History of fee splitting in pathology

[pathstudent]

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The profiting off the professional component of pathology services has become some rampant the last decade, from groups of gastroenterologists hiring a pathologist and paying him/her a flat fee to sign out the case while they bill for the global to pathologists billing urologists to process and interpret their cases for a slashed fee and then letting the urologists bill for the pathology services at a greater amount in order to profit.

How do either of these scenarios sound ethical? Would that seem ethical for a urologist to bill an internal medicine doc for seeing a patient and then have the internal medicine doc bill for the insurance company or patient for the urologist's services? Because that is what is rampant in pathology.

When did fee splitting become cool in pathology. Does anybody know the history?

 

[2121115]

Every academic center does this - pays the surgical pathologist less than their professional fee. Every private group that hires a pre-partner newbie does this as well. I probably generated my enitre month's salary in the last couple of days alone; the rest goes right to the group as dividends. It is complicated. Ask an academic urologist if they get less than their professional fee for operating at an academic center. They will LOL. My friend is a newbie academic radiologist fresh out of training. His salary? 500k. Pathology has always done this to themselves. It is what it is.

 

[pathstudent]

Every academic center does this - pays the surgical pathologist less than their professional fee. Every private group that hires a pre-partner newbie does this as well. I probably generated my enitre month's salary in the last couple of days alone; the rest goes right to the group as dividends. It is complicated. Ask an academic urologist if they get less than their professional fee for operating at an academic center. They will LOL. My friend is a newbie academic radiologist fresh out of training. His salary? 500k. Pathology has always done this to themselves. It is what it is.

Not analogous at all.

 

[2121115]

Not analogous at all.

Maybe not morally, but it is exceedinly difficult to write a law that allows academic centers and private pathology practices to do this but doesn't allow a physician owned lab to do it. The legal world is very different from the moral world.

 

[pathstudent]

Maybe not morally, but it is exceedinly difficult to write a law that allows academic centers and private pathology practices to do this but doesn't allow a physician owned lab to do it. The legal world is very different from the moral world.

An academic department of pathology bills for pathology services. Takes the money and splits it up among the faculty and other ancillary staff.

That is not at all like a urologist sending a biopsy to a pathologist who charges then say 50 bucks to process a biopsy and interpret it then the urologist turns around and bills the patient or insurance a 100.

Your private group pays you a salary. It is a group of pathologists billing for pathology services. Maybe they pay you less than an even split the first couple of years because you have less responsibility with regards to management and administrative tasks or maybe you can't fully function yet. Maybe they are just economically hazing you for a couple years. Who knows.

That is not the same as a group of gastroenterologists paying your 40 to sign out 8 gi biopsies while they bill the patient or insurance 400 for the PC on the biopsies.

So you are saying it is OK for a internist to refer a patient to a urologist if the urologist gives him 50% of whatever he collects for his services back to the urologist? That is so patently unethical but it is what is running rampant in pathology.

We need some sort of law that says another physician can bill professional component for services outside of his or her scope of practice. THat would end these unethical practices.

 

[2121115]

An academic department of pathology bills for pathology services. Takes the money and splits it up among the faculty and other ancillary staff.

That is not at all like a urologist sending a biopsy to a pathologist who charges then say 50 bucks to process a biopsy and interpret it then the urologist turns around and bills the patient or insurance a 100.

Your private group pays you a salary. It is a group of pathologists billing for pathology services. Maybe they pay you less than an even split the first couple of years because you have less responsibility with regards to management and administrative tasks or maybe you can't fully function yet. Maybe they are just economically hazing you for a couple years. Who knows.

That is not the same as a group of gastroenterologists paying your 40 to sign out 8 gi biopsies while they bill the patient or insurance 400 for the PC on the biopsies.

So you are saying it is OK for a internist to refer a patient to a urologist if the urologist gives him 50% of whatever he collects for his services back to the urologist? That is so patently unethical but it is what is running rampant in pathology.

We need some sort of law that says another physician can bill professional component for services outside of his or her scope of practice. THat would end these unethical practices.

No I am not saying that it is OK. But defining scope of practice is very difficult when it comes to legal terminology. No other specialties are limited to what CPT codes they can bill. If we proposed to limit certain pathology codes to pathologists only other physicians would strike it down because then there would be risk that their codes would start being limited, etc, etc. There is no incentive for them to vote for that (outside of radiology).

 

[Thrombus]

Fee splitting is impossible to stop and will occur until there is a shortage of pathologists which will never come thanks to guys like Remick et al who post and believe in myths and have absolute no clue about the number of underemployed/underpaid pathologists who are out there.

We will always get exploited in proportion to how oversupplied we are. That oversupply is getting much worse, not better.

Medical students enter this field at your own peril. The great majority of you will not be practicing pathology/medicine in a capacity that resembles a professional. You will be treated and paid as a commodity/employee, one that is perhaps more replaceable than a histotech.

