Future looking more grim by the day for the lab industry. Flee while you can.

[WEBB PINKERTON]

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[coroner]

I briefly heard from one of my colleagues today that we're now using something called a G-code for an 88342 instead instead of CPT for Medicare pts. But I didn't get a chance to talk with him in further detail. I guess this must be related to this new law. Either way, I'm guessing this is probably not good for our practice.

A few thoughts on some of the excerpts:

The other section of PAMA limits how deeply CMS can cut the price of a single lab test in each of the six years from 2017 to 2022.

What good is this if a potential cut of 75% for certain tests will eventually occur over this time period? It's almost death by a thousand cuts, but instead you're left on life support...

Another heavy burden that will fall on applicable clinical labs is the requirement that, starting January 1, 2016, they must report the market data that CMS will to use to determine CLFS prices. Failure to report this data can result in a penalty to the clinical laboratory of as much as $10,000 per day per unreported test.

I can see the intent (though not necessarily practicality) of this measure. Something that sounds along the lines of 'Meaningful Use' that hospital departments (including labs) must comply to in order to receive federal reimbursement and/or avoid penalties. But hopefully they don't plan on executing this as it could essentially make labs so tied up with red tape, they might as well have politicians running it. Oh wait, they are...

If CMS aggressively slashes the prices of the top 20 CLFS tests by volume from 2017 forward, the resulting financial carnage suffered by community laboratories and hospital laboratory outreach programs will cause many to go out of business. Should such events come to pass, the irony is that it will be the national lab companies that survive to pick over the bones of these failed labs, thus increasing their market share.

These statements forebode a sky is falling type atmosphere. Except it's hard to brush these off as the usual glass-is-half-empty posts often seen on this forum because this is now the law. If this is the case, it seems that it will be harder and harder for the independent private practice pathologist to carry on as before. Will they exist...sure but probably not in the same capacity as they once did in previous decades which was well before my time. Even for those who may feel insulated in academia or make up the ever-growing proportion of hospital-employed physicians, and don't have to worry about ratcheting up business by beating the bushes or undercutting neighbors this has potential effects as well. Can their incomes be maintained in the long run if this is fully implemented? What do you think will happen when hospital administrators look at the bottom line of lab revenue and realize the losses must be offset by adjusting costs i.e. wages, regardless of X number of RVU's such employees generate? Achieving equilibrium between milking the system e.g. individual billing of CP tests pre-1980s and adequate reimbursement for health-care is not an exact science. Unfortunately, the pendulum swings in extremes and recompensing services that once existed for practioners is non-existent or rare at best. The OP's header ended with "...flee while you can" which may be discouraging, but hey, on the bright side in the next few years I'm sure Quest will be hiring...

 

[pathstudent]

I briefly heard from one of my colleagues today that we're now using something called a G-code? for an 88342 instead instead of CPT for Medicare pts. But I didn't get a chance to talk with him in further detail. I guess this must be related to this new law. Either way, I'm guessing this is probably not good for our practice.

I find it shocking that you just heard about this. Do you not follow cap updates or what has been written about in this forum constantly. I guess that's how academic centers and corporate groups like ameripath get away with their low salaries. The second Ihc on a specimen is a g0462 and the cms gave themselves a 70% discount and that is less than the cost of preparing the stain for some of the more expensive antibodies.

And did you know that cms changed how they reimburse ISH and they did it in a stealth manner. No announcements that it was coming. No chance for input from us. They just decreed it after January 1. You always billed FISH or CISH per antibody. So a her 2 test would be an 88368 x 2 if manually interpreted. Will they just decreed that you can only bill it once per staining procedure. So now when we test a breast cancer for her2 we are paying money out of our own pocket. I am negotiating with the company to reduce the cost of the test but for now I am cutting a check to perform a required test on every Medicare breast cancer patient. And 88368 and 88367 are on the chopping block for 2015. It will force all testing to be centralized in a handful of corporate labs where they pay bottom dollar for employees and pathologists to do the work. Big government loves big pathology labs.

