GOOD CAP Webinar

[pathstudent]

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Good CAP webinar today about Whole Genome Analysis. I

Unbelievable that we have gone to the point where it took 5 years and 2.5 billion to analyze the first genome back in 95 and by 2020 we will be able to do it in 15 minutes for 100. It seems like it will radically change how we practice pathology and produce reports. Our reports won't just be gross/micro/diagnosis but will intergrate whole genome analysis and direct therapy. Will be get paid to do it? I don't know as the money will likely go to the companies making the tests.

 

[KeratinPearls]

Good CAP webinar today about Whole Genome Analysis. I

Unbelievable that we have gone to the point where it took 5 years and 2.5 billion to analyze the first genome back in 95 and by 2020 we will be able to do it in 15 minutes for 100. It seems like it will radically change how we practice pathology and produce reports. Our reports won't just be gross/micro/diagnosis but will intergrate whole genome analysis and direct therapy. Will be get paid to do it? I don't know as the money will likely go to the companies making the tests.

These molecular tests are quite expensive. If we were to report on it, we should be reimbursed for it.

Is the webinar still available to be viewed?

 

[gbwillner]

These molecular tests are quite expensive. If we were to report on it, we should be reimbursed for it.

Is the webinar still available to be viewed?

Why even bother? By 2025 cancer will be eradicated, but in 2032 the great Asteroid will kill off most of earth's population. This will lead the rest of us completely helpless by the Great Ape takeover of 2034.

 

[pathstudent]

These molecular tests are quite expensive. If we were to report on it, we should be reimbursed for it.

Is the webinar still available to be viewed?

That is just it. They will be dirt cheap in a few years (costing less than an MRI) with one day turn around time (versus 5 years for the first one back in 1995)

The companies that do the test will likely be the ones that get paid for the technical and interpretation of the results. It will be like you including the chromosome results in a bone marrow or a Her-2 FISH result in breast cancer. You don't get paid for that stuff, you just put it together with the gross/micro. It will be the same Complete Genome Analysis.

All of CAP's recent webinars are available online. This one will be too.

The next one advertised will be on May 25th. It will be about Accountable Care Organizations (ACOs). This will be immensely important for hospital based private practice pathologists. It will likely be the end of high-paying hospital based partnership private practice jobs and force all pathologists to become salaried employess, ala VA, academics or Kaiser. It will make the outpatient biopsy cases that much more competitive, but on the bright side it could finally induce a broad retirement of pathologists used to making 500-800k a rather than being an employee in an ACO for 300k.

 

[2121115]

The next one advertised will be on May 25th. It will be about Accountable Care Organizations (ACOs). This will be immensely important for hospital based private practice pathologists. It will likely be the end of high-paying hospital based partnership private practice jobs and force all pathologists to become salaried employess, ala VA, academics or Kaiser. It will make the outpatient biopsy cases that much more competitive, but on the bright side it could finally induce a broad retirement of pathologists used to making 500-800k a rather than being an employee in an ACO for 300k.

I think that may be over-reacting a bit. Things will be different and they are going to try to curb cost growth, but that kind of cut would be drastic and cause a revolt of many hospital based docs, not just pathologists. Rads and anesthesia would be up in arms as well. The million dollar days may be over, but 50% reimbursement cuts are not likely (although anything is possible).

 

[pathstudent]

I think that may be over-reacting a bit. Things will be different and they are going to try to curb cost growth, but that kind of cut would be drastic and cause a revolt of many hospital based docs, not just pathologists. Rads and anesthesia would be up in arms as well. The million dollar days may be over, but 50% reimbursement cuts are not likely (although anything is possible).

I don't know. Don't you think you could see the corporations that own hospitals and will be in charge of the ACOs come in and say, "we don't think you guys are worth 500k. We'll pay you 300k, let us know if you aren't interested".

 

[Enkidu]

Our reports won't just be gross/micro/diagnosis but will intergrate whole genome analysis and direct therapy. Will be get paid to do it? I don't know as the money will likely go to the companies making the tests.

How do you know that pathologists will necessarily interpret these? Why wouldn't the clinicians interpret them?

 

[pathstudent]

How do you know that pathologists will necessarily interpret these? Why wouldn't the clinicians interpret them?

pathologists likely won't interpret them unless they are especially trained. THey (we) will integrate them into our reports.

