the most biggest darkest downside to POD labs

[pathstudent]

They are going to screw up pathology billing for the rest of us. Urologists that own their own pathologists all biopsy 12 different spots and put it in 12 different containers, resulting in a pathology bill that is way over 1000 (for T and P). GI groups do similar with 12-20 biopsies per colon. Medicare is going to shut this down and screw up how real pathologists are compensated for doing multiple specimens in true complicated cases, like a TAHBSO for malignancy. **** all gastros and uros who open up POD labs and **** all pathologists who take those jobs.

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[Path or bust]

They are going to screw up pathology billing for the rest of us. Urologists that own their own pathologists all biopsy 12 different spots and put it in 12 different containers, resulting in a pathology bill that is way over 1000 (for T and P). GI groups do similar with 12-20 biopsies per colon. Medicare is going to shut this down and screw up how real pathologists are compensated for doing multiple specimens in true complicated cases, like a TAHBSO for malignancy. **** all gastros and uros who open up POD labs and **** all pathologists who take those jobs.

there have been recent changes to the 2008 medicare reimbursement rules that apparently placed a stop on POD labs, or at least their ability to function as the have previously.


Any new updates on POD Labs? I wonder if they are able to find loopholes.

 

[yaah]

I am confident that whatever rules medicare instituted or proposed will be watered down at the last minute by political hacks. And there will be loopholes. And pod lab people don't care who they are hurting as long as they get their income somehow. I really do not understand how they can justify billing for work that they do not perform. I suspect that they either justify it by saying they are recouping costs from some other money losing practice or that they aren't aware that it is an abusive billing practice. Bull****, I say. You don't just decide to create a pod lab out of convenience to your patients or to somehow improve patient care. I would love to see a pod lab advocate's response to the question, "How is it that you can justify billing for work that someone else is doing?"

The larger specimen "multiple specimen" cases already have some rules - like mandatory bundling in TAH-BSOs and laryngectomies, for example. What will probably happen with prostates and gi bxs is a cap at a certain number of specimens (like 6, for example) after which point reimbursement either goes down or is eliminated. Maybe that's the proposal. There are supposedly new rules to take effect on prostate saturation biopsies - at some point it stops being worthwhile to add more specimen containers.

 

[Pathwrath]

The clinicians have moved beyond POD labs. They are in-sourcing surgical pathology services and hiring their own cut-rate pathologists as employees or independent contractors.

 

[LADoc00]

The clinicians have moved beyond POD labs. They are in-sourcing surgical pathology services and hiring their own cut-rate pathologists as employees or independent contractors.

aka Death Star'ing. A brutal tactic that pretty much requires a national collaboration amongst the Path community and a drastic 80%+ of residency training programs. Perhaps even consider closing path training for 5 years.

 

[Path or bust]

The clinicians have moved beyond POD labs. They are in-sourcing surgical pathology services and hiring their own cut-rate pathologists as employees or independent contractors.

How are they getting past self-referral or vested-interest issues?

 

[Gene_]

The clinicians have moved beyond POD labs. They are in-sourcing surgical pathology services and hiring their own cut-rate pathologists as employees or independent contractors.

I would argue the statement that pathologists that work for pod labs are "cut-rate." Pod lab (or similar arrangements) pay is excellent, especially considering the hours and relatively little administrative/clinical pathology duties. OTOH, you won't become a partner at a pod lab - and therefore won't make the big bucks.

 

[HESC]

How are they getting past self-referral or vested-interest issues?

loop holes, specifically, i think it is an in-office exemption. they rent condo space which then becomes their "office", where the pod lab operates. hence, there is an avenue to avoid the self-referral thing.

The medicare anti-markup rules that went into effect (and shut down uropath) only apply to medicare cases though. the thought is that what medicare does other private insurers will eventually follow.

 

[HESC]

The clinicians have moved beyond POD labs. They are in-sourcing surgical pathology services and hiring their own cut-rate pathologists as employees or independent contractors.

i agree, i think this is the next big problem. i think the CAP is trying to lobby for rules to make this harder for non-pathologist physicians to do this.

Large specialty groups have been doing this with their radiology services for years now. I know of an internal med group that has their own CT and MRI and send out the images for the read.

 

[pathstudent]

How are they getting past self-referral or vested-interest issues?

It is pretty simple. A group of gastroentelogists and a pathologists form an entity with a salary for those involved. It is not unlike when a new hire joins a practice and is paid a salary for a few years before making partner. The others in the group make money off the new hire for a few years for work they are not doing. I have decided there is no way to stop it other than pathologists to quit taking the jobs. However, as I have said before pathology is full of Type B types who don't want to hustle or run the show or take call or interact with physicians. They just to want to show up have some put the slides in front of them and then go home. The gastroenterologists don't really or don't really understand what goes into interpreting a slide and the importance of experience and having q/a. To them I think it is no different than sending out blood for a CBC.

