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Medicare's Quality Payment Program Continues to Evolve: What Pathologists Need to Know to Succeed.

The development of the Medicare Access and the Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) was ultimately the result of the Centers for Medicare and Medicaid Services (CMS) reflecting on how it was purchasing services for its beneficiaries and how that contributed to increasing cost for health care nationally. (1) Historically, CMS compensated providers based on the volume of services provided not the quality of the service or product provided, in contrast to almost every other part of the economy, where the quality of the product determines its value. Thus, MACRA codified the concept of value-based payment for medical services by introducing the Quality Payment Program (QPP). (1) The QPP is designed to accomplish MACRA's goals of lowering cost, improving the health of patients, and expanding access to care by paying physicians who perform better on measures of healthcare quality and cost higher reimbursement rates than those who perform poorly on those metrics. Unfortunately, the reporting requirements for providers to comply with the QPP have been increasing each year since reporting first began in 2017 and specifically, the quality measures available in the program are becoming more complicated. (2,3)

As the stewards of laboratory medicine, pathologists are responsible for ensuring their laboratories deliver accurate, precise, and timely results. An accurate diagnosis is essential for a patient to receive timely and appropriate medical care. Furthermore, an incorrect diagnosis could not only lead to inappropriate or delayed treatment but may increase the cost of care with unnecessary additional testing or intervention. Since 1988, the CMS has sought to ensure laboratory quality through the Clinical Laboratory Improvement Amendments (CLIA). The CLIA regulations set quality standards that labs must meet in order to be eligible for Medicare and Medicaid payments. Laboratory accreditation and proficiency testing programs have historically been the way the CMS certifies the quality of care laboratories and pathologists deliver. (4) MACRA, on the other hand, was intended to provide financial incentives for clinicians to demonstrate higher quality while lowering the cost of providing care. (1)

As with the practice of laboratory medicine, quality programs are integral to the practice of anatomic pathology to ensure the accuracy and timeliness of diagnoses rendered. While these activities have previously been tied to accreditation and compliance with CLIA, both governmental and private healthcare payers are increasingly considering quality and reimbursement to be interrelated. Historically, health insurance was a matter for private companies. During World War II, the United States began to see the introduction and proliferation of medical insurance, which quickly became cost prohibitive for many Americans. (5-7) The steep rise in national medical expenditures was further ignited by the advent of Medicare and Medicaid, created by the Social Security Act in 1965. These programs were meant to provide individuals older than the age of 65, with significant disability, and/or poverty, with healthcare coverage. (7-9) The CMS was then created to manage these programs and by 2016, CMS alone provided healthcare coverage for more than 105 million beneficiaries at a cost of $1.2 trillion. (8)

In 1997, Congress recognized that the steady increase in expenditures was unsustainable and passed the Balance Budget Act. This law created the Sustainable Growth Rate (SGR) formula to ensure the yearly Medicare beneficiary expense did not exceed the gross domestic product growth. (9) However, the SGR formula was never implemented due to repeated delays passed by Congress. These SGR delays eventually created a large potential reduction in physician payment rates (>25 percentage point reduction). (10) Seeing the SGR formula was not effective, the medical community was able to advocate for the repeal of the SGR. However, the problem of exponentially growing healthcare expenditures still needed to be addressed. In 2015, Congress acted by passing the bipartisan supported MACRA and ultimately the creation of the QPP. (1)

In the following short series of articles, the authors will review the details of how the practice of pathology specifically fits into the QPP. Hopefully, this will enable pathologists to comply with the regulatory requirements of the QPP while also demonstrating the quality care and value they provide their patients. To this end, the College of American Pathologists has both advocated on behalf of our specialty for equal opportunities to succeed within the program and for reductions in reporting burden. Additionally, the College of American Pathologists is actively creating numerous meaningful quality measures for the QPP.

I would like to acknowledge the effort put forth by the College of American Pathologists Advocacy staff, specifically Stephanie Peditto, Loveleen Singh, and Colleen Skau, for their guidance in creating this series and ongoing advocacy benefiting our specialty. Additionally, I would like to extend a very special thank you to all the members of the College of American Pathologists Economic Affairs Committee, past and present, for their effort related to measure development and advocacy related to the QPP.