 

[pathstudent]

No I am not saying that it is OK. But defining scope of practice is very difficult when it comes to legal terminology. No other specialties are limited to what CPT codes they can bill. If we proposed to limit certain pathology codes to pathologists only other physicians would strike it down because then there would be risk that their codes would start being limited, etc, etc. There is no incentive for them to vote for that (outside of radiology).

It wouldn't limit their CPT codes they can bill. It would just require them to actually perform the service.

 

[WEBB PINKERTON]

If it makes everyone feel better, a local hospital south of me just laid off some physicians because they are losing a lot of money. In that town all the physicians are hospital employees. None of the 3 pathologists were laid off thankfully.

Maybe if all physicians end up working for large hospital conglomerates, this will kill off in-office labs. In my town, the local hospital has been on a buying spree in this recession gobbling up surgery centers and obgyns etc. One internal medicine group had a lab in their office and the hospital closed it after they took control. We have thankfully had a large increase in cytology specimens but our surgicals are down due to many reasons.

 

[Thrombus]

If it makes everyone feel better, a local hospital south of me just laid off some physicians because they are losing a lot of money. In that town all the physicians are hospital employees. None of the 3 pathologists were laid off thankfully.

Maybe if all physicians end up working for large hospital conglomerates, this will kill off in-office labs. In my town, the local hospital has been on a buying spree in this recession gobbling up surgery centers and obgyns etc. One internal medicine group had a lab in their office and the hospital closed it after they took control. We have thankfully had a large increase in cytology specimens but our surgicals are down due to many reasons.

Its not good to see hospitals become so powerful in my opinion. In the absence of unfair regulation (Obamacare, that makes it illegal for physicians to own their own hospitals -- i.e. anyone in the country EXCEPT physicians can open a hospital) hospitals need physicians but physicians do not need hundreds of hospital administrators. However, Obamacare screwed us over in more ways than one the biggest in my opinion giving hospitals much more leverage over the physicians (Thanks, AMA for supporting this Obamination). This is just one more step into putting us into a commodity/employee role instead of the professionals that we should be and that the patient's deserve.

I love how we go through training learning how to be a professional but in the end they don't ever want to pay us or treat us like one.....its a one way street IMO.

 

[yaah]

I love how we go through training learning how to be a professional but in the end they don't ever want to pay us or treat us like one.....its a one way street IMO.

OK, but a lot of the job of being a professional includes ancillary duties. When you are in a private, partnership group you have to market. You have to do administration. You have to deal with lawyers and contracts and hospitals. You can't just sit in your office and sign out slides. Well, you can, but you're going to get paid less. Competition requires more than just sitting there and having things given to you. There are two major ways to do very little other than signout duties and get paid well - one is to do a specialty with high volume, in which you also are likely giving up income because someone else has to deal with all "that other stuff." The second is to be older and powerful and tenured in your group. But this latter model is vanishing, thank goodness, but still exists in many places. Retired partners still pull the strings in many groups, kind of like in some unions.

In truth, you really don't learn much about being a professional in training. You learn how to do your medical duties, but you don't learn much about the administrative aspect unless you are proactive. As this is becoming more important in daily practice, programs need to recognize this more. However, this is almost impossible to teach well and I do not envy program directors having to consider this aspect.

 

[WEBB PINKERTON]

Its not good to see hospitals become so powerful in my opinion. In the absence of unfair regulation (Obamacare, that makes it illegal for physicians to own their own hospitals -- i.e. anyone in the country EXCEPT physicians can open a hospital) hospitals need physicians but physicians do not need hundreds of hospital administrators. However, Obamacare screwed us over in more ways than one the biggest in my opinion giving hospitals much more leverage over the physicians (Thanks, AMA for supporting this Obamination). This is just one more step into putting us into a commodity/employee role instead of the professionals that we should be and that the patient's deserve.

I love how we go through training learning how to be a professional but in the end they don't ever want to pay us or treat us like one.....its a one way street IMO.

We are already a commodity unfortunantly. It does suck that hospitals are becoming so powerful but its helped our practice. Offices that refused to do business with us are now sending their work. I just hope the hospital buying sprees kill off the ameripath, labcorp, quests and bioreference labs of the world. I would much rather work for a non-profit hospital chain than those slide mills. I once worked at a corporate sweatshop lab and have no desire to ever work in such a reckless environment again.

 

[SLUsagar]

The profiting off the professional component of pathology services has become some rampant the last decade, from groups of gastroenterologists hiring a pathologist and paying him/her a flat fee to sign out the case while they bill for the global to pathologists billing urologists to process and interpret their cases for a slashed fee and then letting the urologists bill for the pathology services at a greater amount in order to profit.

How do either of these scenarios sound ethical? Would that seem ethical for a urologist to bill an internal medicine doc for seeing a patient and then have the internal medicine doc bill for the insurance company or patient for the urologist's services? Because that is what is rampant in pathology.

When did fee splitting become cool in pathology. Does anybody know the history?

