RESECT AND DISCARD, NEW ARTICLE IN GENERAL SURGERY NEWS

[WEBB PINKERTON]

Bundled payments will be making resect and discard very attractive. Bet someday a lot of pathology specimens go in the garbage rather than to the lab.

http://www.generalsurgerynews.com/V...&d_id=69&i=November+2014&i_id=1123&a_id=28738

---

Members don't see this ad.

 

[LADoc00]

That is madness. And all it takes is a handful of cases to utterly blow up in their face before this is front page of the Wall Street Journal.

Ask Gyns who were using J&J morcellators without doing any biopsies beforehand...now I get 5-6 more EMBX per day!

Seriously, if you are screw your patients by chucking specimens to save them 20 bucks why not go the distance and pull a full on Bill Cosby??

 

[pathperson]

The morcellators were over on the Ob Gyn forum talking about how the risk of LMS being found in a "benign fibroid" was so low it was acceptable. (Numbers vary from 1 in 300 to 1 in 500 that I have seen). They were saying how much faster it is to do the surgery, cleaner site, fewer infections, etc, when you morcellate. I get that surgeons have different concerns than we do. I really try to understand that.

But those posts were so stupid and so dangerous I could not respond. I just couldn't. Its like saying that if you carefully select a population to donate blood, and carefully screen donors, maybe even with a lie detector test, then the risk of having infectious diseases transmitted by blood transfusion is "acceptably low" so we don't need to test the blood supply more.

In fact, I bet with the properly chosen population and careful screening, the risk of untested blood transmitting HIV or hep B or C is LESS than the risk of flinging LMS around a woman's abdomen with the morcellator.

So it is with the GI polyps. All these docs can just get untested blood from now on if this is how they think. But wait, its a different story when THEY are the patient.

The mighty dollar speaks again. Patients will not stand for this. I would not if I were a patient. What is the point of spending the time and expense of a colonoscopy if they aren't going to follow through with DIAGNOSING the tissue that looks abnormal? Why are we all going for scoping? To enrich GI docs? They made all the effort to get you the appointment, you have to show up, park, pay, get zonked with drugs, then they find some polyps and when you wake up they tell you there was nothing to worry about and they THREW THEM IN THE GARBAGE??

And the guy in the article is just silly. So there is variability in making the diagnosis on some polyps. So the solution is.....THROW THEM IN THE GARBAGE? I have a small child who exhibits better critical thinking than this. Thinly veiled justification for more money for GI pockets.

I know of places in the world where tissue is tossed in the trash. They are places where they do not have the money, equipment, power grid or expertise to perform pathology. I have visited places like this. Where frozen sections are a pipe dream. Where no one gets scoped or a pap smear. It is sad.

If people in the US want to be a first world country, not throwing tissue out after an expensive procedure whose alleged purpose is to procure said tissue for diagnosis would be a fine start.

 

[WEBB PINKERTON]

Bundling of payments will lead to this kind of stuff. It is an issue that people need to take very seriously.

 

[schrute]

If Rex is so concerned about health care costs, how about cutting reimbursement for endoscopies in half...no patient risk involved there...

 

[WEBB PINKERTON]

Dr Rex has ties to American BioOptics it says. Another one of those "Shine a light on some tissue and get a diagnosis" companies.

http://www.americanbiooptics.com/technology/detailed.shtml

 

[Path or bust]

Disruptive technologies.

 

[pathstudent]

The morcellators were over on the Ob Gyn forum talking about how the risk of LMS being found in a "benign fibroid" was so low it was acceptable. (Numbers vary from 1 in 300 to 1 in 500 that I have seen). They were saying how much faster it is to do the surgery, cleaner site, fewer infections, etc, when you morcellate. I get that surgeons have different concerns than we do. I really try to understand that.

But those posts were so stupid and so dangerous I could not respond. I just couldn't. Its like saying that if you carefully select a population to donate blood, and carefully screen donors, maybe even with a lie detector test, then the risk of having infectious diseases transmitted by blood transfusion is "acceptably low" so we don't need to test the blood supply more.

In fact, I bet with the properly chosen population and careful screening, the risk of untested blood transmitting HIV or hep B or C is LESS than the risk of flinging LMS around a woman's abdomen with the morcellator.

So it is with the GI polyps. All these docs can just get untested blood from now on if this is how they think. But wait, its a different story when THEY are the patient.

The mighty dollar speaks again. Patients will not stand for this. I would not if I were a patient. What is the point of spending the time and expense of a colonoscopy if they aren't going to follow through with DIAGNOSING the tissue that looks abnormal? Why are we all going for scoping? To enrich GI docs? They made all the effort to get you the appointment, you have to show up, park, pay, get zonked with drugs, then they find some polyps and when you wake up they tell you there was nothing to worry about and they THREW THEM IN THE GARBAGE??

