. . . Massachusetts Society of Pathologists Newsletter Our thanks to Genzyme, Inc., for their generous sponsorship of our spring meeting. April 2009 Comments from the Our advocacy activity requires the assitance of professional lobbyists and President attorneys. All of this does not come cheap; in fact, we have been fortunate to Donald G. Ross, MD, PhD date that we do not have a major battle to fight every year, so we have time to With mixed feelings of satisfaction, replenish the “war chest.” Our principal relief, and regret at what has not yet Inside this Issue been finished, I write my last newsletter source of revenue is your membership dues. I appeal to all of you, once again, as President of the MSP. Dean Pappas, if there are pathologists in your practice Comments from the MD, will be taking over later this 1 President month. I thank you all for the confidence you showed in me, and the or of your aquaintance who live and/or work in Massachusetts, who are not MSP members, approach them and see many exp ressions of support I’ve if you can bring them in. Remember, it Cytology Proficiency 1 Testing received fro m you over the last two years. I hope that you will give Dean the same kind of backing and assistance is now possible to join and reg ister for events online at http://masspath.org. “The Blues” Discourage I have received. 2 Use of Hospital Labs Thanks. Don Ross The “Medical Home” The speaker for our April meeting is our 3 own Rebecca Johnson, MD, of Berkshire Medical Center. Becky’s presentation is on the topic of Maintenance of Certificat ion. Many Cytology Proficiency specialty boards already require periodic recertificat ion. The A merican Testing Board of Pathology has had this requirement for a few years for new Donald G. Ross, MD, PhD diplo mates, but people who passed their boards in earlier years do not (yet) have And the beat goes on… to do this. This issue may be fo rced upon us, however, by insurors and/or The CAP-endorsed Cytology state medical boards, wh ich are Proficiency Improvement Act of 2007 increasingly reluctant to recognize (HR1237) was passed by the House last lifetime board certificat ion. summer. The Senate version of the bill (S2510) was moving long nicely until the present financial crisis hit us. Your Massachusetts Society of Understandably, Congress is Pathologists is the only organization preoccupied at the mo ment with the which advocates for the practice of very pressing economic issues, and pathology at the state level. NESP, fixing cytology proficiency testing has ASCP and CAP do not do this. CAP moved to the back burner. advocates for pathologists on the national level, but many issues must be So, we are still using the existing, Mass. Society of Pathologists tackled at the state level, and even the flawed proficiency testing system. Into 22 Hutchins Road national issues require local advocacy; the “vacuum” came CM S, with a Medford, MA 02155 our state representatives in Congress email@example.com want to hear fro m their o wn Continued on page 2. constituents, not fro m strangers. . . . . . . . . . . . . . . . . . . . . . . . April 2009 Continued from page 1. director must use to assess the proposed improvement to the system, a performance of laboratory personnel. For example, laboratory directors “The Blues” (pathologists) conduct monthly 20-slide test every two years instead of a 10-slide test every year – not much of assessments of cytotechnologists Discourage Use of screening Pap tests, on a daily basis a change! assess cytotechnologist’s screening Hospital Labs totals and monitor daily workload, The following is the text o f a letter rescreen at least 10% of negative cases, Donald G. Ross, MD, PhD authored by CAP and signed by me as as well as any negative cases from the your President, sent to CMS regarding previous five years on any current Early this year, Blue Cross/Blue Shield this issue: HGSIL case. However, the proposed of Massachusetts (BCBSMA) sent a regulation fails to consider a communicat ion to their primary care To Whom It May Concern: proficiency testing approach that would docs offering an unspecified incentive take into account these existing for using office labs or co mmercial labs I am w riting to express my concern with performance requirements. in preference to hospital labs. As many the content of the Centers for Medicare of us are hospital-based, we were and Medicaid Services’ (CMS) Both the current and proposed puzzled and alarmed by this policy. I proposed regulation concerning proficiency tests suffer from the same wrote to John Fallon, MD, the Ch ief cytology proficiency testing, CMS-2252- scientific and statistical deficiencies. Medical Officer of BCBSMA, about P. I urge you to withdraw the Yet, a test of 100 slides is neither cost this issue: regulation and develop an alternative effective nor practical. CMS should proficiency testing model that will be consider the alternative approach more meaningful and effective in March 2, 2009 provided in the Cytology Proficiency improving quality and women’s health. Improvement Act of 2007. The The Cytology Proficiency Improvement alternative provides for proficiency Act, passed by the House of John Fallon, MD testing and documented assessment of Representatives last year, provides such Blue Cross/Blue Shield of skills in the context of an educational an alternative. Massachusetts, Inc. framework. It also has significant advantages over the test proposed in the The Landmark Center I have repeatedly taken the proficiency 401 Park Drive regulation in that it would incorporate test in its current form and find that it Boston, MA 02215-3326 complex, difficult Pap tests, keep neither represents normal practice nor contemporary with best practices and is an effective measure o f competency. new technologies and ensure on the Experts in the field have concluded that Dear Dr. Fallon: ground oversight through lab directors, CMS would have to administer a accrediting agencies as well as CMS. program consisting of at least 100 Pap I am the current President of the test slides to ensure that this testing Massachusetts Society of Pathologists. The proposed regulation mandates a model is statistically valid. Simply Many of our members are dismayed proficiency test that is of no value to my increasing the number of slides from 10 with the recent