Correct me if I'm wrong, but to my knowledge in certain states (California comes to mind) the situation you described above regarding the urologists "re-billing" for the same services for an inflated rate is illegal. Unfortunately, the situation of a group (e.g., GI or GU) hiring a pathologist and paying them pennies (either flat salary or on a CPT-code level basis) is fair game and a too-common occurrence.

 

[mlw03]

In truth, you really don't learn much about being a professional in training. You learn how to do your medical duties, but you don't learn much about the administrative aspect unless you are proactive. As this is becoming more important in daily practice, programs need to recognize this more. However, this is almost impossible to teach well and I do not envy program directors having to consider this aspect.

Are residency programs even qualified to do this, even if they wanted to? Most academic pathologists don't themselves know this stuff. I only recall a few of the faculty at my program having been private practice at some point in their careers.

 

[2121115]

Are residency programs even qualified to do this, even if they wanted to? Most academic pathologists don't themselves know this stuff. I only recall a few of the faculty at my program having been private practice at some point in their careers.

I can't tell you the number of times while I was in training that I heard "when you get into private practice..." from people who had never been in private practice. How could they be expected to prepare someone for a job they have never done themselves? Unrealistic.

 

[KCShaw]

Are residency programs even qualified to do this, even if they wanted to? Most academic pathologists don't themselves know this stuff. I only recall a few of the faculty at my program having been private practice at some point in their careers.

👍

IMO one of the best ways to learn this kind of thing is to actually be involved in some way in it -- at the very least, sitting in on those "boring" meetings at which the practice's medical director, admins, and/or marketers deal with obtaining and maintaining client contracts, internal budgeting, billing, politicking, disciplining, and so on and so forth. Unfortunately many practices seem to prefer to do a lot of the "business" of pathology behind closed doors, and certainly some amount of it they wouldn't want competitors to know about. The average academic department may deal with this well out of the view of residents -- and face some but not all of the same issues faced in private practice.

 

[yaah]

Are residency programs even qualified to do this, even if they wanted to? Most academic pathologists don't themselves know this stuff. I only recall a few of the faculty at my program having been private practice at some point in their careers.

A lot of it, yes they are qualified. Someone is. Many are not. Marketing is used in academics, so are client relations, administrative functions, etc. Many of these are delegated but that doesn't mean you can't learn from these individuals also. That might require a different sort of program and compensation model for those doing the teaching though.

 

[mlw03]

A lot of it, yes they are qualified. Someone is. Many are not. Marketing is used in academics, so are client relations, administrative functions, etc. Many of these are delegated but that doesn't mean you can't learn from these individuals also. That might require a different sort of program and compensation model for those doing the teaching though.

The stuff you talk about was, best as I could observe, done by non-pathology adminstrators in our department. I don't think it'd go over well for residents on surg path to say, "I can't sit at the scope with you because I'm going to a meeting with our antibody sales reps." That said, could definitely happen on certain CP rotations. Only time I got to do any of these was on a community pathology elective, which was one of the best overall rotations I go to do towards the end of my residency. With everything to learn in residency though, I just don't see programs being willing to give residents the time to learn this material.

 

[yaah]

. With everything to learn in residency though, I just don't see programs being willing to give residents the time to learn this material.

Yep. And which rotation do you think residents would blow off or take all their vacation on, if they did have one? And it's not tested much at all on boards, which also makes it less important. There is a lot to learn in pathology residency, and with the advent of increasing subspecialization it is becoming even more cramped and difficult to become well trained. Residents on AP used to do everything on their AP months. Now they have a month where they do only breast path. Or only dermpath. You can't keep adding rotations. So like I said, it is a difficult task to try and teach this.

 

[mlw03]

Yep. And which rotation do you think residents would blow off or take all their vacation on, if they did have one? And it's not tested much at all on boards, which also makes it less important. There is a lot to learn in pathology residency, and with the advent of increasing subspecialization it is becoming even more cramped and difficult to become well trained. Residents on AP used to do everything on their AP months. Now they have a month where they do only breast path. Or only dermpath. You can't keep adding rotations. So like I said, it is a difficult task to try and teach this.

Well, from my experience as both a resident and a fellow, I'd say forensic path. For the reason you said (2-3 questions max on the boards).

You said you can't keep adding rotations, but maybe we ought to. Maybe people planning to do general community pathology really should be doing 5 year residencies, and then either going to work or a fellowship.

I do not know the solution, and it's no longer my issue, but I strongly agree with the sentiment that a pathology residency leaves one very ill-prepared for the business aspect of pathology practice.

 

[KCShaw]

Well, supposedly there are more laboratory administration type questions on the RISE and boards, and some programs are at least giving lip service to the topic. Not to say they've all come very far with it, but I think there's some semblance of recognition that everyone seems to say the topic they wish they had learned earlier is the business/admin side of pathology. As a resident, of course, everyone is primarily concerned with surg path, as that's where the work product mainly is -- and there's truth in the fact that if you can't sign out a case you're screwed, but if you've got diagnostic skillz but no business acumen you can usually survive until you latch onto someone who does (or learn enough yourself).