 

[pathstudent]

Here's where the CAP webinars can be found. In a few days the whole genome analysis one will be available 24/7. These webinars are all part of CAPs master plan to transform pathologists in the new era of healthcare delivery where quality is valued over quantity.


http://www.cap.org/apps/docs/membership/transformation/new/institute_index.html

 

[2121115]

I don't know. Don't you think you could see the corporations that own hospitals and will be in charge of the ACOs come in and say, "we don't think you guys are worth 500k. We'll pay you 300k, let us know if you aren't interested".

I have seen a similar phenomenon before. There was a hospital take over and the buyer wanted to make significant cuts to hospital based physicians. There was massive unrest and then a mass exodous of docs (not just paths, but also rads, gas, hospitalists, ID, etc). The hospital didn't not completely fold but it lost a lot of money and suffered major damage in the public eye (news media, etc).

Look, I'm not saying that you're scenario is impossible. It isn't. And I'm not saying reimbursement won't change. I'm saying that 50% cuts in physician income isn't really the goal of the ACO program. They want to curb the cost growth line long term, which they will do. It is still unclear, however, how radiology and pathology will fit into an ACO and, although your version of the story is not impossible, I think it is unlikely.

Edit: Oh and one more thing, ACO's will likely affect how academic pathologists get paid also. If there are cuts to pathology's portion of the pie in a health care system it will be passed on to the junior attendings, who already get paid pennies basically. Junior attendings at my program are already jumping ship and looking for jobs elsewhere since the word has come down the pike. Since they have been subspecialized for several years now they are looking at places where they can only sign out one organ and don't have to do generals (i.e. some even going the corporate lab route, trying to play the Petras @ Ameripath card).

 

[pathstudent]

I have seen a similar phenomenon before. There was a hospital take over and the buyer wanted to make significant cuts to hospital based physicians. There was massive unrest and then a mass exodous of docs (not just paths, but also rads, gas, hospitalists, ID, etc). The hospital didn't not completely fold but it lost a lot of money and suffered major damage in the public eye (news media, etc).

Look, I'm not saying that you're scenario is impossible. It isn't. And I'm not saying reimbursement won't change. I'm saying that 50% cuts in physician income isn't really the goal of the ACO program. They want to curb the cost growth line long term, which they will do. It is still unclear, however, how radiology and pathology will fit into an ACO and, although your version of the story is not impossible, I think it is unlikely.

Edit: Oh and one more thing, ACO's will likely affect how academic pathologists get paid also. If there are cuts to pathology's portion of the pie in a health care system it will be passed on to the junior attendings, who already get paid pennies basically. Junior attendings at my program are already jumping ship and looking for jobs elsewhere since the word has come down the pike. Since they have been subspecialized for several years now they are looking at places where they can only sign out one organ and don't have to do generals (i.e. some even going the corporate lab route, trying to play the Petras @ Ameripath card).

I am not saying it is the goal of ACOs either, but it could be ominous for small independent groups like hospital based pathologists when the money will be controlled by for profit or even "non-profit" corporations (which are usually trying to make profit also but "hide" it in some other organizations).

 

[zao275]

How do you know that pathologists will necessarily interpret these? Why wouldn't the clinicians interpret them?

As more and more tests are becoming available, I think pathologists have a role in helping clinicians understand the meaning of results. This is especially the case in molecular/genomic medicine. If we take the lead in this, we can really add value.

I believe there was a recent study of young docs (British maybe...I don't have the reference) and their feelings of competency with interpreting lab test results. A surprising number felt less than competent in this area. Anyone have the reference for this study? I heard it at a meeting, I think.

BTW, who gave the webinar? Was it Mark Boguski? He is really into the whole genome thing.

 

[BU Pathology]

Some institutions are developing lab formularies, modeled along the lines of a hospital formulary. With a hospital formulary only approved drugs are available for use. New drugs are considered by a committee for approval to the formulary, and the committee includes end users as well as the pharmacists.

With a lab formulary, a committee would decide what tests would be offered using available peer-reviewed medicine. Tests which are not approved would not be available. Part of the thought process is to have a formal structure and policy regarding laboratory tests to ensure that the correct tests are available. This would prevent having a patient come in with a multi-page printout of a genetic test and asking for an interpretation. The provider could look this up in the lab formulary and tell the patient, our institution does not believe that this test provides usefull information about you and your disesase.