I talked to a gastroenterologist a couple weeks ago who told me they were bringing pathology "into" the group and he was asking me how to go about setting up a histo lab. I told him that I was sure there were consultants out there that would take care of it for a fee. In his words he said "we have been losing all this money by sending out the pathology". So to them it is not unethical or fee splitting or anything like that. It is a resource to be taken advantage of to generate more revenue for the group. It is not a tough choice for them to make as they can do nothing different and have an extra 50K a year in their pocket. That is basically a free BMW or money for their kid's tuition every year. Wouldn't you do it too?

 

[yaah]

How do they justify the "we've been losing money" argument? I mean, they are not doing any of the work, so how is it exactly that they are losing money? You can't lose money that you don't really deserve to get, or that you aren't getting now anyway. To me that suggests they aren't really being honest about it. What he should say is, "We could be making money off of pathology."

I dunno, to me it's kind of unethical to be making money off of someone else's work, but what do I know. It's not an entirely different situation from a private group paying a new associate less money, but of course there is an expectation that income will eventually equalize.

 

[Pingu]

I have heard that they get shafted on their equipment costs (processors, etc) because they have no clue how much it is really supposed to cost and it is not like they can call up their friendly neighborhood pathology lab and ask if it is a fair price.

 

[yaah]

I have heard that they get shafted on their equipment costs (processors, etc) because they have no clue how much it is really supposed to cost and it is not like they can call up their friendly neighborhood pathology lab and ask if it is a fair price.

Good! That's the cost of doing business. You'd think they want people to just pay them for not doing anything, for crying out loud.

 

[HESC]

so in the lastest issue of the CAP's Statline, they report that ohio's governor just signed into law a direct billing law that makes POD labs and other abusive billing practices harder. A few states already have this law and medicare cases have been required to be directly billed by the lab since 1984.

Also, they are working on CMS to address the issue of clinicians "in-sourcing" histo labs by lobbying for pathology services to be excluded from "in-house ancillary services".

If they can get CMS to do this it would make it a lot harder for gastros/uros to bring the path lab in house. If you actually look at what the CAP has lobbied for over the last couple years (Antimarkup, Competitive bidding etc.. ) they seemed to have been quite effective so I am thinking that it wont be too long before they get this through to CMS.

http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=statline%2Findex.html&_state=maximized&_pageLabel=cntvwrhttp://www.cap.org/apps/cap.portal?...index.html&_state=maximized&_pageLabel=cntvwr

 

[yaah]

Yes, I saw that. There was an exception in there for derms who read their own slides, which I think is ok because there is such a tradition of doing that. When I saw that there was that exception it made me think it actually was a real law with actual teeth - because if there was no exception for derms it would mean there were still tons of loopholes (because the derms would NEVER stand for being shut out like that).

 

[pathstudent]

Personally I don't care if they want to try to make their own slides. Pathologists don't have a God-given right to the histolab (which btw is the most lucrative part of pathology). It is the profiting off the diagnostic work that is really offensive.

 

[number]

How many pathologists own or partially own a lab? I thought most labs were owned by the hospitals.

 

[pathstudent]

How many pathologists own or partially own a lab? I thought most labs were owned by the hospitals.

For the most part hospitals provide laboratory services for the inpatients. This includes AP, micro, chem, flow etc... Some hospital may not provide all services and send things out when not available in-house. But the biggest competition is for outpatient business. That stuff can go anywhere and it is compensated the best by how medicare set it up.

Greed of pathologists sort of got this whole thing started. Back in the 90s, pathologists griped and griped that they weren't getting compensated enough for the processing of slides. So CMS said "fine" and hacked off a lump from the professional component and moved it to the technical. This made the technical very profitable and pushed the reference labs into the field of AP as well as creating POD labs and what we have today. So now pathologists are losing out on the TC part and the PC was slashed to make the TC more remunerative. So in some ironic sense the field of pathology is being punished for its greed 10-15 years ago. Had people just kept their mouths shut and enjoyed their great salaries, we would be doing awesome and not dealing with fighting for the tissue with our fellow physicians and the reference labs.

 

[KeratinPearls]

what is the typical salaries these POD labs offer? How many hours a week is one asked to work?

kinda curious as to what draws these pathologists to these types of jobs?

 

[yaah]

Some are minimal - like 8-10 hours a week, others are probably close to full time. They can pay the equivalent of around $300k/year (for full time, extrapolate out for part time) or more. I doubt that includes any benefits though.

 

[Pathwrath]

I would argue the statement that pathologists that work for pod labs are "cut-rate." Pod lab (or similar arrangements) pay is excellent, especially considering the hours and relatively little administrative/clinical pathology duties. OTOH, you won't become a partner at a pod lab - and therefore won't make the big bucks.

In-sourced pathology services are often piecemeal arrangements, where the pathologist earns a reduced professional fee ( I've been quoted less than $20 per 88305). By definition, that is "cut-rate". Now, if you sign out a million of these biopsies per day, you would still make decent money, but your fee is still cut-rate regardless.

 

[skinknee]

I wonder how people on the GI threads would react to these pod labs? and also about how GI is totally treading on the pathologists' turf.

