Lab and Pathology Industry Responds to Proposed MACRA Rules

Last year the long-maligned Sustainable Growth Rate payment formula was replaced with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a system where providers are paid in part based on the quality of care they deliver.

“This is the biggest change in how physicians are paid ... since the creation of DRGs,” said Emily Volk, M.D., a pathologist and chief quality officer for the Baptist Health System in San Antonio who also sits on the board of governors for the College of American Pathologists.

MACRA won’t be fully implemented until 2019 at the earliest (and likely later than that), but the U.S. Department of Health and Human Services released draft regulations for how the new law would be implemented earlier this year. The agency received nearly 4,000 comments on the proposed regulations from members of the public. The vast majority were physicians, but a handful were pathologists or groups representing that medical specialty as well as laboratories.

The sector is taking a fairly cautious wait-and-see attitude. The CMS will take months digesting the comments it received (although hundreds of them were template submissions from members of the Texas Medical Association). It will likely be the end of the year or even 2017 before the final regulations are announced.

“I’m not getting exorcised about it right now,” said Barry Portugal, president of Health Care Development Services, a Florida-based consulting firm to pathology practices. For the moment, Portugal said he is most concerned about the record- keeping required for quality measures, particularly for smaller practices.

“It’s a (challenge) keeping track of all of that work and trying to statistically infer how well you’re doing,” he said.

Concern about Smaller Practices
The consensus among many in the health care industry is also that smaller or solo medical practices will be overwhelmed by the many reporting requirements.

“All of the items in MACRA and going back to the (Affordable Care Act) have the secondary impact of increasing administrative costs,” Volk said. “Does this hit a smaller practice more than a larger one? No doubt that it does.”

CAP represents the group of laboratory-oriented clinicians who will be most impacted by the rule. It submitted 27 pages of comments, one of the lengthiest documents submitted by commenters. The organization wants an expansion of potential quality measurement categories for pathologists and a minimization of clinical practice improvement activities until more specifics for meeting the objectives are created.

“Pathologists for years have been making contributions to delivering value, but the current program was designed with primary care physicians in mind and not our group,” Volk said.

Both Volk and Portugal suggested that pathologists might be measured in areas such as blood management and conservation, as well potentially reducing duplicative testing. Perhaps most importantly, CAP wants a liberalization of the definition of non-patient facing physicians to automatically default pathologists to that category, where scoring is weighted in a manner more favorable to clinicians that don’t regularly interact with patients. Under the current proposal, physicians or group practices qualify for a non-patient facing designation if they have less than 25 patient encounters a year.

“If there is a change in someone’s status (late in the year), it would be difficult for them to retrospectively meet the reporting requirements,” Volk said.

Quality Improvement Possibilities Seen
COLA, the laboratory quality and safety organization, sees a potential opportunity in MACRA to improve the objectives of its mission.

“There are opportunities to expand and improve upon the rule’s existing list of clinical practice improvement activities to recognize the significant impact laboratory medicine plays in the delivery of quality care,” said COLA Chief Executive Officer Douglas Beigel.

Of particular interest is the measurement category known as clinical practice improvement activities, which would comprise 15 percent of a clinician’s score for an incentive or penalty.

“A CPIA that focuses on enhancing practice safety in waived testing through educational support, training and practice management tools will undoubtedly make a clear impact on the quality of care received by patients by encouraging clinicians to take a closer look at the existing waived testing practices,” Beigel said.

Another area where a CPIA would make sense is in improving quality control during the pre-analytic phase of testing. According to Beigel, up to 68 percent of all testing errors occur during this phase.

“A CPIA that highlights initiatives focused on quality control measures and proper training for the entire care team will help to enhance practice safety,” he said.

Takeaway: The laboratory/pathology sector has taken its first look at the proposed MACRA regulations and has asked for relatively few changes so far.