the ugly truth about pod labs

[pathstudent]

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I was at a local path society meeting and I was talking to a community practice doc sitting at my table. He was talking about how a group of 10 urologists had moved onto his hospital's "campus", which is a lot urologists and a lot of prostate biopsies. They asked them to do the pathology for their pod lab, but in order to bill medicare for the global they had to have the histo lab in their office and the pathologist had to come sign the cases out in the office everyday. I guess it is some sort of loop hole that allows the urologists to bill for global and not be in violation of STARK laws or some law like that. The pathologists said they said they would do it as long as they got to bill the professional. The urologist said "No" and that they would pay them $10 per biopsy (for a 12 quadrant biopsy case). The pathologists said that medicare paid them $35 for an 88305. The head of the urologist group said "well we think you are worth about $2 per biopsy but we will give you $10". The pathologists walked. But he said the urologists are there and operating the pathology lab in their office are there is some pathology group in the city providing them the service. So this is the reality for community pathologists. The urologists are billing the global which medicare pays about 100, and they are giving the pathologist 10. So the urologists are keeping 90% and giving the pathologists 10%. And some pathologist or pathology group is fine with taking that. It is true that you can read out 12 prostate biopsies in about 15 minutes and that would pay 120 for the pathologist for a mere 15 minutes of time. But the urologist would be collecting over a 1000 for that same 15 minutes, for basically doing nothing but buying a super simple rudimentary histo lab and paying a low level functioning tech to gross and process the biopsies.

You see community practice pathologists are being left with the mastectomies and prostatectomies and the huge specimens that take a ton of time to gross and read out and all the high yield stuff is being picked off by more savvy Alpha-type physicians. So instead of having a nice mix of specimens in terms of reimbursement, hospital based community practice types are left basically holding their wieners. It is unfortunate. And it is another reason why in this era of medicine, you should go into academics. Because you don't have to worry about any of this. You can at least maintain your dignity and earn a starting salary of almost 200K plus benefits and in about 10 years you will be the MAN in your area and making bank for consults.

He said another thing urologists are doing is billing for "analyzing" urovision FISH on their own. Labs like neogenomics and U.S. Labs prepare all the stuff for them and they just click normal or abnormal and the software generates a report with their name on it as the interpreting physician. He said that the urologists earn about 300-400 per urinalysis for basically doing nothing (as medicare pays about 60 per probe for "interpretation" but they are interpreting nothing. The reference labs are just happy to keep the technical component and don't care who gets the professional) and again they are taking money out of what was the realm of pathologists.

Community practice pathology really seems like a race to the bottom. If someone is willing to read out an 88305 for $10, will someone soon be willing to do it for $9 and then $8 and finally down to what a urologist thinks a pathologist is worth, $2 for an 88305, while they keep $98 for being the hero that sticks something up a man's anus and biopsies the prostate 12 times and puts each biopsy in a different container, because why....because medicare pays based on the container.

Medicine is broke. I demand reform now. There is no hope for pathologists in the current system. At least help us keep our dignity.

 

[KeratinPearls]

I was at a local path society meeting and I was talking to a community practice doc sitting at my table. He was talking about how a group of 10 urologists had moved onto his hospital's "campus". They asked them to do the pathology for their pod lab, but in order to bill medicare for the global they had to have the histo lab in their office and the pathologist had to come sign the cases out in the office everyday. I guess it is some sort of loop hole. The pathologists said they said they would do it as long as they got to bill the professional. The urologist said "No" and that they would pay them $10 per biopsy (for a 12 quadrant biopsy case). The pathologists said that medicare paid them $35 for an 88305. The head of the urologist group said "well we think you are worth about $2 per biopsy but we will give you $10". The pathologists walked. But he said the urologists are there and operating the pathology lab in their office are there is some pathology group in the city providing them the service. So this is the reality for community pathologists. The urologists are billing the global which medicare pays about 100, and they are giving the pathologist 10. So the urologists are keeping 90% and giving the pathologists 10%. And some pathologist or pathology group is fine with taking that. It is true that you can read out 12 biopsies in about 15 minutes and that would pay 120 for the pathologist for a mere 15 minutes of time. But the urologist would be collecting over a 1000 for that same 15 minutes, for basically doing nothing but buying a super simple rudimentary histo lab and paying a low level functioning tech to gross and process the biopsies.

