ACO's

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If they actually come in action in any signigicant way - I think they will be an unmitigated disaster for pathologists.
 
ACO = accountable care organization. It would basically have the effect of bundling payments and establishing a flat fee payed to the physicians/hospital involved in a patient's care from the outset. So basically the more stuff done to the patient, the more money is taken out of the "pie", and whatever is left over is distributed to the physicians. How the leftovers are distributed remains to be seen, but one could reasonably assume that those at the top of the totem pole would get as much as they could while those at the bottom would get the leftovers of the leftovers.
 
Basically bottom feeders like pathologists would basically be totally screwed while trying to bargain with hospital administrators, subspecialty surgeons, rad oncs, radiologists and anesthesiologists. No matter how much they love you and value you, when it comes to money, all that goes out of the window.
 
Why should this happen if pathologists function as a group and stand up for their interests? Like every other specialty, hospitals cannot function without pathologists, and on-site at that. The hot-shot thoracic surgeon who makes the hospital $5 million per year - someone has to do frozen sections for him. Same for the neurosurgeons and many other big money surgical specialties. Much of what pathologists do can be done off-site and with some delay (although turnaround time was always a sore point for me in residency), but some of it cannot, including frozens and certain lab results. If pathologists don't have the guts to stare down hospital administrators when it comes time to divy up the pie, then it's our own fault. If the hospitals aren't willing to pay a competant pathologist fairly, then let them hire someone who isn't competant and deal with the fall-out the first time a surgeon takes someone's right lung out and the frozen turns out to have been massively overinterpreted.

pathstudent said:
Basically bottom feeders like pathologists would basically be totally screwed while trying to bargain with hospital administrators, subspecialty surgeons, rad oncs, radiologists and anesthesiologists. No matter how much they love you and value you, when it comes to money, all that goes out of the window.
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mlw03 said:
Why should this happen if pathologists function as a group and stand up for their interests? Like every other specialty, hospitals cannot function without pathologists, and on-site at that. The hot-shot thoracic surgeon who makes the hospital $5 million per year - someone has to do frozen sections for him. Same for the neurosurgeons and many other big money surgical specialties. Much of what pathologists do can be done off-site and with some delay (although turnaround time was always a sore point for me in residency), but some of it cannot, including frozens and certain lab results. If pathologists don't have the guts to stare down hospital administrators when it comes time to divy up the pie, then it's our own fault. If the hospitals aren't willing to pay a competant pathologist fairly, then let them hire someone who isn't competant and deal with the fall-out the first time a surgeon takes someone's right lung out and the frozen turns out to have been massively overinterpreted.
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Hospitals can function fine just renting someone from Ameripath. We are in no position to put up much of a fight.
 
mlw03 said:
If we don't stand together, you are correct.
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Gotta get rid of the pathologist surplus for one thing. As long as there are too many of us out there, who can blame people for exploiting us? The surplus will be even worse as health care rationing starts kicking in. Heck, just read all the articles out in recent times about over screening for cancer. If any of the new guidelines are followed, say goodbye to a hell of a lot of business.
 
WEBB PINKERTON said:
Gotta get rid of the pathologist surplus for one thing. As long as there are too many of us out there, who can blame people for exploiting us? The surplus will be even worse as health care rationing starts kicking in. Heck, just read all the articles out in recent times about over screening for cancer. If any of the new guidelines are followed, say goodbye to a hell of a lot of business.
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I blame us for allowing ourselves to be exploited. It's a quote from a Dear Abby or something like that, but no one can take advantage of you more than once without your permission.
 
Entgegen said:
ACO = accountable care organization. It would basically have the effect of bundling payments and establishing a flat fee payed to the physicians/hospital involved in a patient's care from the outset. So basically the more stuff done to the patient, the more money is taken out of the "pie", and whatever is left over is distributed to the physicians. How the leftovers are distributed remains to be seen, but one could reasonably assume that those at the top of the totem pole would get as much as they could while those at the bottom would get the leftovers of the leftovers.
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But how does the pathologist even fit into this model? If you get a patient sample, will you be paid a flat rate from the same pool of money as the surgeons and then have to subtract the cost of your IHC and whatever from that? Or do you get paid a variable rate depending on how much money was wasted by the referring clinicians by the time your sample gets to you? And if you order up a ton of stains, is that also supposed to decrease what the surgeon gets paid?