You always see turf battles throughout medicine. IR competes with cardio sometimes for cardiac cath. In FL physicians have turf battles with pharmacists who try to lobby for prescriptive authority! You really need an active group of individuals to be able bat down trespassers treading on your turf otherwise be ready to forfeit territory.

 

[levels x3]

Personally I don't care if they want to try to make their own slides. Pathologists don't have a God-given right to the histolab (which btw is the most lucrative part of pathology). It is the profiting off the diagnostic work that is really offensive.

I don't know if it's a god-given right that pathologists control the histo lab, but it's certainly better if we do. The quality of the final H&E varies greatly depending on how well the processing is done. I see it regularly as my residency now has its prostate slides made at an outside GU lab (yes the abomination that is the in-office histo lab is intruding into some residency programs even). They were borderline unreadable when the lab got started and they are only slightly better now. A suspicous gland or two gets much more difficult on a bad slide. It's akin to our owning the endoscopy suite and stocking it with the cheapest, poorest quality colonoscopes we can find. After all, we're losing all kinds of money by not controlling the tissue procurement...

And the 6 part biopsies they used to send us when I was a PGY 1 are now 12 parts...go figure.....

By the way, I second the final sentiment in the original post...

 

[yaah]

Should note that this is not limited to path - many medical groups now own their own radiology equipment and hire radiologists to read the scans out.

 

[levels x3]

I've been thinking about this a bit as I sign out the ugly microwave processed prostates from that GU group and it really is an infuriating practice. The fact that some urologist is skimming off our Part B fee for an interpretation they have no part of has already been covered.

I've been wondering why hospitals let this happen though. Why would a hospital that had previously been getting the Part A fee for processing the specimens, let that go out the door? Would it violate some other law to require that clinicians send their out-patient specimens to the hospital lab?

 

[Gene_]

so in the lastest issue of the CAP's Statline, they report that ohio's governor just signed into law a direct billing law that makes POD labs and other abusive billing practices harder. A few states already have this law and medicare cases have been required to be directly billed by the lab since 1984.

http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=statline%2Findex.html&_state=maximized&_pageLabel=cntvwrhttp://www.cap.org/apps/cap.portal?...index.html&_state=maximized&_pageLabel=cntvwr

I'm not too excited about what CAP can do. In Texas we got a very watered down version of direct billing passed. Why watered down? Because the pathologists lobbyists were not as powerful as the lobbyists from orthopedics, urology, gastroenterology, internal medicine, and family practice.

 

[yaah]

I've been wondering why hospitals let this happen though. Why would a hospital that had previously been getting the Part A fee for processing the specimens, let that go out the door?

Because otherwise they potentially could lose their business. And surgeries are more lucrative for the hospital, so if they have to give up some lab money in return for more robotic prostatectomies, it's an easy choice for the administrators.

 

[levels x3]

Is that a real choice? Patients usually keep to a general geographic location and large hospitals often have physician networks that referrals stay within. I can see how small hospitals could lose patients, but what's happened here is different. We're the 800 pound gorilla so to speak. It's not as if the surrounding hospitals could absorb this patient load.

I'm sure you're right though. Hospital administrators aren't going to let money slip away if they have a choice.

 

[Path or bust]

I'm not too excited about what CAP can do. In Texas we got a very watered down version of direct billing passed. Why watered down? Because the pathologists lobbyists were not as powerful as the lobbyists from orthopedics, urology, gastroenterology, internal medicine, and family practice.

Well actually, its not that pathology lobbyist didn't have as much power, its that it was Pathology against EVERYONE else....and they still managed to get most of what they wanted. Probably the biggest reason for their win was that at the time, the President of the Texas Medical Association was a pathologist and he used every resource of the TMA to this end.

 

[Torsed]

They are going to screw up pathology billing for the rest of us. Urologists that own their own pathologists all biopsy 12 different spots and put it in 12 different containers, resulting in a pathology bill that is way over 1000 (for T and P). GI groups do similar with 12-20 biopsies per colon. Medicare is going to shut this down and screw up how real pathologists are compensated for doing multiple specimens in true complicated cases, like a TAHBSO for malignancy. **** all gastros and uros who open up POD labs and **** all pathologists who take those jobs.

Strong feelings, but way would you just randomly throw cores into the same container, some of the Ob-gyn's do that with cervical bx and it just seems silly (are you really gonna just LEEP the whole cervix out). I doubt that many urologists or GI's bill much Medicare, if private insurance and the patient are paying (as someone obviously is) the practice will continue. You are right about the potential to screw things up though, I can't imagine it would be markedly rewarding looking at just prostates all day, I know some pathologists who work their normal jobs and look at a urologist's biopsies on the side for extra income. It will be interesting to see how all this pans out.

 

[scurred]

I thought most hospital labs actually were one of the largest revenue producers for the hospital...Numerous programs have told me this regarding their lab, it never made sense to me the programs that sent out tissue.

I guess it depends on the logistics of everything and how competent leadership is.