You see community practice pathologists are being left with the mastectomies and prostatectomies and the huge specimens that take a ton of time to gross and read out and all the high yield stuff is being picked off by more savvy Alpha-type physicians. So instead of having a nice mix of specimens in terms of reimbursement, hospital based community practice types are left basically holding their wieners. It is unfortunate. And it is another reason why in this era of medicine, you should go into academics. Because you don't have to worry about any of this. You can at least maintain your dignity.

He said another thing urologists are doing is billing for "analyzing" urovision FISH on their own. Labs like neogenomics and U.S. Labs prepare all the stuff for them and they just click normal or abnormal and the software generates a report. He said that the urologists earn about another 300-400 per case for basically doing nothing (as medicare pays about 60 per probe for "interpretation" and again they are taking money out of what was the realm of pathologists.

Community practice pathology really seems like a race to the bottom.

Pathologists are glorified techs. We are like the nerds who get beat up by bullies at lunch hour and do nothing about it. We are getting out butts whooped and exploited by clinicians.

Pretty sad to see another group take on that urology group for 10 bucks. Seriously sad. It's like beggars running for pennies.

Urovysion and all those molec diagnostic tests have been taken over by huge labs. Pathologists will never get a penny from molec diagnostics, but we should have control over receiving full reimbursement for reading slides (which has sadly been taken away from us).

 

[pathstudent]

This is an example about how medicine might be a little messed up. Does it really affect mortality and morbidity wether the biopsies go in one container or two containers for left and right or 12 different containers? I am not GU expert but I do know that surgery versus drug therapy is usually based on Gleason score on the biopsy and staging is based on the prostatectomy specimen. Does it really matter whether you just know that one of 12 cores had 15% 3+4=7 cancer or does it really help to know that it was from the right upper mid apex?

This is could be an example where the critics are right where doctors are just trying to rack up the bill. The pathology bill is 12 times what it would be if the cores were just in one container, but do you really get 12 times us much knowledge or patient benefit? No probably not but you do make 12 times as much money. It is borderline fraud even though you are following the rules.

Hopefully Obama is reading this and will put a stop to this madness.

 

[djmd]

This is an example about how medicine might be a little messed up. Does it really affect mortality and morbidity wether the biopsies go in one container or two containers for left and right or 12 different containers? I am not GU expert but I do know that surgery versus drug therapy is usually based on Gleason score on the biopsy and staging is based on the prostatectomy specimen. Does it really matter whether you just know that one of 12 cores had 15% 3+4=7 cancer or does it really help to know that it was from the right upper mid apex?

This is could be an example where the critics are right where doctors are just trying to rack up the bill. The pathology bill is 12 times what it would be if the cores were just in one container, but do you really get 12 times us much knowledge or patient benefit? No probably not but you do make 12 times as much money. It is borderline fraud even though you are following the rules.

Hopefully Obama is reading this and will put a stop to this madness.

Think about it for a second if there were two spots of CA on your 12 biopsies, would it make a difference if they were from adjacent or disparate areas? Left and right? apex and base? or both from the right mid...

 

[Pathwrath]

Prospective pathologists need to read and understand this thread. Please read my earlier comments on this subject.

These are not POD labs, but the widespread clinician in-sourcing of surgical pathology biopsy services, and the Stark Law is powerless to stop it.

You want evidence of how the pathologist glut affects you even if you are (currently) happily employed? This is a good place to start.