 

[scienceguy19]

How about this solution?

We start having 1 year clinical fellowships in pathology which teach us how to do biopsies. We could learn how to do prostate biopsies, or skin punch/shave biopsies. We could do the routine screening colonoscopies looking for polyps and leave the more complicated IBD colitides for the GI specialists. These fellowships would be highly practical and pathologists could help ameliorate the shortage of clinicians in other fields.

We market ourselves as clinicians who obtain read and interpret our own biopsies. We are the biopsy doctors / tissue doctors and make ourselves known to the public of our value.

And then we don't have to worry about GI doctors and urologists unfairly collecting a large percentage of our compensation.

I mean, how hard could it possibly be to do a prostate needle biopsy or a skin biopsy??? After all, we were able to read through and retain information from Rosai and Henry's so we're not that stupid.

Now the issue is, how would we get the ball rolling? We would need people to train us.

 

[mlw03]

Nice idea scienceguy, but i don't see urologists or GIs referring some of their most profitable business to us. I mean, what kind of doctor would voluntarily give up a significant portion of their income to another specialty... only a pathologist it would seem.

 

[scienceguy19]

We wouldn't need their referral. The primary care doctors could send them to us for routine screening colonoscopies and for elevated PSAs.

Nice idea scienceguy, but i don't see urologists or GIs referring some of their most profitable business to us. I mean, what kind of doctor would voluntarily give up a significant portion of their income to another specialty... only a pathologist it would seem.

 

[mlw03]

We wouldn't need their referral. The primary care doctors could send them to us for routine screening colonoscopies and for elevated PSAs.

Why would they do that? If it's abnormal biopsy they're gonna need referral to the specialist anyway. I just don't see the incentive from anyone's end other than the pathologist.

 

[Pathwrath]

In terms of the original thread, any history of fee-splitting as you call it must include the original contribution of pathologists themselves. When you have "entrepreneurial" pathologists setting up free-standing labs, employing drones, and siphoning off community biopsies, you can't really fault clinicians for doing the same with the biopsies they themselves procure.

 

[Thaitanium]

In terms of the original thread, any history of fee-splitting as you call it must include the original contribution of pathologists themselves. When you have "entrepreneurial" pathologists setting up free-standing labs, employing drones, and siphoning off community biopsies, you can't really fault clinicians for doing the same with the biopsies they themselves procure.

How do these entrepreneurial pathologists market themselves to attract business? Is there illegal stuff involved?

 

[Thaitanium]

How about this solution?

We start having 1 year clinical fellowships in pathology which teach us how to do biopsies. We could learn how to do prostate biopsies, or skin punch/shave biopsies. We could do the routine screening colonoscopies looking for polyps and leave the more complicated IBD colitides for the GI specialists. These fellowships would be highly practical and pathologists could help ameliorate the shortage of clinicians in other fields.

We market ourselves as clinicians who obtain read and interpret our own biopsies. We are the biopsy doctors / tissue doctors and make ourselves known to the public of our value.

And then we don't have to worry about GI doctors and urologists unfairly collecting a large percentage of our compensation.

I mean, how hard could it possibly be to do a prostate needle biopsy or a skin biopsy??? After all, we were able to read through and retain information from Rosai and Henry's so we're not that stupid.

Now the issue is, how would we get the ball rolling? We would need people to train us.

Thats a great idea but how are you going to get access to patients? Patients are going to go to an internist not a biopsy doctor. They want a doctor who can manage other issues too like HTN diabetes. How are you going to advertise yourself to patients?

This has been brought up by Raider in the past.

 

[Pathwrath]

Is there illegal stuff involved?

There's nothing illegal about putting up the money to build a free lab and staffing it with techs and employee-pathologists, whether the owner is a pathologist, a clinician, or a candlestick maker. Pathologists have been doing this long before clinicians got into the game. You have an owner paying his employees an agreed-upon wage and pocketing the difference. It's called capitalism.

Now, self-referral may come into play when clinicians are incentivized to perform more biopsies, but so far Stark says otherwise.

 

[pathstudent]

How do these entrepreneurial pathologists market themselves to attract business? Is there illegal stuff involved?

Here is how they market themselves: http://www.iopathology.com/

Here is how they compare setting up an IOP lab vs using "your hospital based pathology friends". and note, they pay their pathologist 20 a case (which is about 1/2 to 1/3 what they get reimbursed for the PC). http://www.iopathology.com/images/agreements_7_3470329995.pdf

 

[Thaitanium]

Do internists exploit specialists? I mean internists have access to all the patients. If I were an internist, I would build a nice suite in my office and have gastros and uros come to take biopsies and make some $$ off of them. Primary care gets a lot of (#*# but if you have business sense I think you can make a great living since they have the leverage (aka patients).