(1.) Medicare Access and CHIP Reauthorization Act of 2015. 42 USC 1305 note. April 16, 2015. Congress Web site. publ10/PLAW-114publ10.pdf. Accessed December 10, 2019.

(2.) Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment. Final rule with comment period 81 FR 77008. November 4, 2016. Federal Register Web site. https://www. 6/11/04/201 6-2 5240/medicare-programmerit-based -incentive-payment-system-mips-and-alternative-payment-model-apm. Accessed January 3, 2020.

(3.) Medicare Program;CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment For Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule: Final Rule and Interim Final Rule 84 FR 62568. November 15, 2019. Federal Register Web Site. medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other. Accessed November 19, 2019.

(4.) Clinical Laboratory Improvement Amendments (CLIA). Centers for Medicare & Medicaid Web site. Accessed January 2, 2020.

(5.) A Common Thread of Service. An Historical Guide to HEW. Department of Health, Education, and Welfare Publication No. (OS) 73-45. July 1, 1972. Office for the Assistant Secretary of Planning and Evaluation Web site. https://aspe.hhs. gov/report/common-thread-service. Accessed January 2, 2020.

(6.) Martin AB, Hartman M, Washington B, et al. National health care spending: faster growth in 2015 as coverage expands and utilization increases. Health Aff. 2017;36(1):166-176.

(7.) Stevens RA. Health Care in the early 1960s. Health Care Finance Rev. 1996; 18(2):11-22.

(8.) 2016 CMS Statistics. Centers for Medicare & Medicaid Web site https:// CMS-Statistics-Reference-Booklet/Downloads/2016_CMS_Stats.pdf. Accessed January 2, 2020.

(9.) Balanced Budget Act of 1997. August 5, 1997. Congress Web site. https:// Accessed December 10, 2019.

(10.) The Sustainable Growth Rate Formula for Setting Medicare's Physician Payment Rates. Congressional Budget Office Economic and Budget Issue Brief. September 2006. Congressional Budget Office Web site. sites/default/files/cbofiles/ftpdocs/75xx/doc7542/09-07-sgr-brief.pdf. Accessed January 3, 2020.

Diana M. Cardona, MD, is a tenured associate professor of pathology at Duke University Medical Center (Durham, North Carolina), where she is the vice chair and director of Anatomic Pathology Laboratories for the health system. Diana graduated from the University of Miami's Miller School of Medicine (Miami, Florida) and completed her Anatomic and Clinical Pathology residency at the University of Florida (Gainesville). She stayed on an additional year at the University of Florida as an adjunct clinical postdoctoral associate in Gastrointestinal and Hepatobiliary Pathology. In 2009, she started as faculty at Duke where she covers the gastrointestinal, liver, transplant, and orthopedic surgical pathology services. Dr Cardona has more than 70 peerreviewed publications and multiple book chapters within the areas of healthcare payment policy, transplant pathology, and orthopedic malignancies. She has received multiple awards, including the "Frank Coleman Public Service Award" from the College of American Pathologists (CAP) and the "Salvatore Pizzo Faculty Research Mentor Award" from the department of Pathology at Duke. Within the CAP, Dr Cardona serves as the chair of the Measure and Performance Assessment Subcommittee, which leads the CAP's MACRA advocacy and quality payment measure development efforts. She also serves as the vice chair of the CAP's Economic Affairs Committee and as a member of the Council on Government and Professional Affairs. Dr Cardona is also a Clinical Effectiveness and Economics section editor for the Archives of Pathology & Laboratory Medicine.

Diana M. Cardona, MD

Accepted for publication January 28, 2020.

From the Department of Pathology, Duke University Medical Center, Durham, North Carolina.

The author has no relevant financial interest in the products or companies described in this article.

doi: 10.5858/arpa.2020-0028-ED

Corresponding author: Diana M. Cardona, MD, Department of Pathology, Duke University Medical Center, Box 3712, Durham, NC 27710 (email:
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Title Annotation:Special Section--Understanding Medicare's Quality Payment Program and Its Impact on Your Practice
Author:Cardona, Diana M.
Publication:Archives of Pathology & Laboratory Medicine
Date:Jun 1, 2020
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