Editorial
The Future of Pathology Is Now A. Joe Saad, MD
T
he challenges facing pathology are daunting and perhaps unprecedented. Medicine is in a state of flux, and pathology is under pressure from Medicare, third-party payers, legislatures (state and federal), regulatory agencies, and other physician entrepreneurs. However, every generation faces new challenges. When I chose pathology as a career in the mid 80s, colleagues offered a pretty dire warning: ‘‘Pathology is a dying specialty and has no future.’’ I was told surgical pathology would soon be obsolete because technology was on the verge of replacing the microscope. Clinical pathology was on life support following the introduction of diagnosis-related groups, and the job market was terrible. More than a quarter century later (no regrets), our specialty is thriving, but now faces new challenges that will likely determine the future of our profession. It is our duty to confront these challenges and find the future opportunities now. The Affordable Care Act (ACA) and other health care initiatives set in motion even before the ACA became the ‘‘law of the land’’ will alter medicine in historic ways. I do not know how pathology will be affected. Those who tell you with a conviction of certainty that they know exactly how pathology will be affected are probably not being entirely truthful. I do know that we will be facing economic challenges, as an aging population in need of health care will expect to receive the best care available. Furthermore, providers will be held accountable for the quality of care they deliver while being expected to simultaneously decrease the cost. Accountable Care Organizations (ACOs) or other forms of coordinated care have received the most attention. The US Centers for Medicare & Medicaid Services (CMS) reports that more than 250 ACOs intend to provide health care services to seniors. Not surprisingly, health systems are merging, and physician groups are consolidating to compete because private insurers are also shopping for value. The future of fee-for-service is uncertain at best, and although it is expected to continue in some fashion, the framework is being built to base payments on episodes of care, bundled payments, and accountable care models. Physicians will be paid based on quality measures and efficiency, intended to keep patients healthy or at least consuming a smaller percentage of health care dollars. Accepted for publication April 29, 2013. From the Department of Pathology, Methodist Dallas Medical Center, Dallas, Texas. doi: 10.5858/arpa.2013-0205-ED Reprints: A. Joe Saad, MD, Department of Pathology, Methodist Dallas Medical Center, 1441 N Beckley Ave, Dallas, TX 75203 (email: [email protected]). Arch Pathol Lab Med—Vol 138, January 2014
Pathologists must become engaged in the process. We must embrace the future as physician leaders in highquality, evidence-based, and value-driven, precision medicine. We must be the physicians who direct testing (80% of medical decisions involve laboratory testing), diagnosis, prognosis, and treatment. Where do we start? Last summer, at the Texas Society of Pathologists (TSP) Young Pathologists Section retreat in San Antonio, Texas, a speaker urged young pathologists to get out from behind the paraffin curtain. Pathologists must be front and center in our hospitals and laboratories to actively engage our clinical colleagues and administrators. We cannot isolate ourselves and hope to weather the storm and to avoid the changes. Also see p 12. We must be part of the planning and implementation; most of all, we must be part of the solution. But even that may not be enough. We must be actively involved in local, state, and national pathology and medical societies, where we must rise to be leaders. We must participate in patient advocacy organizations as trusted physician advisors and concerned citizens. Every pathologist, and especially the younger generation, must actively seek out a role in charting our future, sooner rather than later. Financial pressures to our profession will continue regardless of future delivery systems. The ACA increased CMS’s authority to scrutinize fee-for-service payments to all physicians. The technical component (TC) of several current procedural terminology (CPT) codes were ‘‘revalued,’’ resulting in a 52% cut to CPT 88305-TC this year. Stakeholder comments to CMS on the cost of providing an 88305-TC suggested Medicare should have cut the TC by 75% to $18.00. The revaluation by CMS denied payment for indirect practice expenses, such as computers, software, and clerical and administrative overhead. Medicare expects these cuts to save $400 to $500 million. Scrutiny of additional ‘‘overused’’ and ‘‘high-value’’ codes will continue, and in 2014, we may face cuts to immunohistochemistry and fluorescent in situ hybridization codes. New molecular codes (.100) were adopted to replace the ‘‘stacking codes’’ and placed on the clinical laboratory fee schedule instead of the physician fee schedule while a divided pathology community was feuding over their placement. As we face the 2014 Medicare fee schedule and valuation of the new molecular codes, pathologists have the opportunity to unite, regardless of practice setting—academic, private, independent, and reference laboratories—to comment with one Editorial—Saad 9