 

[Thrombus]

Do internists exploit specialists? I mean internists have access to all the patients. If I were an internist, I would build a nice suite in my office and have gastros and uros come to take biopsies and make some $$ off of them. Primary care gets a lot of (#*# but if you have business sense I think you can make a great living since they have the leverage (aka patients).

In most places, specialists are not in oversupply and thus cannot be exploited like pathologists. This alone is all the evidence any thinking person should need to realize that the huge oversupply of pathologists is a problem.

If you are a primary doc, you will want your patients to have a short window to seeing their specialist, which can be in huge demand (or your patient's will be unhappy and go elsewhere --at least the ones with the best re-imbursement potential); thus, you will not be in a position to "make some money of them" but instead will want to kiss their rear ends in order to take care of your patients.

This is the position pathology should be in, but instead we are a commodity used and abused because of the oversupply. Our "leaders" and academia do not address it because they make money off it themselves.

 

[Pathwrath]

This is the position pathology should be in, but instead we are a commodity used and abused because of the oversupply. Our "leaders" and academia do not address it because they make money off it themselves.

This is exactly right. I like your mentioning commoditization. Surgical pathology was once exclusively hospital-based. The specimens were either procured in hospitals or sent there for analysis. The trend toward outpatient biopsies was not initiated by pathologists, but the notion that specimens could be sent anywhere to the lowest bidder and that pathology services were fungible commodities certainly was.

 

[WEBB PINKERTON]

Pathology better find a way to go interventional. If young pathologists think the future is gonna be sitting at desk screening cases all day, they are gonna be in for a rude awakening. We will see disruptive technology that threatens how we do things over the course of the next few decades. More and more people will be invading our scope of practice thanks to technology.

 

[yaah]

Pathology better find a way to go interventional. If young pathologists think the future is gonna be sitting at desk screening cases all day, they are gonna be in for a rude awakening. We will see disruptive technology that threatens how we do things over the course of the next few decades. More and more people will be invading our scope of practice thanks to technology.

So your solution to the problem described as disruptive technology, other specialties invading parts of practice, and competition which lowers the usefulness of a pathologist and thus payment, is to do the same thing to other specialties? You are proposing to start doing interventional procedures? How exactly? By lowering your prices? Competing on margin? Taking business from other physicians? If you lower your prices to compete, how are you going to mantain an income so that you can actually read out these biopsies and make sure the lab runs properly?

 

[pathstudent]

So your solution to the problem described as disruptive technology, other specialties invading parts of practice, and competition which lowers the usefulness of a pathologist and thus payment, is to do the same thing to other specialties? You are proposing to start doing interventional procedures? How exactly? By lowering your prices? Competing on margin? Taking business from other physicians? If you lower your prices to compete, how are you going to mantain an income so that you can actually read out these biopsies and make sure the lab runs properly?

Competition does not lower the payment to a physician.

Pathologists willing to split fees is causing the race to the bottom. We need to do away with fee splitting.

An internal medicine doc can not send a patient to a urologist and then pay the urologist X dollars for his professional services while billing the patient or insurance company X+500 dollars. For some reason this same set up is being allowed in pathology. We need an end to the culture of fee splitting in pathology.

Read the IOP model I posted above. That is what they do. The gastroenterologists pay the pathologist 20 bucks per CPT and bill the insurance for much more than that and pocket the rest. That is unethical, so much so that it is illegal to do with medicare patients.

 

[Thrombus]

Competition does not lower the payment to a physician.

Pathologists willing to split fees is causing the race to the bottom. We need to do away with fee splitting.

An internal medicine doc can not send a patient to a urologist and then pay the urologist X dollars for his professional services while billing the patient or insurance company X+500 dollars. For some reason this same set up is being allowed in pathology. We need an end to the culture of fee splitting in pathology.

Read the IOP model I posted above. That is what they do. The gastroenterologists pay the pathologist 20 bucks per CPT and bill the insurance for much more than that and pocket the rest. That is unethical, so much so that it is illegal to do with medicare patients.

If it takes 2 months to see a dermatologist in "City XYZ", there is a shortage of dermatologists and a pathologist can step in with a punch biopsy service. With this climate, you don't have to offer competitive pricing.

The local guy used to be able to turn around biopsies less than 48 hours and offered this as a huge competitive advantage. Now you can find a dozen pathology companies clamoring down the door able to do this and thus it is a race to the bottom.

Dermatology gets it. Pathology doesn't get it. As a result we are where we are. Many pathology practices get little dermatology anyway. Its time to step in the gap and get our specimens back, while offering much shorter wait lines and this would be HUGE in patient care as in some places it takes 6 months to see a derm.

I wonder why the CAP doesn't open this can of worms when mentioning "Transforming Pathology"? (it would actually be a great thing for pathologists....)