policy change at profession or the fight against cervical to 20, as the new regulation proposes, BCBSMA which would attempt to direct cancer. Again, I urge you to withdraw still results in a test that lacks validity. laboratory testing away from hospital- this proposed regulation and allow In addition, the proposed regulation based labs and pathologists to commer- alternatives to be considered. maintains a very limited set of cial labs or physician office labs. I diagnostic categories. These refer to a recently-communicated Sincerely, categories, similar to those in the (November 2008): current program, are not representative Donald G. Ross, MD, PhD, FCAP of the slides we see in real practice and Lab Efficiency Measure. This measure President, Massachusetts Society of don’t reflect complex, ambiguous cases, will reward physicians at three levels of Pathologists such as ASCUS, that we seen the performance for the percentage of Chief Pathologist, Holy Family Hospital laboratory every day. The proposed outpatient lab tests performed for their 70 East Street regulation also provides no evidence members at freestanding labs or in Methuen, MA 01844 that either the current or revised testing physician offices. model can enhance skills and produce Please visit www.cap.org to see what better patient outcomes. This measure would adversely affect the status is and what you can do to help promote reform o f this proficiency hospitals and hospital-based patholo- CLIA mandates extensive Pap test testing requirement. quality standards which the laboratory Continued on page 3. 2 . . . . . . . . . . . . . . . . . . . . . . . . Mass achusetts S CAP has provided the follo wing all health care services, including Continued from page 2. summary of the concept: specialist care, community services, hospitalizations, and post-acute gists at a time when many hospitals The Medical Home: At a Glance care. In a medical home, a physician are already under severe financial stress. We are upset that BCBSMA acts as the facilitator and manager of Introduction all the care a patient receives. would institute such a policy, and at a loss to understand why this measure would be adopted. There is no evidence Seeking ways to slow the growth of According to principles endorsed by that physician office labs or commercial Medicare spending and to better the American Medical Association, labs provide higher quality than coordinate the health care it care is coordinated across all hospital labs. Patient care is adversely finances, the federal government is affected when outpatient laboratory elements of the complex health care preparing to test the concept of the results are not available in the system, facilitated by registries "medical home" in the Medicare hospital setting, and costs are increased program. Congress has directed the and information technology, to when tests are unnecessarily repeated ensure that patients get the due to this problem. agency to use the program to "redesign the health care delivery indicated care when and where Thank you for your attention. Could we system to provide targeted, they need and want it in a make an appointment to discuss this accessible, continuous and culturally appropriate manner. policy and the possibility of altering it? coordinated, family-centered care to high-need populations." The federal A medical home incentivizes demonstration program will operate physicians to have regular contact Sincerely, for three years in rural, urban, and with patients, as well as to be Donald G. Ross, MD, PhD underserved areas in up to eight meaningful users of information President, MSP states. The demonstration is technology to ensure patients receive intended to inform future reforms appropriate, evidence-based care. In Dr. Fallon has yet to respond to my related to physician payment and the current demonstrations, letter. providers receive payments and health care delivery. incentives for serving as care Lapses in patient safety and quality, coordinators. attributed to a fragmented health care delivery system and misaligned The “Medical Home” incentives in how care is paid for In the current research and pilot demonstrations of the medical home, Donald G. Ross, MD, PhD has lead payers in the public and in addition to traditional fee-for- private sectors to propose the service arrangements for physician CMS, AMA, Mass. Medical Society medical home as a mechanism to services, providers are eligible to and a host of insurors are interested in better organize how care delivered receive per patient care management the concept of the “medical ho me” as a and paid for. means to make patient care more fees and share in savings that can be efficient and cost-effective. Briefly, the Within a medical home, physicians attributed to the care coordination concept is to place the patient’s primary provide closer management of services provided. care physician in charge of organizing patient care, averting unnecessary all of his/her specialty care and testing. treatments and hospitalizations. Early research on the medial home The PCP would be co mpensated for this model has shown that this care management role, and would be financially incentivized to provide cost What is a medical home? delivery model and alignment of incentives lead to improved patient efficiency. A medical home is not a place but a outcomes with fewer readmissions, process of care in which a physician- How does this affect us as pathologists? more patient-centered care and led team provides comprehensive Sounds a lot like capitation, where better coordination of specialty care. primary cares are incentivized to avoid primary care. A medical home use of specialists, or seek the cheapest allows a physician to provide, and to Stay tuned. provider. be remunerated for, serving as a single point of care coordination for . . . . . . . . . . . . . . . . . . . . . . . . 3 April 2009 . . . . . . . . . . . . . . . . . . . . . . . . Massachusetts Society of Pathologists 22 Hutchins Road BULK RATE Medford, MA 02155 US POSTAGE PAID CITY, STATE PERMIT NO. 000 ADDRESS CORRECTION REQUESTED 4 . . . . . . . . . . . . . . . . . . . . . . . . Mass achusetts S Subscriber Name Number Street Address City, State Postal Code . . . . . . . . . . . . . . . . . . . . . . . . 5 April 2009 6 . . . . . . . . . . . . . . . . . . . . . . . .