 

[Pathwrath]

Because you don't have to worry about any of this. You can at least maintain your dignity and earn a starting salary of almost 200K plus benefits and in about 10 years you will be the MAN in your area and making bank for consults.

This is the part of your informative post I do take issue with. You are deluded if you think academics are somehow immune to the effects of in-sourcing. It is true that academic pathologists have a built-in referral base, but the truly successful ones you dream about becoming have to hustle for biopsies like the rest of us, and that means they too are competing with cut-rate operations. In fact, academic centers may be at a relative disadvantage because they are bloated and inefficient by definition and cannot compete with leaner and meaner operations. For example, we are holding our own (for the time being, at least) with the academics and Ameripath because we have learned to do more for less. And more for less is the future across the board.

Yes, it is a race to the bottom for community pathology, but the academics who puked out all these trainees are going to be riding with us.

 

[106174]

Hopefully Obama is reading this and will put a stop to this madness.

No offense but this (the "putting a stop to this madness" part) is another delusion, I think...

 

[KeratinPearls]

This really pisses me off. Tell me if I'm right: So according to the Stark laws, you cannot send your biopsies/patients to a place that you or your relatives have financial incentives in? So the loophole is that clinicians have brought histo labs in house so they can avoid going to jail and at the same time make $$$ off those biopsies.

Now, are any of the leaders in Path doing anything about this? I mean if nothing is done about this, then its pure negligence. This is exploitation. Hopefully something gets passed so that this practice becomes illegal. Taking a chunk of the professional charge from pathologists, cmon now! If this doesn't become illegal I foresee many clinicians who will see the opportunity and exploit the pathologist as much as they can.

It's not only the oversupply of pathologists but also the suckers that will actually read out a prostate biopsy for $10.

 

[Art]

The POD labs are a problem. According to the CAP website, they brought this to the attention of CMS back in 2007 and proposed rule changes.

http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=statline%2Fcms_analysis.html&_state=maximized&_pageLabel=cntvwr

 

[exPCM]

Prospective pathologists need to read and understand this thread. Please read my earlier comments on this subject.

These are not POD labs, but the widespread clinician in-sourcing of surgical pathology biopsy services, and the Stark Law is powerless to stop it.

You want evidence of how the pathologist glut affects you even if you are (currently) happily employed? This is a good place to start.

As usual Pathwrath is right on the mark here. If there was not a glut of pathologists this problem would not exist. Since there are too many pathologists it becomes a race to the bottom as too many pathologists fight for a piece of the pie. Ten bucks a biopsy is near the bottom. If pathologists were in limited supply they would tell these urologists to go pound sand.

Of course we have those in denial and those who are delusional who say I have or will get a good job so this will not affect me. The fact is these practices are having a major effect on pathology in general. Those who think they are immune are likely to be surprised.

The only answer to this is: CUT PATHOLOGY RESIDENCY SPOTS AT LEAST IN HALF.
Unfortunately we still have too many academic pathologists in CAP and ABP leadership positions. These academics want to keep their supplies of resident labor funded by CMS. The average resident makes about 45-50K plus benefits. CMS reimbursements are often far higher per resident. So the programs will keep filling the spots to keep the money and labor rolling in. The programs lose funding for each spot they do not fill. Please vote for and support community pathologists for all national leadership roles in pathology.

Just look at Dr. Remick's BU path program. He has 1 PGY-4, 0 PGY-3, 6 PGY-2, and 4 PGY-1 residents. ( http://www.bumc.bu.edu/busm-pathology/residency-program/resident-profiles/ ) with numerous IMGs. IMO this looks like a typical example of what I have seen in pathology - when programs lose residents they don't let the spots go empty but instead find somebody to fill the spot to keep the money and labor rolling in. IMO the real truth about academic pathologists is they often care more about getting the bodies for their programs than improving pathology training or matching the number of trainees to the need for pathologists.