 

[caffeinegirl]

Do you think that you as a pathologist would be comfortable setting up a dermatology biopsy clinic? Do you know what that would entail? The overhead and malpractice, informed consent, prior authorizations, as well as follow ups on every biopsy? How about the follow up appointment? How about the litigation if you do not biopsy the "right" lesion? Are you then liable for missing the melanoma since you did not a complete skin examination? What about procedural complications (which are minimal but are present, and include scarring and infection). And when you get back the results and it's an NSMC on an elderly patient, are you going to do a D&C, give Aldara, or send him to Mohs? Who's going to follow up on that diagnosis? And who's going to do the follow up skin exams??

If you think a pathologist can do a dermatologist's job when it comes down to doing biopsies, then I do not think that you really know what a dermatologist does. A derm consult is rarely just "biopsy this" and entails a skin examination. Knowing what is a suspicious lesion and when to biopsy is both a science and an art, and requires lots of visual experience...just as diagnosing a melanoma versus an atypical/dysplastic Spitz.

We have an FNA clinic here where we perform FNAs on palpable lesions. The administrative time spent on prior authorizations is ridiculous...I also experienced this in derm clinic as a dermpath fellow. I'm very happy as a pathologist "sitting at my scope" but also participating in hospital administration, medical laboratory directorship, and being a team player in patient care. We can be more vocal about our role as a pathologist, and work on our "image". However, being a "biopsy doc" is not the answer IMHO.

 

[Thrombus]

Do you think that you as a pathologist would be comfortable setting up a dermatology biopsy clinic? Do you know what that would entail? The overhead and malpractice, informed consent, prior authorizations, as well as follow ups on every biopsy? How about the follow up appointment? How about the litigation if you do not biopsy the "right" lesion? Are you then liable for missing the melanoma since you did not a complete skin examination? What about procedural complications (which are minimal but are present, and include scarring and infection). And when you get back the results and it's an NSMC on an elderly patient, are you going to do a D&C, give Aldara, or send him to Mohs? Who's going to follow up on that diagnosis? And who's going to do the follow up skin exams??

If you think a pathologist can do a dermatologist's job when it comes down to doing biopsies, then I do not think that you really know what a dermatologist does. A derm consult is rarely just "biopsy this" and entails a skin examination. Knowing what is a suspicious lesion and when to biopsy is both a science and an art, and requires lots of visual experience...just as diagnosing a melanoma versus an atypical/dysplastic Spitz.

We have an FNA clinic here where we perform FNAs on palpable lesions. The administrative time spent on prior authorizations is ridiculous...I also experienced this in derm clinic as a dermpath fellow. I'm very happy as a pathologist "sitting at my scope" but also participating in hospital administration, medical laboratory directorship, and being a team player in patient care. We can be more vocal about our role as a pathologist, and work on our "image". However, being a "biopsy doc" is not the answer IMHO.

Thanks for your opinion. I, like you, spent 4 years training as AP/CP and probably could do most punch/shave/excisional biopsies with a week or so of training. During my previous training, I did a lot of stuff you described in learning a fair amount of clinical derm. This could easily fit into the months of "chemistry and microbiology" that are never used by 98% of pathologists. Give me a few more months and I could do a lot more. I could send the patient to a "real" dermatologist or general surgeon for anything that I could not handle. Since a melanoma can grow and spread in 9 months (time to see a Derm in some places) we could be of benefit IMHO and make ourselves useful.

Forgive a guy for brainstorming and trying to help out his struggling field. (also you sound like we are not professionals/physicians...."what about follow-up, complication, etc"....lol -- you should think about "follow-up" every time you read a biopsy)

 

[Thrombus]

being a team player in patient care. We can be more vocal about our role as a pathologist, and work on our "image". However, being a "biopsy doc" is not the answer IMHO.

FWIW you lost me at "being a team player" when many of us have lost significant FTE's due to urologists, OB/GYN's, GI's, Derms, etc. etc. "not being team players"

It goes both ways. You can survive as a specialty or be destroyed. Unfortunately most passive pathologists opt for the latter and our speciality is suffering and being marginalized and turned into a commodity (i.e. kicked off the team) as a result. Thus, the "team player" is not always doing the patient right. We have a role to play and we need to be assertive and play hardball or the patient's 12 part prostate biopsy will get sent back with a bill attached 88305x12 and 88342x36 from some reference lab

 

[yaah]

Competition does not lower the payment to a physician.

Pathologists willing to split fees is causing the race to the bottom. We need to do away with fee splitting.

An internal medicine doc can not send a patient to a urologist and then pay the urologist X dollars for his professional services while billing the patient or insurance company X+500 dollars. For some reason this same set up is being allowed in pathology. We need an end to the culture of fee splitting in pathology.

Read the IOP model I posted above. That is what they do. The gastroenterologists pay the pathologist 20 bucks per CPT and bill the insurance for much more than that and pocket the rest. That is unethical, so much so that it is illegal to do with medicare patients.

Yes, but how are you going to get the business if you don't use the same tactics? And how are you going to get credentialled to do these procedures? And get enough experience and volume to maintain proficiency and licensure?

Why do you assume that this behavior doesn't happen in other fields? It happens all the time. The "everyone bills insurance for the same price" argument is simplistic at best.