voice on future payments. Medicare carriers are currently soliciting stakeholder input that will determine payments for years to come. Not only must we put aside our differences and coordinate our efforts within the pathology community but also we must work with administrators and health care executives to demonstrate the value of our professional services in an increasingly challenging fiscal environment, which was made even more difficult by the recent 2% sequester cuts. Fragmentation of pathology services is another challenge. Scientific advances coupled with targeted therapies often require companion diagnostics and ancillary testing. We attempt to juggle multiple specimens, tests, and billing dilemmas. I am sure that I am not alone in noticing the shrinking size of biopsy specimens and the increasing demands to do more and more tests with less and less tissue. Because not every laboratory can do every test, we have an opportunity to coordinate services by working with colleagues in our community to provide many of these services locally. We can partner with academic centers and reference or large commercial laboratories to form networks that enhance our local practices and give us a stake in new, exciting, and intellectually challenging technologies. Unless we become the leaders in genomic medicine, in vivo diagnostics, and next-generation sequencing, our clinical colleagues will further marginalize us. Pathologists must lead the way and embrace a mentality of collaboration over competition. Advocacy is another major challenge that requires the collective efforts of all pathologists and all medicine. A common misconception is that we are individually helpless in the grand political landscape. Pathologists are the only network of activists for pathology—the ‘‘boots on the ground’’—and remember, all politics is local. For example, TSP expects to deal with the Texas Legislature on balance billing, network adequacy, medical technologists licensure, employment of physicians (corporate practice of medicine), and ACO legislation, including the expansion of Medicaid, issues that are no different in any other state. The TSP introduced a bill, long championed by one of our members, to allow medical examiners to collaborate in institutional review board–approved research using tissues from forensic autopsies that would otherwise be discarded as medical waste. The bill was strongly supported by several medical examiners and the Texas Medical Center. While our bill was moving through committees, pathologists were testifying to our role in patient care, quality, and research. Unfortunately,
10 Arch Pathol Lab Med—Vol 138, January 2014
the bill was modified in committee and had to be withdrawn over concerns that the modifications could have a deleterious effect on a core mandate of medical examiners. Nevertheless, TSP still believes that pathologists need to actively engage legislators and the public by leading the way in advocating for medical education, research, and public health. We hope that our bill will pass in the 2015 legislative session. Federal advocacy is vitally important. The ACA and CPT code payment reductions were mentioned earlier. The TC grandfather died last year after being kept alive for 13 years through a strong grassroots advocacy effort. The sustainable growth rate is very much alive and looms large in the mind of almost all physicians. The current extension, averting a 27.5% cut to Medicare, expires at the end of this year. The Congressional Budget Office (CBO) recently revised their estimate to fix sustainable growth rate downward by $100 billion to around $138 billion throughout a decade. Congress is developing proposals to replace and reform the sustainable growth rate. We must encourage Congress to find a permanent solution this year before the sale ends and the CBO changes its mind! Self-referral, in-office laboratories, laboratory-developed tests, meaningful use, and electronic health record ‘‘donations’’ are other important issues that affect pathology in ways unique to our specialty. Meaningful use is one example where CMS expects us to meet certain criteria in electronic health records that are geared toward primary care (such as charting of vital signs, a list of allergies and immunizations) or face a payment penalty. Most pathology practices will be unable to meet that requirement. Legislation has been introduced to exempt pathology from both the incentives and penalties. We must aggressively pursue our legislators to see that such an exemption is enacted. The final challenge is actually the first step in facing all the other challenges—participatory society membership. Joining one or a dozen societies is not enough. Membership means nothing if we are not actively involved on behalf of the specialty. Everyone must play a role. Furthermore, membership gives us the best opportunity of all—to work together as mentors and mentees, private practitioners and academicians, competitors and collaborators, friends and colleagues—to build strong personal and professional relationships that will carry pathology into the future as a viable, vibrant, and exciting career for the next generation of pathologists.
