the role of pathologists in accountable care organizations

[scienceguy19]

There is a lot of talk now about the shift of reimbursement models from fee for service to accountable care organizations to help reduce overall health care costs while maintaining quality care. I can imagine that the quality of health care services provided by clinicians can be monitored by observing patient outcomes and mortality against overall statistics.

But how would the performance of pathologists be measured? When a pathologist makes a diagnosis, they're either right, wrong, or have omitted important information. Would our diagnoses by audited? Obviously we can't just measure patient outcomes (all our patients may be healthy, or all may have metastatic cancer) and it would be difficult to establish a direct link between our correct diagnosis and a patient outcome.

I'm wondering how this system would work for pathologists. I hear that several hospitals have tested this model and am curious how things worked there.

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[LADoc00]

There is a lot of talk now about the shift of reimbursement models from fee for service to accountable care organizations to help reduce overall health care costs while maintaining quality care. I can imagine that the quality of health care services provided by clinicians can be monitored by observing patient outcomes and mortality against overall statistics.

But how would the performance of pathologists be measured? When a pathologist makes a diagnosis, they're either right, wrong, or have omitted important information. Would our diagnoses by audited? Obviously we can't just measure patient outcomes (all our patients may be healthy, or all may have metastatic cancer) and it would be difficult to establish a direct link between our correct diagnosis and a patient outcome.

I'm wondering how this system would work for pathologists. I hear that several hospitals have tested this model and am curious how things worked there.

Significantly reducing costs of healthcare while IMPROVING quality is political myth, akin to cold fusion, Jesus appearing in toast and Obama being born in Hawaii (I kid.


ACOs will greatly reduce a number of specialist compensations as IPAs did back in the 90's (and still do today in many areas).

 

[gungho]

Significantly reducing costs of healthcare while IMPROVING quality is political myth, akin to cold fusion, Jesus appearing in toast and Obama being born in Hawaii (I kid.


ACOs will greatly reduce a number of specialist compensations as IPAs did back in the 90's (and still do today in many areas).

ditto to all of the above. no one really knows what the final product will look like, but ACO's in some form are inevitable, in my opinion, except maybe for some backwater areas, and i don't plan on seeing a bump in my income, that's for sure-probably a pothole.
ACO's big topic in latest Am. Col. of Phys. Exec. meeting.

 

[lipomas]

Significantly reducing costs of healthcare while IMPROVING quality is political myth, akin to cold fusion, Jesus appearing in toast and Obama being born in Hawaii (I kid.


ACOs will greatly reduce a number of specialist compensations as IPAs did back in the 90's (and still do today in many areas).

Yep. It's all just differnet ways of reducing payment. Theoretically, yes, if you improve everyone's quality of health then healthcare costs will go down. But that doesn't happen overnight. Experts and policy wonks like to cherry pick data and patient populations to "prove" that lower spending improves health quality. But these analyses always leave so much out.

The easiest ways to reduce spending on healthcare will always remain reducing expenses. I mean, you can raise copayments and all that but WE CAN'T DO THAT NOW THIS IS A RECESSION IT WILL HURT THE JOB CREATORS AND BY THE WAY THIS IS A TIME OF WAR AND JOB KILLING TAX CUTS AND DEATH PANELS AND HOW CAN YOU MAKE ME PAY MORE FOR MY MAMMOGRAM AND DON'T CUT MY MEDICARE I PAID FOR IT. How do you reduce expenses? You reduce payments to someone. Since reducing payments for technical things like medical devices or robots or hospital rooms with flat screen TVs is difficult, and reducing payments for drugs is next to impossible due to lobbying cash, we are left with the professional component because god knows "doctors make way too much money." Anything else would require, god forbid, either political courage or a combination of political intelligence and hard work and heaven knows that isn't going to happen.

 

[scienceguy19]

A follow-up to my own question. Here's a recent paper addressing how pathologists would function and be compensated in accountable care organizations...

http://www.cap.org/apps/docs/advocacy/aco_white_paper.pdf

 

[pathstudent]

A follow-up to my own question. Here's a recent paper addressing how pathologists would function and be compensated in accountable care organizations...

http://www.cap.org/apps/docs/advocacy/aco_white_paper.pdf

Making ACOs for primary care docs totally makes sense. However, for pathologists, radiologists, anesthesiologists etc... it doesn't make any sense at all. We live in a fee for service society. A guy fixes your roof and you pay his bill, a guy mows your lawn and you pay his bill, someone gives you a manicure you pay her bill. Someone does a gross micro on your lumpectomy you pay her bill. So if a pathologist is in an ACO and for some reason a lot of women get breast cancer, the pathologist and ACO should make less money for not keeping the women healthy? So stupid.