 

[pathstudent]

Yes, but how are you going to get the business if you don't use the same tactics? And how are you going to get credentialled to do these procedures? And get enough experience and volume to maintain proficiency and licensure?

Why do you assume that this behavior doesn't happen in other fields? It happens all the time. The "everyone bills insurance for the same price" argument is simplistic at best.

I think the idea of pathologists opening biopsy clinics is a little silly. I am not on that bus.

Everyone does not bill insurance for the same price. Different groups negotiate different fees which is almost always a multiplier of medicare.

Lastly, I have never heard of a family practice doc referring to another physician such as a gastroenterologist, then paying that gastroenterologist and then have the family practice profiteer by billing for the GI docs profession services at a great amount than he paid. And the few times I have seen a specialist, the specialist billed my insurance for his services, not the primary care doc.

This is what goes on with the professional component of pathology services. Urologists, gastroenterologists and other physicians are profiteering off the professional work of pathologists. It is so patently unethical that it is illegal to do with CMS patients (except unfortunately with those loop holes) . It should be illegal for all patients.

Pathologists that agree to these fee splitting arrangements for pathology services are not only engaging in an incredibly unethical practice, they are proactively helping to destroy the profession.

It is an unethical practice and it is ripping off patients who pay high deductibles or that are uninsured. A pathologist agrees to read a biopsy for $20, and the urologist turns around and bills the patient for $50. It is treating the profession of pathology like it is TV set or better yet like a bag of cocaine.

 

[caffeinegirl]

Forgive a guy for brainstorming and trying to help out his struggling field. (also you sound like we are not professionals/physicians...."what about follow-up, complication, etc"....lol -- you should think about "follow-up" every time you read a biopsy)

Brainstorming is a good thing, because great ideas do develop from such sessions. However, realizing the implications of making a change, rather than just making the change itself is also part of the process.
And when I mean following up a procedure, I mean the time it takes on the phone with patients, seeing them again for wound check/suture removal/discussion of biopsy results. This does eat a lot of time, and at this point you don't have much time left to read out slides and churn out your pathology volume.
I think the model you might be thinking about is a dermatologist/dermpathologist, who does few days of clinic and few days of dermpath. At the end of the day, the highest revenue they get is from dermpath and not from performing biopsies. So...seeing patients in a biopsy clinic won't give you much more $$ in the bank, as opposed to marketing yourself in the area to increase your dermpath volume. If you want to make $$ in derm, then out of pocket cosmetics or Mohs are considerations

 

[caffeinegirl]

FWIW you lost me at "being a team player" when many of us have lost significant FTE's due to urologists, OB/GYN's, GI's, Derms, etc. etc. "not being team players"

It goes both ways. You can survive as a specialty or be destroyed. Unfortunately most passive pathologists opt for the latter and our speciality is suffering and being marginalized and turned into a commodity (i.e. kicked off the team) as a result. Thus, the "team player" is not always doing the patient right. We have a role to play and we need to be assertive and play hardball or the patient's 12 part prostate biopsy will get sent back with a bill attached 88305x12 and 88342x36 from some reference lab

The squeeze when it comes to prostate and derm biopsies is happening in many places, and at the end of the day I agree that being a team player doesn't compete with $$$/kickbacks. Many of the in house pod labs are very shady, and one of the few ways to overcome this (other than govt regulation) is to offer competitive pricing (to some extent) and also to develop a reputation of excellence in the community. And pod labs aren't the only issue, how about the larger specialty labs that offer EMR's or other "amenities" for using their services?
It's tougher in some areas more than others, and being aggressive and marketing does play a signiciant role. Being passive is not an option.

 

[pathstudent]

Many of the in house pod labs are very shady, and one of the few ways to overcome this (other than govt regulation) is to offer competitive pricing (to some extent) and also to develop a reputation of excellence in the community. .

When you talk about "competitive pricing" you are talking about fee splitting right, the clinician is billing insurance/patient for your services and then paying you your "competitive price"? That's unethical. How would you feel if everytime you went to the doctor that the referring primary care doc was making money off your visit to the specialist, and if you were being sent to a particular specialist simply because she offered the most "competitive price" to the primary care doc which in turn put the most money in the primary care docs pocket? Would you trust that primary care doctor? Is that how you want your care done?

 

[Nilf]

Do you think that you as a pathologist would be comfortable setting up a dermatology biopsy clinic? Do you know what that would entail? The overhead and malpractice, informed consent, prior authorizations, as well as follow ups on every biopsy? How about the follow up appointment? How about the litigation if you do not biopsy the "right" lesion? Are you then liable for missing the melanoma since you did not a complete skin examination? What about procedural complications (which are minimal but are present, and include scarring and infection). And when you get back the results and it's an NSMC on an elderly patient, are you going to do a D&C, give Aldara, or send him to Mohs? Who's going to follow up on that diagnosis? And who's going to do the follow up skin exams??