Clearly pathology will be a central player in this process to decide which tests actually add value. However, it would be a team decision, since the end users would also be on the committee and advocate for adoption of new tests.

Dan Remick, M.D.
Chair and Professor of Pathology and Laboratory Medicine
Boston University School of Medicine and Boston Medical Center

 

[pathstudent]

As more and more tests are becoming available, I think pathologists have a role in helping clinicians understand the meaning of results. This is especially the case in molecular/genomic medicine. If we take the lead in this, we can really add value.

I believe there was a recent study of young docs (British maybe...I don't have the reference) and their feelings of competency with interpreting lab test results. A surprising number felt less than competent in this area. Anyone have the reference for this study? I heard it at a meeting, I think.

BTW, who gave the webinar? Was it Mark Boguski? He is really into the whole genome thing.

That sounds right. He was from BIDMC. Same person?

Pathologists could definitely play a role in limiting the order of lab tests. I remember during my hemepath rotations wondering if ordering cytogenetics was really necessary on every single bone marrow and wondering about the utility of ordering flow on Peripheral Blood for CML or PV or ET or MDS. Alot of that stuff could be eliminated without compromising a diagnosis or patient care.

We also used to order cytogenetics on EVERY soft tissue tumor. What was the point of that? I can't think of a time where we really needed it to make the diagnosis. And for things where you might want to know if a specific translocation is present (ARMS or synovial sarcoma) there is a FISH probe for it.

 

[KCShaw]

I was just about to pipe in that just because a test is available, becoming more cheap, and provides lots of data, doesn't automatically make it useful or applicable, but the flow of the thread seems to have already gotten there. I had heard rumors of the "lab formulary" type model, and it's interesting to hear it may be gaining wider traction; I recall meetings regarding "debated" tests that were requested by the clinicians but the pathologists had reservations, but I don't recall it being a systematic regular process where I've been. I grimace slightly, however, at the thought that many private/outpatient physicians are already likely to order tests through outside private/corporate labs which may have much less incentive (anti-incentive, even) to direct or limit the flow of what is ordered than a hospital system.

 

[zao275]

That sounds right. He was from BIDMC. Same person?

Pathologists could definitely play a role in limiting the order of lab tests. I remember during my hemepath rotations wondering if ordering cytogenetics was really necessary on every single bone marrow and wondering about the utility of ordering flow on Peripheral Blood for CML or PV or ET or MDS. Alot of that stuff could be eliminated without compromising a diagnosis or patient care.

We also used to order cytogenetics on EVERY soft tissue tumor. What was the point of that? I can't think of a time where we really needed it to make the diagnosis. And for things where you might want to know if a specific translocation is present (ARMS or synovial sarcoma) there is a FISH probe for it.

Yes, Dr. Boguski is at Beth Israel.

Cytogenetics on soft tissue tumors: We rarely order it (although most of ours are consult cases, we do still get 300-500 in-house soft tissue cases). However, it can sometimes be useful when submitting pathologists have done it. As you said, we use either FISH (MDM2, EWSR1, FUS) or RT-PCR (synovial sarcoma, alveolar rhabdo) when needed.

 

[Enkidu]

As more and more tests are becoming available, I think pathologists have a role in helping clinicians understand the meaning of results. This is especially the case in molecular/genomic medicine. If we take the lead in this, we can really add value.

I believe there was a recent study of young docs (British maybe...I don't have the reference) and their feelings of competency with interpreting lab test results. A surprising number felt less than competent in this area. Anyone have the reference for this study? I heard it at a meeting, I think.

But is it plausible for the model to be so simple as clinicians checking a box for prolonged PT, or lupus, or anemia, and have the pathologist run the most appropriate tests on the sample and deliver a diagnosis? Maybe referencing the patients genome at some stage of analysis?

 

[KCShaw]

It could be. Of course, many diagnoses are not purely pathologic diagnoses, they are clinico-pathologic ones and require some amount of clinical correlation. Numbers are often meaningless without context. Even otherwise straightforward results, like Hb/Hct, can be meaningless depending on the circumstances of the patient/draw. With that said, it's pretty easy to standardize interpretations with "clinical correlation advised/required" or somesuch, where applicable.