This dude has some serious issues with pathologists. methinks he must have been an abused PA or something. Check out his most recent article. Perhaps we should act as he portrays us and form a posse and go hunting.... P.S he is the same chap who wrote the initial article posted on this thread. Check it...... Pathologists dont order tests and Other Such Fairy Tales By Joseph W. Plandowski Lakewood Consulting Group 10/10/08 I enjoy reading the annual letter from the College of American Pathologists (CAP) to Centers for Medicare and Medicaid Services (CMS) regarding changes in regulations for the upcoming year. This year was no different. For that matter, this years letter was a hoot. You just have to wonder how an organization such as CAP has the brass to actually turn out such a document. This years CAP letter is dated August 29, 2008, the last day for submission of comments to CMS regarding proposed changes in regulations for 2009. These are the issues raised in CAPs letter to CMS that I am addressing: * Pathologists do not order lab tests the statement in question is found on page 2 of CAPs comments to CMS and reads as follows: The CAP believes that self-referral arrangements can only be controlled by removing the economic self-interest of ordering physicians. However, the CAP wants to ensure that any anti-markup rule is drafted in a manner that recognizes that entities like pathology practices and independent laboratories that do not order lab tests not be hindered by any such rule. For many years, CAP has beaten the drum that pathologists do not order tests. Nothing could be further from the truth! I am not talking about an occasional test here or there. Im talking about millions of tests ordered by pathologists every year. How CAP can ignore this fact is akin to politicians, in this active political season, presenting half the case in their favor and then conveniently forgetting the other half of the case that is obviously not in their favor. Lets consider special stains. Who orders those? Perhaps its the tooth fairy. I will offer a contrary view that it is actually pathologists who order those stains. In most cases that is appropriate and good medicine. A newsletter entitled Lab Economics recently carried test volume data derived from CMS files that I found particularly interesting. The data is only from payments made by Medicare to cover services to their beneficiaries. Number of: 2000 2005 CGR Tissue slides diagnosed; (88304/88305/88307) 14,796,583 19,445,174 5.6% Special stains ordered; (88312/88313/88342) 2,784,288 4,804,280 11.5% % of Stains to Slides 18.8% 24.7% na Medicare pays for about one-third of all the laboratory tests performed in this country. That would imply about 14 to 15 million special stains were ordered in 2005. Its probably safe to state that the number of stains done today is higher than it was in 2005. For the most part, special stains are ordered by a pathologist to assist in diagnosing the particularly difficult cases. For the most part, that is good medicine. Why is CAP hiding from the ordering of special stains when it is blatantly known fact to all in the laboratory industry? Clearly CAP is trying to steer pathologists away from being tarred with a brush of self-referral. CAP deftly spins a web of self-referral to be used against dermatologists, gastroenterologists and urologists but then professes that its members are above the self-referral fray. That is simply not true. CMS is aware of pathologist self-referral. CMS is also aware of pathologists ordering a lot more special stains than they did before. Data from the table indicates that pathologists were ordering about one special stain for every five tissue slides in 2000 and upped that rate to about one special stain for every four tissue slides just five years later. This increase can also be seen in the compound growth rate (CGR) of stains which grew at more than twice the growth rate of tissue slides (11.5% vs. 5.6%). How much longer can CAP continue hiding under a rock on this issue? * Exempt pathologists from anti-markup provisions the statement in question is found also on page 2 of CAPs comments to CMS and reads as follows: In this regard, the CAP urges CMS to except from application of the anti-markup provision single-specialty pathology physician groups and independent laboratories who generally do not order tests and utilize pathology/laboratory CPT codes for at least 75% of their billings. CAP has been beating their drums for years that CMS should not allow physicians who order reference tests to mark them up before sending them on to Medicare for payment. I support that position and believe it was a noble position for CAP to take with CMS. A not so funny thing however happened to pathologists last year. CMS agreed with CAP and issued a change to the regulations that stopped payment to physicians who were purchasing technical work, marking it up and reselling it to Medicare. The problem that CAP created for its members is that CMS included pathologists in the new rules. To put this in simple terms, previously a pathologist was able to buy technical work from his/her local hospital, perform the professional work and bill Medicare a global fee. That ended with a new rule eliminating the markup pathologists were getting on the technical work they were purchasing and subsequently billing to Medicare at substantially inflated fees relative to the actual fees paid for the technical work. Apparently, CAP is trying to convince CMS that pathologists should be exempt from those non-markup rules. In CAPs eyes, it is all those bad boys of medicine (dermatologists, gastroenterologists and urologists) who should be prevented