On the CP side, if a patient doesn't get sick and just has some minor chem 10 test or something, does the lab get paid a lot for that test because the patient's money pool was still large. But if a very sick patient gets a chem 10, maybe the lab gets nothing because his clinicians overspent?
 
Enkidu said:
But how does the pathologist even fit into this model? If you get a patient sample, will you be paid a flat rate from the same pool of money as the surgeons and then have to subtract the cost of your IHC and whatever from that? Or do you get paid a variable rate depending on how much money was wasted by the referring clinicians by the time your sample gets to you? And if you order up a ton of stains, is that also supposed to decrease what the surgeon gets paid?

On the CP side, if a patient doesn't get sick and just has some minor chem 10 test or something, does the lab get paid a lot for that test because the patient's money pool was still large. But if a very sick patient gets a chem 10, maybe the lab gets nothing because his clinicians overspent?
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No they will pay a fixed amount for a drg let the entities figure out how to split it up. It really is a terrible system and could only have been conceived by by people who don't practice medicine.

No ordering stains will not decrease what anyone gets paid. It will just add cost to the lab.
 
Good comments....anyone want to extend the conversation and comment on the possible end to the TC "grandfather" clause...I'm less informed about this issue, although it seems like instead of billing CMS for the technical component, independent labs (whatever that means) would have to bill hospitals directly.
 
WEBB PINKERTON said:
Gotta get rid of the pathologist surplus for one thing. As long as there are too many of us out there, who can blame people for exploiting us?
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But it seems like an ACO is closer to a free market solution, isn't it? Pathologists are in oversupply, so there is no incentive for an ACO to give them very much money. That's different from how things are now, right? I guess our current system is more socialized in that the reimbursements are fixed by however they're coded and do not decrease fluidly with oversupply. If the number of pathologists dropped precipitously, ACO reimbursement would have to go up, whereas reimbursement from whatever code would stay the same.

Isn't pathology kind of "damned if you do" here?

WEBB PINKERTON said:
The surplus will be even worse as health care rationing starts kicking in. Heck, just read all the articles out in recent times about over screening for cancer. If any of the new guidelines are followed, say goodbye to a hell of a lot of business.
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Is this an example of health care rationing or just evidence based medicine? Over screening for cancer is bad medicine, even if it is good business.
 
I've seen this general kind of system, however I was so early in training I never learned much detail about it. The basic concept is that if someone presents to the ER and is diagnosed with "pneumonia NOS" then that hospital receives 100, irrespective of whether they got X-rays, antibiotics, biopsy, chem, transfusion, etc., or merely a quick H&P in the ER. If that person happens to not do well and stays in hospital 1 week, costing the hospital 10000, tough luck. If the hospital doesn't generate new/additional diagnoses (dehydration, ARF, CHF, sepsis, etc..) then they don't get any more money. On the other hand if the person is discharged in 1 hour from the ER they still get their 100. It's up to the hospital what to do with that money. So as a system it generally promotes clinical overdiagnosis and rapid discharges, but doesn't take into account that every patient is different and may have different needs, and without appropriate oversight kinda allows for double-dipping by having the same incompletely treated patient re-present in the short term with the same problem. Then of course there's the problem of how to set what each diagnosis is worth, and historically such determinations seem to be based on the most cost effective isolated system in the country for that one thing (i.e. one extreme of the bell curve rather than the middle of it).

I.e., it appears no different than any other system which doesn't really take the individual patient into account, and isn't likely to save the system any money because it doesn't promote efficient evidenced based medicine either as a system or as applied to an individual patient. At least the health insurance companies generally have some incentive to understand and somewhat apply EBM as a system, if at the expense of the individual.
 