Editorial—Saad
Dr Saad is chairman of Pathology for the Methodist Health System in Dallas, Texas. He is also medical director of Surgical Pathologists of Dallas, an independent anatomic pathology laboratory, and Prism Pathology, an independent molecular pathology laboratory. Dr Saad received his undergraduate and medical degrees from the American University of Beirut. After a research fellowship and internship in general surgery, he completed an anatomic and clinical pathology residency at the University of Texas Medical Branch and a fellowship in cytopathology at Baylor College of Medicine. He is president of the Texas Society of Pathologists. He is vice chair of the Federal and State Affairs Committee of the College of American Pathologists (CAP) and has served as a Texas delegate to the CAP House of Delegates for many years. He chaired the TSP council on legislation for 5 years; is a member of the Dallas County Medical Society, where he served on the legislative council; and is a member of the Texas Medical Association. He is a founding member and past president of the North Texas Society of Pathology. Dr Saad serves on numerous hospital committees including the medical executive committee at 4 hospitals and has chaired several, including the Institutional Review Board for the Methodist Health System. He advocates tirelessly for pathology in Washington, DC, and Austin, Texas, where he recently testified before the Texas Senate Health and Human Services Committee in favor of the medical examiner research bill.
Arch Pathol Lab Med—Vol 138, January 2014
Editorial—Saad 11
Copyright of Archives of Pathology & Laboratory Medicine is the property of College of American Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
The Future of Pathology Is Now A. Joe Saad, MD
T
he challenges facing pathology are daunting and perhaps unprecedented. Medicine is in a state of flux, and pathology is under pressure from Medicare, third-party payers, legislatures (state and federal), regulatory agencies, and other physician entrepreneurs. However, every generation faces new challenges. When I chose pathology as a career in the mid 80s, colleagues offered a pretty dire warning: ‘‘Pathology is a dying specialty and has no future.’’ I was told surgical pathology would soon be obsolete because technology was on the verge of replacing the microscope. Clinical pathology was on life support following the introduction of diagnosis-related groups, and the job market was terrible. More than a quarter century later (no regrets), our specialty is thriving, but now faces new challenges that will likely determine the future of our profession. It is our duty to confront these challenges and find the future opportunities now. The Affordable Care Act (ACA) and other health care initiatives set in motion even before the ACA became the ‘‘law of the land’’ will alter medicine in historic ways. I do not know how pathology will be affected. Those who tell you with a conviction of certainty that they know exactly how pathology will be affected are probably not being entirely truthful. I do know that we will be facing economic challenges, as an aging population in need of health care will expect to receive the best care available. Furthermore, providers will be held accountable for the quality of care they deliver while being expected to simultaneously decrease the cost. Accountable Care Organizations (ACOs) or other forms of coordinated care have received the most attention. The US Centers for Medicare & Medicaid Services (CMS) reports that more than 250 ACOs intend to provide health care services to seniors. Not surprisingly, health systems are merging, and physician groups are consolidating to compete because private insurers are also shopping for value. The future of fee-for-service is uncertain at best, and although it is expected to continue in some fashion, the framework is being built to base payments on episodes of care, bundled payments, and accountable care models. Physicians will be paid based on quality measures and efficiency, intended to keep patients healthy or at least consuming a smaller percentage of health care dollars. Accepted for publication April 29, 2013. From the Department of Pathology, Methodist Dallas Medical Center, Dallas, Texas. doi: 10.5858/arpa.2013-0205-ED Reprints: A. Joe Saad, MD, Department of Pathology, Methodist Dallas Medical Center, 1441 N Beckley Ave, Dallas, TX 75203 (email: [email protected]). Arch Pathol Lab Med—Vol 138, January 2014