 

[coroner]

I do recall the chatter about this last year, but there's usually a lag when enacting changes of fee scheduling and they give some time for the transition to take place so it's more like a soft start. So we kept riding the ol' 88342 gravy train until we got the memo that the hospital wasn't getting paid anymore. But the above link was about a law that was just passed last month. This will basically enact more measures that will put the vice grip on small independent practices and community hospitals. The declines in reimbursement will affect us all, but the blows will be a little softer for the corporate types at AmeriPath, Quest, LabCorp, and Clarient because they will be able to find ways to reduce overhead and/or get bundled discounts like Sam's Club because they operate in bulk. This will effectively price out the little guy...

 

[pathbot]

What does this eventually mean for community hospital pathologists? Hospitals will always need pathologists onsite to signout inhouse specimens, cover tumor boards, do frozens, manage the lab etc. I have even talked to a number of pathologists whose 88305s are increasing as hospital systems buy out clinician practices (which will probably be much more common in coming years). I understand that traditional small "private" practices may find it hard to survive, but are these groups more likely to become "ameripath" employees or employees of their hospital system?

 

[Johnny Sunshine]

I'm not so sure pathologists will always need to be on site.

At some point, it's cheaper for a hospital to send out all specimens, and I suspect that soon telepathology will be fairly common for frozens. From what I've seen, many clinicians would not mind a lack of pathologist at tumor boards.

 

[Pathwrath]

I'm not so sure pathologists will always need to be on site.

At some point, it's cheaper for a hospital to send out all specimens, and I suspect that soon telepathology will be fairly common for frozens. From what I've seen, many clinicians would not mind a lack of pathologist at tumor boards.

Interesting. My experience has been that with the single exception of autopsies, hospitals are requiring more of everything that pays pathologists little or nothing commensurate with the work involved (after-hours and off-site frozens, rapid assessments, complex resections, conferences, administrative duties, etc., etc.) while providing less of that which actually does pay (bread-and-butter 88305's).

 

[pathstudent]

These statements forebode a sky is falling type atmosphere. Except it's hard to brush these off as the usual glass-is-half-empty posts often seen on this forum because this is now the law. If this is the case, it seems that it will be harder and harder for the independent private practice pathologist to carry on as before. Will they exist...sure but probably not in the same capacity as they once did in previous decades which was well before my time. Even for those who may feel insulated in academia or make up the ever-growing proportion of hospital-employed physicians, and don't have to worry about ratcheting up business by beating the bushes or undercutting neighbors this has potential effects as well. Can their incomes be maintained in the long run if this is fully implemented? What do you think will happen when hospital administrators look at the bottom line of lab revenue and realize the losses must be offset by adjusting costs i.e. wages, regardless of X number of RVU's such employees generate? Achieving equilibrium between milking the system e.g. individual billing of CP tests pre-1980s and adequate reimbursement for health-care is not an exact science. Unfortunately, the pendulum swings in extremes and recompensing services that once existed for practioners is non-existent or rare at best. The OP's header ended with "...flee while you can" which may be discouraging, but hey, on the bright side in the next few years I'm sure Quest will be hiring...

This will only change CLFS which is pretty much irrelevant to most but not all private practice pathologists. Most of us only care only care about the PFS. CLFS reductions will be much tougher for academic centers which try to offer outpatient lab testing. Academic centers simply don't have the volume nor labor contracts to compete with national labs.

 

[LADoc00]

I don't think the future will be bad for path!! It will be good!
Just think, with Obamacare, so many more patients will be in the system and there will be so many more blood tests needed!!! I think the job market will be booming in 10 years if it isn't already!! XD

Is this a joke? I can handle this poster. Please someone do something...

 

[Thrombus]

I don't think the future will be bad for path!! It will be good!
Just think, with Obamacare, so many more patients will be in the system and there will be so many more blood tests needed!!! I think the job market will be booming in 10 years if it isn't already!! XD

With all due offense intended, this is written with the perspective not of even a junior resident but more in line with that of a junior in high school.

 

[deleted314957]

I don't think the future will be bad for path!! It will be good!
Just think, with Obamacare, so many more patients will be in the system and there will be so many more blood tests needed!!! I think the job market will be booming in 10 years if it isn't already!! XD

1) What the heck does "XD" mean".
2) How in the hell do you think "more blood tests" will translate to a need for more pathologists?

There is currently a massive over-supply of pathologists. Look at any ad from an academic center and they usually have a comment to the effect " 16 pathologists and 4 PhD's ( and, un-stated, 12 residents and 4 fellows)
with 22,000 surgicals, etc." They have enough paths that they could form 2-3 foursomes for bridge every day. When you are REALLY working in the REAL world you should be doing AT LEAST 12,000 ACCESSIONS
(not specimens) per year. 14,000 is more realistic to be a hitter. That's what I did as an associate in PP, a partner in PP and an employee of big path. If this were the norm we would need about 1/4 to 1/3 of the number of pathologists we have today. There are paths who bitch about having to sign out 5K cases per year. That is <20 cases/day!! And please don't give me this line about "big " specimens and liver biopsies. Colon or renal resections have lots of slides that are almost all no brainers and, well, i've gone on long enough.

 

[turtle1966]

I don't think the future will be bad for path!! It will be good!
Just think, with Obamacare, so many more patients will be in the system and there will be so many more blood tests needed!!! I think the job market will be booming in 10 years if it isn't already!! XD

The problem is Obamacare is turning out to be a health care "rationing", fashioned by Democrats. High deductible, high premium, narrower provider network, loaded with unneeded features, heavy on paperwork and stuffed with bureaucratic waste. It is more of an expensive catastrophic policy. Others can chime in, however, it is my impression, that specimen volume at many places went down since Obamacare.

Quality of "health care" is a reflection of wealth of a Nation. As US gradually declines, size of health care pie will shrink, and with it our income. You may slow the descent, but not the trajectory.

 

[2121115]

When you are REALLY working in the REAL world you should be doing AT LEAST 12,000 ACCESSIONS
(not specimens) per year. 14,000 is more realistic to be a hitter.

With all due respect, that is total BS. No one is out there signing out 12-14,000 large cancer resection accessions with multiple specimens per accession. Not and doing high quality work. Not and managing a clinical lab, doing cytologies, frozens, and conferences. Just doesn't happen. Sorry. Thanks for playing.

 

[coroner]

^^^This^^^ 12-14K cases per yr translates to a minimum two man practice, but most likely three. I even interviewed at a three-man group with 11K surgicals/yr. I don't know if this a generational gap mike because I know you're retired, but this is not the norm nowadays. Not it academics, not in hospital-based private practice. The closest you'd probably get is a reference lab or derm/GI POD-type place. I'm not saying there's some pockets out there where it might be done, but how sustainable would it be in the long run before burnout or making numerous errors. Unless you're just signing out everything as either benign/malignant. Either that or sending half your cases out...

 

[reedsposer22]

I'm not so sure pathologists will always need to be on site.

At some point, it's cheaper for a hospital to send out all specimens, and I suspect that soon telepathology will be fairly common for frozens. From what I've seen, many clinicians would not mind a lack of pathologist at tumor boards.

Why are ypu saying tumor board would not mind a pathologist?

 

[stickyshift]

I'm the only pathologist at my site, and last year I signed out 5200 surgicals. Also have busy FNA service (I do the adequacies), bone marrow service (I perform the marrows), as well as the usual frozen sections, non-gyne cytologies, etc. Monitoring blood product utilization on a daily basis is a pain in the ass. My hands are plenty full.

 

[deleted314957]

With all due respect, that is total BS. No one is out there signing out 12-14,000 large cancer resection accessions with multiple specimens per accession. Not and doing high quality work. Not and managing a clinical lab, doing cytologies, frozens, and conferences. Just doesn't happen. Sorry. Thanks for playing.

80%of my work was GI. Certainly nobody can do that many big resections

 

[2121115]

80%of my work was GI. Certainly nobody can do that many big resections

Makes sense.

 

[longlakeboy]

Why are ypu saying tumor board would not mind a pathologist?

Because most clinicians couldn't give a damn about the pathology at tumor board.

Are you going to be at Rush next year (just guessing based on your avatar)? You'll learn a lot preparing for a couple of tumor boards as a resident (GYN in particular), but most clinicians either ignore the path portion or argue just to show off their MS2 level understanding of histology.

 

[2121115]

Because most clinicians couldn't give a damn about the pathology at tumor board.

Then they are not doing their job or you are not doing yours. One or the other.

 

[icpshootyz]

Then they are not doing their job or you are not doing yours. One or the other.

Agreed. At our tumor boards the surgeons and oncologists are always very interested in the pathology, as it's a huge factor in guiding their operations and care. At tumor board path is essential. Sure, once they get the diagnosis it moves on to more nuanced discussions about specific treatment options, but without a solid path diagnosis they are in the dark. And if you can't discuss the path well, they can tell.