Well, this system doesn't seem well suited to decrease healthcare costs, but which system does? Just from the perspective of pathology, what increases healthcare costs that can be done away with? I guess over-ordering special stains and cytogenetic tests or whatever is the major cost, but what system would fairly encourage proper utilization?
 
Physician payments account for less than 10% of medicare spending according to the congressional budget office. If they want to curb medicare spending, maybe they should try to cut something that will make a difference.
 
With the implementation of ACO's, pathologists will need to start cold-calling for reimbursement.
 
2121115 said:
Physician payments account for less than 10% of medicare spending according to the congressional budget office. If they want to curb medicare spending, maybe they should try to cut something that will make a difference.
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Yeah but all of that is hard. It's easy to cut physician payments.
 
Only idiot pathologists will be dragged into ACOs without clear legal counsel to ensure they dont suffer reimbursement drops.

Of course there are many idiot pathologists so this is very unlikely to go well....
 
So are our current pathology billing systems going to go away with ACO's? I am under the impression (and I am rather new at this) that despite DRG in the current system, we still bill for our professional services despite the DRG the hosptial gets stuck with. How would an ACO tell you not to use the pathology billing system, unless they do it for you and give you a salary from this and it ends up being some sort of odd massive hospital POD lab. At my hospital the hospital charges the technical component for anatomic services and we separately have a billing company that handles our professional charges. Quite an interesting post and there are people coming to talk in our community about ACO's soon, ironically one of the moderators is a GI clinician who owns a local pod lab. Ummmm hmmmm.
 
KluverB said:
Meh, who needs ACO's, when the future is now...
http://www.ama-assn.org/amednews/2012/02/06/bil20206.htm
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Can you imagine how nasty that room must be, people getting all undressed showing some on-screen MD various anatomical "sores." Sounds like a good option for 3rd world docs to make some extra money.

Maybe they can look me up with my cytopathology fellowship from a drop down list....ooooo.....he didn't got to MGH! Don't want him as my doc in a box! Slide a credit card what a scam!

I'm am willing to bet the usual consult would run: A) Go to ER. B) See your primary care MD, thanks for the cheddar.
 
So I went to a local meeting by a lot of the local doctors about starting an ACO in this area (and they had free food). Basically, this particular flavor of ACO started in Nevada (Vegas area) and has been a large success with the primary care physicians there and this ACO has acquired a physician practice every 18 days for the past 6 months or so (becoming very large very fast). I lot of the talking was performed by a DO eye MD who had his had in the pie and some administrator type cronies).

Basically, they are going to be assigned 5000 patients or so to an ACO group (comprised of primary care and subspecialties) and they will be reimbursed X amount if their savings are under the amount (I presume per quarter) of the money given to them by CMS. He mentioned the current policy is for 3 years buy into the ACO.

The primary care physician controls all the referrals to specialists in the ACO and they are all charged with "being accountable" for costs. Quality measures such as documentation and review of things such as cholesterol and HAIC control are some of the things montiored by CMS. He mentioned that there were 32 measures of quality to be montiored in defining whether or not costs are being controlled. The idea is that the ACO will have such a large patient base that this will give them leverage in negotiating with hosptials / out patient surgery centers / insurance companies / and pharmapheutical companies to lower costs.

Naturally pathology didn't come up and a lot of the questions didn't have answers because these haven't really been enacted widespread so there are not a lot of answers. The GI specialist sitting next to me muttered this is bs and left an hour into it. IMO it looks like primary care trying to consolidate some sort of power over specialists, seems as though the specialists were upset with it and the primary care doctors were all nodding and grinning. I presume for us it will just be a larger vesion of some pod lab set up where we all get screwed again. Don't think I am any better for going to this thing.
 
Torsed- Tell them you will join for 6xEBITA in cash up front. Sell them on it being a "good investment". A variable buffet of Pathology and Lab Medicine: "all you can eat!" (or in this case maybe "all you can hold down!").


5-6xEBITA, hold the line there.
 
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