Pathologists must become engaged in the process. We must embrace the future as physician leaders in highquality, evidence-based, and value-driven, precision medicine. We must be the physicians who direct testing (80% of medical decisions involve laboratory testing), diagnosis, prognosis, and treatment. Where do we start? Last summer, at the Texas Society of Pathologists (TSP) Young Pathologists Section retreat in San Antonio, Texas, a speaker urged young pathologists to get out from behind the paraffin curtain. Pathologists must be front and center in our hospitals and laboratories to actively engage our clinical colleagues and administrators. We cannot isolate ourselves and hope to weather the storm and to avoid the changes. Also see p 12. We must be part of the planning and implementation; most of all, we must be part of the solution. But even that may not be enough. We must be actively involved in local, state, and national pathology and medical societies, where we must rise to be leaders. We must participate in patient advocacy organizations as trusted physician advisors and concerned citizens. Every pathologist, and especially the younger generation, must actively seek out a role in charting our future, sooner rather than later. Financial pressures to our profession will continue regardless of future delivery systems. The ACA increased CMS’s authority to scrutinize fee-for-service payments to all physicians. The technical component (TC) of several current procedural terminology (CPT) codes were ‘‘revalued,’’ resulting in a 52% cut to CPT 88305-TC this year. Stakeholder comments to CMS on the cost of providing an 88305-TC suggested Medicare should have cut the TC by 75% to $18.00. The revaluation by CMS denied payment for indirect practice expenses, such as computers, software, and clerical and administrative overhead. Medicare expects these cuts to save $400 to $500 million. Scrutiny of additional ‘‘overused’’ and ‘‘high-value’’ codes will continue, and in 2014, we may face cuts to immunohistochemistry and fluorescent in situ hybridization codes. New molecular codes (.100) were adopted to replace the ‘‘stacking codes’’ and placed on the clinical laboratory fee schedule instead of the physician fee schedule while a divided pathology community was feuding over their placement. As we face the 2014 Medicare fee schedule and valuation of the new molecular codes, pathologists have the opportunity to unite, regardless of practice setting—academic, private, independent, and reference laboratories—to comment with one Editorial—Saad 9
voice on future payments. Medicare carriers are currently soliciting stakeholder input that will determine payments for years to come. Not only must we put aside our differences and coordinate our efforts within the pathology community but also we must work with administrators and health care executives to demonstrate the value of our professional services in an increasingly challenging fiscal environment, which was made even more difficult by the recent 2% sequester cuts. Fragmentation of pathology services is another challenge. Scientific advances coupled with targeted therapies often require companion diagnostics and ancillary testing. We attempt to juggle multiple specimens, tests, and billing dilemmas. I am sure that I am not alone in noticing the shrinking size of biopsy specimens and the increasing demands to do more and more tests with less and less tissue. Because not every laboratory can do every test, we have an opportunity to coordinate services by working with colleagues in our community to provide many of these services locally. We can partner with academic centers and reference or large commercial laboratories to form networks that enhance our local practices and give us a stake in new, exciting, and intellectually challenging technologies. Unless we become the leaders in genomic medicine, in vivo diagnostics, and next-generation sequencing, our clinical colleagues will further marginalize us. Pathologists must lead the way and embrace a mentality of collaboration over competition. Advocacy is another major challenge that requires the collective efforts of all pathologists and all medicine. A common misconception is that we are individually helpless in the grand political landscape. Pathologists are the only network of activists for pathology—the ‘‘boots on the ground’’—and remember, all politics is local. For example, TSP expects to deal with the Texas Legislature on balance billing, network adequacy, medical technologists licensure, employment of physicians (corporate practice of medicine), and ACO legislation, including the expansion of Medicaid, issues that are no different in any other state. The TSP introduced a bill, long championed by one of our members, to allow medical examiners to collaborate in institutional review board–approved research using tissues from forensic autopsies that would otherwise be discarded as medical waste. The bill was strongly supported by several medical examiners and the Texas Medical Center. While our bill was moving through committees, pathologists were testifying to our role in patient care, quality, and research. Unfortunately,