C'mon.... You are making basic derm sound way more complicated than it is. A monkey can run the ABCDEs and take a punch or a shave. In fact, many trained monkeys otherwise known as PAs do just that... with only nominal supervision by doctors. Overhead and malpractice, how is it different from running path practice? Authorizations, follow up call, follow up appointment--bohooo what's so scary about that. Not biopsing the 'right' lesion and 'missing melanoma'? Know your s*** and don't do it. If you don't know what melanoma looks like on human skin, leave it to someone who does. Procedural complication, LMAO. 3rd year in medschool should prepare you for that. Yes it is a clinical decision how to treat NMSC, and I see a wiiiiiiide range of treatment for these... and for melanocytic lesions as well.

I am not saying that anybody can do dermatology. I am just saying that you don't need a residency to do basic derm. Many primary care docs and internists do that.

 

[caffeinegirl]

When you talk about "competitive pricing" you are talking about fee splitting right, the clinician is billing insurance/patient for your services and then paying you your "competitive price"? That's unethical. How would you feel if everytime you went to the doctor that the referring primary care doc was making money off your visit to the specialist, and if you were being sent to a particular specialist simply because she offered the most "competitive price" to the primary care doc which in turn put the most money in the primary care docs pocket? Would you trust that primary care doctor? Is that how you want your care done?

I'm talking about a competitive PC+TC price compared to other labs for surg path billing. Not talking about the splitting between PC and TC that occurs with in house labs. Out in the community, charges for a basic 88305 vary as well as reimbursements by payor...and if a patient gets a stiff bill and complains to the clinician, then the outpatient doc will go to another pathology practice. I think there may have been a miscommunication, as your interpretation of what I wrote was not my intention.

 

[caffeinegirl]

C'mon.... You are making basic derm sound way more complicated than it is. A monkey can run the ABCDEs and take a punch or a shave. In fact, many trained monkeys otherwise known as PAs do just that... with only nominal supervision by doctors. Overhead and malpractice, how is it different from running path practice? Authorizations, follow up call, follow up appointment--bohooo what's so scary about that. Not biopsing the 'right' lesion and 'missing melanoma'? Know your s*** and don't do it. If you don't know what melanoma looks like on human skin, leave it to someone who does. Procedural complication, LMAO. 3rd year in medschool should prepare you for that. Yes it is a clinical decision how to treat NMSC, and I see a wiiiiiiide range of treatment for these... and for melanocytic lesions as well.

I am not saying that anybody can do dermatology. I am just saying that you don't need a residency to do basic derm. Many primary care docs and internists do that.

Yes, PA's can do the biopsies...and yes, the overhead and everything else can be done as well, and are run by MD's. But the question is if this as profitable compared to reading your 88305's....and whether the fixed and operating costs of having a biopsy clinic are worth the reimbursement. I don't think so, based on my experience with dermatology/dermpath's (see my previous post).

 

[Thrombus]

Yes, PA's can do the biopsies...and yes, the overhead and everything else can be done as well, and are run by MD's. But the question is if this as profitable compared to reading your 88305's....and whether the fixed and operating costs of having a biopsy clinic are worth the reimbursement. I don't think so, based on my experience with dermatology/dermpath's (see my previous post).

Many groups are losing FTE's due a loss of 88305's. That is the premise of the whole equation. Of course nothing is profitable as those but pathologists are in huge oversupply and most young pathologists cannot get jobs that pay them what the CMS/Insurance "going rate" for their labor due to exploitation.

A solution is to procure specimens and you raise all kinds of issues that secretaries do making it sound like it is a waste of a physicians time, when physicians don't do those tasks anyway.

You must not be aware of the situation out in the field with corporations stealing specimens away. A common sense solution is to gain control of the specimens as some of us have been detailing. For those that cannot get enough work (88305's) the best solution seems to go get them themselves.

 

[caffeinegirl]

A solution is to procure specimens and you raise all kinds of issues that secretaries do making it sound like it is a waste of a physicians time, when physicians don't do those tasks anyway.

You must not be aware of the situation out in the field with corporations stealing specimens away. A common sense solution is to gain control of the specimens as some of us have been detailing. For those that cannot get enough work (88305's) the best solution seems to go get them themselves.

My point about running a clinic is the fixed and operating costs, and hiring secretaries, PA's and medical assistants are all part of that equation. The reimbursement you'd get from doing a procedure would have to be used for those costs...and your profit margin would be minimal. I do sympathize with those who have lost FTE's due to the loss of 88305's..and I'm just trying to be realistic as to the feasibility of the option you present.

Regardless of what you think of CAP, they have brought out some other efforts as well as part of their "Transformation Program". These include "Patient to Pathologist Consultations" (although the reimbursement/charges for such a service haven't been delineated). Dr. Jennifer Hunt was featured in an article in CAP Today several months back regarding such encounters, and now CAP has standardized patient simulation sessions that you can participate in.
They also have courses in which you can learn to perform ultrasound-guided FNA's...where you can charge for that image-guided procedure as well as the cytology.