from marking up purchased tests. While some might disparage the brain trust at CMS, they are bright enough to see right through CAPs exemption request. Even if they were not, CAP should take the high road on this issue. Why should pathologists have the right to markup tests they purchase and resell to Medicare while their organization is trying to shut down every other physician from doing the same thing? CAP is trying to exempt pathologists from the very same anti-markup rules that CAP wants applied to all other physicians. This is not a fairy tale. * Overutilization the word in question is found on page 2 of CAPs comments to CMS and reads as follows: CMS has long recognized that when physicians who order diagnostic testing also have an economic interest in billing and collecting for the tests ordered, the result often is program abuse and patient abuse, over utilization and higher costs. Over the years, CMS and Congress have imposed rules and limitations to prohibit physician self-referral for tests. CAP has claimed overutilization for as long as I can remember. And, it is always the non-pathologist physician who is overutilizing test ordering and gouging the system. Overutilization hits close to home when we consider special staining. We saw it in the table above. There is nowhere to hide from that data. Pathologists are on the hot seat, rightly or wrongly, when it comes to that data because they order the stains. Laying blame for overutilization of special staining solely on pathologists is somewhat unfair because they do not have standards in place. No organization has tackled that problem, including CAP. And why would they? It is the wild-west when special stains are involved. What you get are some pathologists playing defensive medicine to cover every possible base by driving up the number of stains done. You also get flat out abuse by pathologists ordering special stains on each and every tissue specimen that enters the laboratory, whether or not it is needed. Some specialty-pathology companies are also contributing to the problem by offering a large menu of combinations of special stains. An interesting anecdotal comment I can share involves a large gastroenterology practice in the Midwest that owns an office-based pathology laboratory. Pathology services were provided by a large local pathology group that also provided pathology services to one of the countrys largest commercial laboratories. After months of operating the laboratory, the gastroenterologists began receiving complaints from their patients about the size of the bills they were receiving. Upon investigation it became clear that the pathology group was using the same staining protocol at the gastroenterologist-owned laboratory that they were using at the large commercial laboratory. The managing gastroenterology partner forced the pathology group to change their staining protocol at his laboratory from blanket staining all slides to selective staining of slides on an as-needed basis. CMS, if they are not doing so right now, will be looking hard at what is happening in the ordering of special stains and their associated payments. CAP should take the lead in defining rational staining protocols. It will remove the utilization issue from the backs of pathologists. Unfortunately, it also takes away CAPs argument of overutilization by others. However, CAP will be better served if they take the high road. Unless there are standardized protocols that clearly spell out what stains should be applied and when they should be applied, neither CAP nor CMS can factually claim overutilization or underutilization. Without some standard, how can any rational claim be made that these are occurring? CAP is taking considerable liberties on this issue when they would better serve all parties if they established staining standards. Then perhaps, one could judge whether over- or underutilization are occurring rather than spinning more fairy tales. * Pathologist dedicated to solely a physician organization the statement in question is found on page 3 of CAPs comments to CMS and reads as follows: Accordingly, CAP strongly urges CMS to focus on its first proposal to apply the anti-markup provision to all TC and PC diagnostic tests that are ordered by the billing physician or other supplier unless the physician who performs and supervises the pathology services is dedicated solely to that physician organization. This is an attempt by CAP to shutdown all in-office anatomic pathology laboratories by forcing them to hire or contract a full-time pathologist to operate the in-office laboratory. It has at least one major downside for local pathologists. That is, if implemented, the large in-office anatomic pathology laboratories operated by specialty physicians will be hiring their own pathologists and tossing out local contracted pathologists who are enjoying premium fees in the existing arrangements. Hired pathologists will cost most of these larger in-office pathology laboratories less than they are currently spending for pathology services. There will be some unhappy pathologists if CAP is able to convince CMS to make the changes CAP has requested. This attempt to force a full-time pathologist upon an in-office anatomic pathology does not appear to be well thought out. Besides hurting local pathologist members of CAP as noted in the paragraph above, it creates an unhealthy situation for the patient. Consider that a hired or a contracted full-time pathologist will take a vacation or attend a CME meeting or may be sick or whatever. What happens with the slides? They will sit in the laboratory awaiting the pathologists return impacting turnaround time rather than being