10 Arch Pathol Lab Med—Vol 138, January 2014
the bill was modified in committee and had to be withdrawn over concerns that the modifications could have a deleterious effect on a core mandate of medical examiners. Nevertheless, TSP still believes that pathologists need to actively engage legislators and the public by leading the way in advocating for medical education, research, and public health. We hope that our bill will pass in the 2015 legislative session. Federal advocacy is vitally important. The ACA and CPT code payment reductions were mentioned earlier. The TC grandfather died last year after being kept alive for 13 years through a strong grassroots advocacy effort. The sustainable growth rate is very much alive and looms large in the mind of almost all physicians. The current extension, averting a 27.5% cut to Medicare, expires at the end of this year. The Congressional Budget Office (CBO) recently revised their estimate to fix sustainable growth rate downward by $100 billion to around $138 billion throughout a decade. Congress is developing proposals to replace and reform the sustainable growth rate. We must encourage Congress to find a permanent solution this year before the sale ends and the CBO changes its mind! Self-referral, in-office laboratories, laboratory-developed tests, meaningful use, and electronic health record ‘‘donations’’ are other important issues that affect pathology in ways unique to our specialty. Meaningful use is one example where CMS expects us to meet certain criteria in electronic health records that are geared toward primary care (such as charting of vital signs, a list of allergies and immunizations) or face a payment penalty. Most pathology practices will be unable to meet that requirement. Legislation has been introduced to exempt pathology from both the incentives and penalties. We must aggressively pursue our legislators to see that such an exemption is enacted. The final challenge is actually the first step in facing all the other challenges—participatory society membership. Joining one or a dozen societies is not enough. Membership means nothing if we are not actively involved on behalf of the specialty. Everyone must play a role. Furthermore, membership gives us the best opportunity of all—to work together as mentors and mentees, private practitioners and academicians, competitors and collaborators, friends and colleagues—to build strong personal and professional relationships that will carry pathology into the future as a viable, vibrant, and exciting career for the next generation of pathologists.
Editorial—Saad
Dr Saad is chairman of Pathology for the Methodist Health System in Dallas, Texas. He is also medical director of Surgical Pathologists of Dallas, an independent anatomic pathology laboratory, and Prism Pathology, an independent molecular pathology laboratory. Dr Saad received his undergraduate and medical degrees from the American University of Beirut. After a research fellowship and internship in general surgery, he completed an anatomic and clinical pathology residency at the University of Texas Medical Branch and a fellowship in cytopathology at Baylor College of Medicine. He is president of the Texas Society of Pathologists. He is vice chair of the Federal and State Affairs Committee of the College of American Pathologists (CAP) and has served as a Texas delegate to the CAP House of Delegates for many years. He chaired the TSP council on legislation for 5 years; is a member of the Dallas County Medical Society, where he served on the legislative council; and is a member of the Texas Medical Association. He is a founding member and past president of the North Texas Society of Pathology. Dr Saad serves on numerous hospital committees including the medical executive committee at 4 hospitals and has chaired several, including the Institutional Review Board for the Methodist Health System. He advocates tirelessly for pathology in Washington, DC, and Austin, Texas, where he recently testified before the Texas Senate Health and Human Services Committee in favor of the medical examiner research bill.
Arch Pathol Lab Med—Vol 138, January 2014
Editorial—Saad 11
Copyright of Archives of Pathology & Laboratory Medicine is the property of College of American Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