 

[longlakeboy]

Agreed. At our tumor boards the surgeons and oncologists are always very interested in the pathology, as it's a huge factor in guiding their operations and care. At tumor board path is essential. Sure, once they get the diagnosis it moves on to more nuanced discussions about specific treatment options, but without a solid path diagnosis they are in the dark. And if you can't discuss the path well, they can tell.

I wish I had the experience you guys have had. My tumor board experiences as a resident was one conference where they were combative for the sake of being combative and a whole lot of others where I had to constantly speak up to even be able to show the slides or pictures before they moved onto the next case.

It's been a bit better now in the real world, but it's still mostly just three seconds on the diagnosis and then move on to treatment...

 

[icpshootyz]

I wish I had the experience you guys have had. My tumor board experiences as a resident was one conference where they were combative for the sake of being combative and a whole lot of others where I had to constantly speak up to even be able to show the slides or pictures before they moved onto the next case.

It's been a bit better now in the real world, but it's still mostly just three seconds on the diagnosis and then move on to treatment...

True, as a resident tumor boards were not as friendly, as for some reason path liked to have residents present while all the other services (surgery, oncology) had the attending of record grilling you. Although radiology also sent residents. But we always had an attending there to back us up, we never did tumor boards alone at my residency. And sure, if it's a straight-forward diagnosis then they don't need to discuss the pathology at length. But many of the cases that go to tumor board aren't as straight-forward, and there can be lengthy discussion of margins, prognostic features, etc before they move completely to treatment. But realistically the purpose of the tumor board is to determine the best course of treatment, so of course that's the focus of the conference.

 

[WEBB PINKERTON]

Better change careers by 2017

http://insurancenewsnet.com/oarticl...to-eliminate-market-competition-a-525532.html

 

[univlad]

I'm the only pathologist at my site, and last year I signed out 5200 surgicals. Also have busy FNA service (I do the adequacies), bone marrow service (I perform the marrows), as well as the usual frozen sections, non-gyne cytologies, etc. Monitoring blood product utilization on a daily basis is a pain in the ass. My hands are plenty full.

What do you do for blood product utilization each day?

 

[stickyshift]

What do you do for blood product utilization each day?

Audit the reqs from the previous day, make sure that the blood products are indicated.
If not, the clinician gets a letter from me. Our Performance Improvement Committee stipulates that any clinician receiving 10 or more such letters in a quarter gets to visit the committee to explain his noncompliance.

 

[LADoc00]

blood product utilization review on a DAILY basis is pretty hardcore and not the standard...

5200 surgical accession numbers, assuming a balanced case mix and payor mix + full up CP duties SOLO should net you a hefty 750K+ a year SShift.

Nice work, assuming you are indeed punching at that weight.

 

[stickyshift]

blood product utilization review on a DAILY basis is pretty hardcore and not the standard...

5200 surgical accession numbers, assuming a balanced case mix and payor mix + full up CP duties SOLO should net you a hefty 750K+ a year SShift.

Nice work, assuming you are indeed punching at that weight.

Ha ha ha. I wish that were true, but I make only a little more than half that!
That said, I like my job and am in a fairly secure position. A few of my friends who used to make that kind of money have had serious setbacks in their career (and might even be down to my level now!).

 

[LADoc00]

if you are punching at 50% of that weight, who is riding your back Harrison Bergeron-style??

you an employee of a group, a hospital or bubba gubberment?

cast off the yoke my friend, cast off the yoke.

everyone should know the value of their labor. it is the only way to avoid "Asymmetrical Information Advantages."

you are doing roughly 600-750,000 US Dollars in billable work, that is a fact.

 

[stickyshift]

if you are punching at 50% of that weight, who is riding your back Harrison Bergeron-style??

you an employee of a group, a hospital or bubba gubberment?

cast off the yoke my friend, cast off the yoke.

everyone should know the value of their labor. it is the only way to avoid "Asymmetrical Information Advantages."

you are doing roughly 600-750,000 US Dollars in billable work, that is a fact.

Employed by a private group, of which I am a partner (one of many).
Sure, that's what I might make in collections, but we have expenses, including the salaries of the associates and staff, insurance, etc. You know the drill.

 

[LADoc00]

gah. That sucks. Associates and staff can definitely drain the coffers. Hence why I like to travel light.