And the guy in the article is just silly. So there is variability in making the diagnosis on some polyps. So the solution is.....THROW THEM IN THE GARBAGE? I have a small child who exhibits better critical thinking than this. Thinly veiled justification for more money for GI pockets.

I know of places in the world where tissue is tossed in the trash. They are places where they do not have the money, equipment, power grid or expertise to perform pathology. I have visited places like this. Where frozen sections are a pipe dream. Where no one gets scoped or a pap smear. It is sad.

If people in the US want to be a first world country, not throwing tissue out after an expensive procedure whose alleged purpose is to procure said tissue for diagnosis would be a fine start.

This doesn't make more money for endoscopists. In fact for those that make money off pathology would lose out. It would probably also eliminate the need for a follow up visit.

I think their contention is that a polyp less than 5mm is so unlikely to harbor and invasive adenocarcinoma that it doesn't matter what the classification of the polyp is. They contend that the patient just needs to be cleaned out and then rescheduled to come back in 3 years to repeat it. I would say that there is probably some practicality in that. I would also say that there might be rare instances where a 3mm polyp harbors something ominous and the delay in diagnosis could be significant.

These are the decisions that society or the government will need to make. We could probably reduce a lot of cancer mortality if we all got full body MRIs and CTs once a month allowing us to intervene on lesions before they are symptomatic but the expense of that would be staggering.

Personally I feel I do a lot of gross/micros on specimens that I know have nothing in them based on gross exam alone. You know obviously benign utes, simple cystademomas of the ovary, sebaceous cysts, neuromas, mature cystic teratomas, etc.. Every gallbladder that unexpectedly had cancer was grossly suspicious. Every gallbladder that was grossly benign was. I guess I need to document rokitansky aschoff sinuses to prove the operation was indicated.

 

[WEBB PINKERTON]

Did anyone else read that article in September about whether or not Pathologists should receive bariatric surgery specimens? Some argued that we should since it can occasionally find GIST, adeno, gastritis.

All the CT scanning they are now doing to screen smokers has lead to a lot more bronchs for us. Not many show "early" cancer however.

 

[yaah]

I think the legal issues will reduce a lot of this. No one is going to throw away colon polyps, because while the incidence of cancer in a polyp is low, it's not zero.

 

[Silent Cool]

That is madness. And all it takes is a handful of cases to utterly blow up in their face before this is front page of the Wall Street Journal.

Ask Gyns who were using J&J morcellators without doing any biopsies beforehand...now I get 5-6 more EMBX per day!

Seriously, if you are screw your patients by chucking specimens to save them 20 bucks why not go the distance and pull a full on Bill Cosby??

LA,

I love your style, man!

 

[2121115]

This isn't ever going to happen.

What will happen is the same number of specimens while just getting paid less per specimen. CMS doesn't actually care what you do, as long as they aren't paying much for it.

 

[doctalaughs]

I cant comment on other specialties but i do wonder sometimes in dermatology why I send excised epidermal inclusion cysts and pilar cysts instead of throwing them away. They are probably 5-10% of specimens and are obvious clinically.

 

[WEBB PINKERTON]

This isn't ever going to happen.

What will happen is the same number of specimens while just getting paid less per specimen. CMS doesn't actually care what you do, as long as they aren't paying much for it.

Never say never...Under a bundled payment system, it will encourage specimens to not be submitted. The decision will be made by people like HCA, Kaiser etc.

 

[yaah]

I had a great uncle who had a skin lump cut out and discarded in the 60s. A couple of years later he was dead of melanoma. He had no other history of skin lesions. Doubt it would have changed his prognosis much back then but can you imagine if that happened today?

 

[royal blue]

These decisions can't be purely money driven, there has to be a clinical context that factors into the "cost" analysis. And since whole operations are centered around detecting significant pathology in those rare 0.0001% (making up a number) of cases, it can be easy to trivialize the whole process and attempt to cut corners whenever possible, hoping that big resection years later never comes. Just rolling the dice, and taking the big risk to make an extra buck. Patient care notwithstanding.

Look at the places that have certain specimens as "gross only". That list has expanded, but is still surprisingly tight and restrictive, considering all that we receive. For the longest time, I thought gallbladders were a waste for histology, until I saw incidental adenocarcinoma in a grossly normal non wall thickened specimen. True story. And looking at the many many normal gallbladders over this time now seems worth it now just for that one pickup. That's the mentality patients and physicians have. That's the principle behind screening tests to begin with. If anybody wants to seriously challenge that, they still have quite an uphill battle, and they risk significant PR implications.

 

[2121115]

Never say never...Under a bundled payment system, it will encourage specimens to not be submitted. The decision will be made by people like HCA, Kaiser etc.

If it doesn't cost anything to submit the specimen, it will get submitted.