ACOs make sense for primary care docs taking care of hypertension, diabetes, back pain etc....

I know people hate the term but what the government needs is death panels. If you are 80 years old with small cell cancer you don't get a pet scan and radiation and chemotherapy and then die six months later. You go die a dignified death now. If you are 83 and demented and fall you don't get a hip replacement. If you are 83 and demented you don't get referred to a bone marrow biopsy to look for MDS because your platelet count is 123k. Or if you do want all that stuff, you pay for it yourself. That is where we can save public money and make medicare last for decades.

And to help prevent all that primary care chronic disease BS ban tobacco and get MFers to work out a little and lose weight.

Of course we have to act like we are team players when it comes to ACOs and sure I can help reduce laboratory costs by not letting docs order tests that are worthless, but if you want me to look at your breast biopsy or look at your brain tumor you better pay me my $50.

The other option is just have government nationalize all the hospitals and force all docs to be federal employees and just salary us all. If that happens, I'll look at your breast biopsy maybe tomorrow or maybe next week or when I get around to it.

 

[deleted314957]

Making ACOs for primary care docs totally makes sense. However, for pathologists, radiologists, anesthesiologists etc... it doesn't make any sense at all. We live in a fee for service society. A guy fixes your roof and you pay his bill, a guy mows your lawn and you pay his bill, someone gives you a manicure you pay her bill. Someone does a gross micro on your lumpectomy you pay her bill. So if a pathologist is in an ACO and for some reason a lot of women get breast cancer, the pathologist and ACO should make less money for not keeping the women healthy? So stupid.

ACOs make sense for primary care docs taking care of hypertension, diabetes, back pain etc....

I know people hate the term but what the government needs is death panels. If you are 80 years old with small cell cancer you don't get a pet scan and radiation and chemotherapy and then die six months later. You go die a dignified death now. If you are 83 and demented and fall you don't get a hip replacement. If you are 83 and demented you don't get referred to a bone marrow biopsy to look for MDS because your platelet count is 123k. Or if you do want all that stuff, you pay for it yourself. That is where we can save public money and make medicare last for decades.

And to help prevent all that primary care chronic disease BS ban tobacco and get MFers to work out a little and lose weight.

Of course we have to act like we are team players when it comes to ACOs and sure I can help reduce laboratory costs by not letting docs order tests that are worthless, but if you want me to look at your breast biopsy or look at your brain tumor you better pay me my $50.

The other option is just have government nationalize all the hospitals and force all docs to be federal employees and just salary us all. If that happens, I'll look at your breast biopsy maybe tomorrow or maybe next week or when I get around to it.

your last sentence is exactly what the government wants and what will happen. it will be just like military medicine.

 

[scienceguy19]

Another interesting read...
In Canada, it looks like clinicians and pathologists have different compensated differently...

Less than 15% of pathologists have any fee-for-service component to their practice (salaried), whereas most clinicians are compensated by fee-for-service...

http://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2011-0188-OA

Making ACOs for primary care docs totally makes sense. However, for pathologists, radiologists, anesthesiologists etc... it doesn't make any sense at all. We live in a fee for service society. A guy fixes your roof and you pay his bill, a guy mows your lawn and you pay his bill, someone gives you a manicure you pay her bill. Someone does a gross micro on your lumpectomy you pay her bill. So if a pathologist is in an ACO and for some reason a lot of women get breast cancer, the pathologist and ACO should make less money for not keeping the women healthy? So stupid.

ACOs make sense for primary care docs taking care of hypertension, diabetes, back pain etc....

I know people hate the term but what the government needs is death panels. If you are 80 years old with small cell cancer you don't get a pet scan and radiation and chemotherapy and then die six months later. You go die a dignified death now. If you are 83 and demented and fall you don't get a hip replacement. If you are 83 and demented you don't get referred to a bone marrow biopsy to look for MDS because your platelet count is 123k. Or if you do want all that stuff, you pay for it yourself. That is where we can save public money and make medicare last for decades.

And to help prevent all that primary care chronic disease BS ban tobacco and get MFers to work out a little and lose weight.

Of course we have to act like we are team players when it comes to ACOs and sure I can help reduce laboratory costs by not letting docs order tests that are worthless, but if you want me to look at your breast biopsy or look at your brain tumor you better pay me my $50.

The other option is just have government nationalize all the hospitals and force all docs to be federal employees and just salary us all. If that happens, I'll look at your breast biopsy maybe tomorrow or maybe next week or when I get around to it.