diagnosed by another local pathologist. In addition, a single full-time pathologist may not be the best available pathologist for all cases compared to a local pathology group with some members having sub-specialization training. And, some of the part-time positions will be taken by a segment of the pathology work force interested in that arrangement. Part-time pathologists perform an important role in many pathology practices. As with the anti-markup provision bullet point above where CAP fell through the ice for its members, CAP is skating on thin ice and may easily fall through on this issue. At least this time they recognize that a problem may exist. But like the last time around, once the rules are set it is over with for at least a year and all you can hope for is a strong lobbying effort to change the rules in subsequent years. On page 4 of CAPs comments to CMS, they note In this regard, the CAP is concerned that by defining a physician who does not share a practice as the dividing line, a pathologist who provides 99% of the pathologist services to a pathology practice and 1% of the pathologists services to an outside practice may be subject to the anti-markup provisions in all settings. This would be an untenable situation for most pathology groups. * Quality issues the words in question are found on page 7 of CAPs comments to CMS and reads as follows: There are real quality issues associated with the provision of anatomic pathology services by non-specialists, and no reason to sacrifice quality to achieve expediency. This claim by CAP is a little far-fetched for anyone to believe. All the in-office anatomic pathology laboratories I have ever seen are directed by pathologists. If quality is being sacrificed, then it is being sacrificed by a pathologist who is the individual diagnosing the case. Every slide is viewed by a pathologist. If the slide quality is poor, it is a pathologist who rejects it. That individual, the pathologist, is the final arbitrator of quality. If quality suffers due to the pathologists ability to diagnose cases that issue should have been addressed by the pathology community that worked with the individual long before he/she joined the in-office laboratory. Claiming real quality issues is a smoke screen and is a disservice to pathologists who perform professional services at in-office labs. For the most part, a pathologist is not going to tolerate poor quality. After all, it is their name that goes on the report to the ordering physician. It is a fairy tale for CAP to imply to CMS that quality suffers at in-office laboratory settings. CAP should understand by now that a pathologist, one of their members, is performing on-site services. No one is bypassing the need for the work done by a pathologist. There are many times I thought about a pathologists reaction to their own organization, CAP, that ripped pod/condo labs and now in-office laboratories for questionable quality and overutilization while that same pathologist was providing professional services to such laboratories. I got the sense CAP was trying to shame pathologists from offering to do that work. What CAP is missing, and this is no fairy tale, is that the work available at in-office laboratories is work a local pathologist would almost never receive because the pathologist could not compete with big specialty pathology laboratories such as Caris, CBLPath, Bostwick Laboratories and a host of others if that work was referenced out. * Profit the word in question is found also on page 7 of comments to CMS and reads as follows: There is no medical reason for performing laboratory tests in the physicians office that cannot be completed at the time of the office visit. The only reason why a practice seeks to perform such tests is to profit from the tests that the physician orders. Oh yes, how could CAP forget that claim? It is nonsensical. If pathologists did not profit from doing the same test, I might have some sympathy for that claim. But pathologists do profit from the same tests. It appears to be a matter of allowing a pathologist to profit from testing but woe to any other physician who even thinks about it. In a sense it is a teamster mentality with a mindset of if it is a truck, only a teamster can be behind the wheel. Profit has been claimed time and again by CAP. Its as if profit is a bad thing. If laboratories did not make a profit, they would cease to exist. That goes for laboratories owned by pathologists or specialty physicians. The point that doesnt escape me is that only a pathologist can diagnose tissue slides. It would seem that it should not matter whether the slides are diagnosed in a hospital setting, in a private pathology laboratory, in a commercial laboratory or in an in-office pathology laboratory. In all these cases, a pathologist is assured of performing the professional work. It is not as if pathologists are losing the ability to capture the work. The difference is some of this work has to be done outside a traditional hospital setting. CAPs letter to CMS is instructive. It should be read by all pathologists and management within the laboratory industry. It may provide an understanding of CMSs direction and the thinking going on at CAP which at times appears to function as a labor union rather than an organization for medical professionals. All parties would be further ahead if the focus of attention was the patient and how we can all deliver quality medical care to the patient regardless of the setting.
LOL, you're too much! Sorry I know by quoting you it seems as those comments were targeted at you, but they were not. It is just frustrating when every other post is about the same damn topic:
