to hospitals and providers
  • Started as voluntary bonus payments for good

performance

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Pay-for-performance (P4P), etc.

  • Started in 2000 with Benefits Improvement and

Protection Act

  • Reinforced with

2009 HITECH Act 2010 Affordable Care Act

  • Applies to hospitals and providers
  • Started as voluntary bonus payments for good

performance . . . in 2015  involuntary payment penalties for non-compliance or poor performance

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Pay-for-performance (P4P)

  • Physician Quality Reporting System

(PQRS)

  • Value-Based Modifier (VBM) for

providers

  • Value-Based Purchasing (VBP) for

hospitals

etc.

  • Meaningful Use of HIT
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Value-based health care – 2015

Currently voluntary . . . but for how long?

  • Accountable care organizations
  • Patient-centered medical homes
  • Bundled payment/episodes of care

arrangements Involuntary  penalties starting in 2015

  • Pay-for-performance (P4P)
  • Meaningful use of HIT
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HHS targets for value-based payments

  • By 2016
  • 85% of provider payments  value-based
  • 30% of payments  “alternative” models
  • By 2018
  • 90% of provider payments  value-based
  • 50% of payments  “alternative” models
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Value-based health care: Challenges for pathologists

  • Payment increasingly moving from FFS to

capitated/bundled payment  requires internal sharing of payment among providers, hospital, etc.

  • Voluntary models becoming more common
  • Involuntary P4P requirements and penalties

increasing

  • Quality and performance measures difficult

to meet; most don’t apply to pathologists

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Value-based health care: Meeting the challenges  Value-based pathology

As bundled/capitated payment increases, pathologists need to . . .

  • 1. Establish value-added roles in support of

ACOs, PCMHs, bundled payment arrangements, etc.

  • 2. Gain internal recognition for these roles
  • 3. Get paid fairly for these roles
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Pathology payment . . . in 3 minutes

Anatomic pathology

–Surgical pathology – General, subspecialties 80% – Cytopathology 10% – Autopsy pathology

Clinical pathology

– Clinical chemistry, hematology, transfusion medicine, microbiology, immunology, etc. 10%?? Special areas

  • Molecular/genomic pathology ??
  • Forensic pathology
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Value-based health care: Meeting the challenges  Value-based pathology

Value-added roles for pathologists . . . some examples:

  • Lab utilization management – CP and AP
  • Consultation – Pre-order and post-result
  • Assist in chronic disease/population health

management

  • Ensure actionable lab/pathology result format in EHR
  • Use HIT/informatics for practice analytics, care

improvement

  • Management of tissue biorepository
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Value-based health care: Meeting the challenges  Value-based pathology

Value-added roles for pathologists . . . some examples:

  • Lab utilization management – CP and AP

CP – Develop lab test order sets, testing algorithms, test formularies; emphasis on molecular and other high-cost tests  “the right test at the right time” AP – Manage ancillary testing in surgical pathology, hematopathology

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Value-based health care: Meeting the challenges  Value-based pathology

Value-added roles for pathologists . . . some examples:

  • Lab utilization management – CP and AP
  • Consultation – Pre-order and post-result
  • With clinicians
  • With patients
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Value-based health care: Meeting the challenges  Value-based pathology

Value-added roles for pathologists . . . some examples:

  • Lab utilization management – CP and AP
  • Consultation – Pre-order and post-result
  • Assist in chronic disease/population health

management

  • Use HIT for scheduled testing alerts, testing

compliance/test result tracking, intervention alerts

  • Develop and apply clinical decision support tools
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Value-based health care: Meeting the challenges  Value-based pathology

Value-added roles for pathologists . . . some examples:

  • Lab utilization management – CP and AP
  • Consultation – Pre-order and post-result
  • Assist in chronic disease/population health

management

  • Ensure actionable lab/pathology result format in EHR

 Provides clinical decision support to clinicians

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Value-based health care: Meeting the challenges  Value-based pathology

Value-added roles for pathologists . . . some examples:

  • Lab utilization management – CP and AP
  • Consultation – Pre-order and post-result
  • Assist in chronic disease/population health

management

  • Ensure actionable lab/pathology result format in EHR
  • Use HIT/informatics for practice analytics, care

improvement

  • Management of tissue biorepository
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Value-based pathology

Payment of pathologists

  • Employee  $ incentives
  • Member  share in capitation/bundles
  • Vendor/subcontractor  low FFS?

 Involvement in ACO/organizational leadership Be at the table . . . or on the menu.

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“As soon as possible, Medicare should extend competitive bidding to medical devices, laboratory tests, radiographic diagnostic services, and all other commodities.”

− The Center for American Progress, et al NEJM, August 1, 2012

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Value =

Quality/Outcome Cost

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OCPI pathology project?

Pathology “cost per diagnosis” of cancer

  • CMMI interested in utilization management
  • CMMI interested in cancer care (e.g. new

CMMI Oncology Care Model)

  • CAP, ASCO, ASH, etc. developing cancer

diagnostic guidelines  study drivers of pathology cost in cancer diagnosis  develop a CMMI pilot: Episodes of care?

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The Impact of Health Care Reform on Pathology Practice and Payment: From Volume to Value

Donald Karcher, MD Chair, Department of Pathology The George Washington University Medical Center