 

[Path or bust]

Another interesting read...
In Canada, it looks like clinicians and pathologists have different compensated differently...

Less than 15% of pathologists have any fee-for-service component to their practice (salaried), whereas most clinicians are compensated by fee-for-service...

http://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2011-0188-OA

None of this may happen if the Supreme Court overturns obamacare. I have mixed feelings, but I fear that the statusquo may be better, for now.

 

[Path or bust]

Another interesting read...
In Canada, it looks like clinicians and pathologists have different compensated differently...

Less than 15% of pathologists have any fee-for-service component to their practice (salaried), whereas most clinicians are compensated by fee-for-service...

http://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2011-0188-OA

Very interesting paper. They state that management brought decreased "need for pathologists" in Canada and that we may see the same here too. We have been warned.

Our data do suggest that as American pathology
organizations develop models for predicting pathologist
supply in a new era of managed care, they must consider
the possibility, or likelihood, that managed care can lead
to significant downward pressures on the supply of
pathologists.

 

[mlw03]

While bad perhaps in the short run for some pathologists, would this be bad for the system and for patient care as a whole? I don't do community pathology, but what percentage of biopsy specimens are un-necessary? I'm really asking, not just being confrontational. For example, we know plenty of urologists over-biopsy prostates for both CYA and making-money reasons. How does that play out on the larger scale? If ACOs lead to docs taking few biopsies, and to pathologists not doing lots of unwarranted stains, isn't that a good thing?

Very interesting paper. They state that management brought decreased "need for pathologists" in Canada and that we may see the same here too. We have been warned.

Our data do suggest that as American pathology
organizations develop models for predicting pathologist
supply in a new era of managed care, they must consider
the possibility, or likelihood, that managed care can lead
to significant downward pressures on the supply of
pathologists.

 

[scienceguy19]

It's a good thing to decrease the number of unnecessary tests and decrease healthcare spending.

I think though there are many grey areas where it's difficult to come to gauge whether something is necessary or not. Should you order the FISH, molecular, or a couple extra immunostains to clinch the diagnosis? Should you order some prognostic marker? Is a pathology department going to be rewarded for keeping costs down by ordering fewer of these 'ancillary' tests with the tradeoff of a less precise diagnosis? It's hard to imagine the government coming up with guidelines for pathologists of which tests we are obligated to do or should not do.

I don't know how the logistics would work under an ACO model of reimbursement as opposed to fee-for service. I wonder how Canada deals with these issues.

 

[Torsed]

I know people hate the term but what the government needs is death panels. If you are 80 years old with small cell cancer you don't get a pet scan and radiation and chemotherapy and then die six months later. You go die a dignified death now. If you are 83 and demented and fall you don't get a hip replacement. If you are 83 and demented you don't get referred to a bone marrow biopsy to look for MDS because your platelet count is 123k. Or if you do want all that stuff, you pay for it yourself. That is where we can save public money and make medicare last for decades.

To continue this subject, what about the 20 or 30 shave biopsies of basal cells I get a week on 90 year old people. Sweet god if medicare only knew and the 90 y/o's didn't vote. Its all a racket.

 

[Torsed]

BTW we already birthed this baby previously. Searching can do wonders, yes I know you know!

http://forums.studentdoctor.net/showthread.php?t=863188

 

[mlw03]

To continue this subject, what about the 20 or 30 shave biopsies of basal cells I get a week on 90 year old people. Sweet god if medicare only knew and the 90 y/o's didn't vote. Its all a racket.

Yeah, but picture this: "Government won't pay for doctors to remove CANCER from healthy older Americans!!!!"

 

[Path or bust]

While bad perhaps in the short run for some pathologists, would this be bad for the system and for patient care as a whole? I don't do community pathology, but what percentage of biopsy specimens are un-necessary? I'm really asking, not just being confrontational. For example, we know plenty of urologists over-biopsy prostates for both CYA and making-money reasons. How does that play out on the larger scale? If ACOs lead to docs taking few biopsies, and to pathologists not doing lots of unwarranted stains, isn't that a good thing?

I completely agree, but do our leaders have the same foresight?

Like it or not, with new confocal and other technologies on the horizon, we may see a decrease in demand for biopsies. But all the predictions that are coming from pathology have the projected number of specimens going up through 2040! Really?

 

[path24]

Well, house prices always go up. So specimens must always go up too. Academics and community docs both like their unnecessary tests. Its everywhere in medicine.

Shortage of pathologists in the future... If I owned/managed a pathology business/department, I would always say there is a shortage also....cheaper labor for me. I want cheap techs, docs...too exploit.