P.S. Here is a table which indicates the money just from Medicare (does not include VA and state/Medicaid GME funding) that hospitals raked in from 2001-2005 for GME funding: http://www.graham-center.org/online...s.Par.0001.File.tmp/dt-teaching-hospitals.pdf The 2005 numbers are towards the end of the pdf.
I could not find an online table for 2006-2009 but the fact is that it is great deal for hospitals to bring in people to do work (residents) and have someone else (the government) pay their salaries.

 

[Gyric]

This is a serious threat, should be illegal, and will need to be addressed definitively through CMS. It is bad for patients and I think eventually it will be fixed. In the meantime, there are ways to fight back, you don't have to just give up your lunch money. There are lawyers who specialize in this, APF has given whole seminars on how to win this fight, etc. If we did band together, as a profession we could end this; for example we could require that you not engage in this type of practice in order to re-certify. Also, that path group should be requiring review of outside biopsies and FISH along with the resultant prostatectomy and bladders; I am betting that the lowest bid type of pathologist, and certainly the urologist trying to read FISH, is going to make mistakes. You could make sure the patient was aware of the error made by these physicians that lead to his surgery (and any complications) ... a few million dollar law suits later, they should have some sense of why our services are worth more than $2.

 

[exPCM]

This is a serious threat, should be illegal, and will need to be addressed definitively through CMS.

It is not illegal in most states and the Gastroenterologist, Urologist, and Dermatologist lobbies will fight to keep it that way.

If we did band together, as a profession we could end this; for example we could require that you not engage in this type of practice in order to re-certify.

Interesting idea but I hold out no hope that the current ABP would implement this.

Also, that path group should be requiring review of outside biopsies and FISH along with the resultant prostatectomy and bladders.

The urologists would howl to the hospital about this and urologists bring in revenue to the hospital. Do you think most hospitals will side with the urologists or pathologists on this? I know of one hospital where the path group fought for this and the result was that it was agreed that the path from outside should be reviewed as part of quality control but the path group was not allowed to bill for these path reviews.

I am betting that the lowest bid type of pathologist, and certainly the urologist trying to read FISH, is going to make mistakes. You could make sure the patient was aware of the error made by these physicians that lead to his surgery (and any complications) ... a few million dollar law suits later, they should have some sense of why our services are worth more than $2.

This is the type of argument I have heard for years about NPs, PAs, and CRNAs. The logic is that these midlevels will screw up so much that malpractice issues will put them out of business. This has not happened and I doubt that it ever will. PA and NP school enrollment is booming.

 

[2121115]

Anatomic pathology was included in an exception that allowed clinicians to bring finger stick glucose and other office based testing into their offices. Honestly, anatomic pathology was not excluded simply because nobody had the foresight to see this coming. The exception exists (and is worded as such) for the clinicians to be able to perform tests that would immediately affect treatment while the patient is still in clinic. Obviously, anatomic path does not meet this stipulation. However, now that it is included it is going to be a bear to get it taken out because so many other specialties are starting to depend on this revenue because their own reimbursements are being cut as well (not just happening in path).

The good news is that there are leaders in pathology who are actively trying to get anatomic path removed from this exception by talking with congress during these reform talks (check out statline). The bad news is that I can only assume that pathologists are probably the only docs that want it taken out (obviously) so every time they try to do so, other specialty organizations oppose it and pathology becomes a lone voice. That is just the way that the democratic process works, for better or worse.

 

[fna]

And it is another reason why in this era of medicine, you should go into academics. Because you don't have to worry about any of this. You can at least maintain your dignity and earn a starting salary of almost 200K plus benefits and in about 10 years you will be the MAN in your area and making bank for consults.

Community practice pathology really seems like a race to the bottom. If someone is willing to read out an 88305 for $10, will someone soon be willing to do it for $9

Yes, POD labs give money to urologists and take money away from pathologists. But somehow you don't think this will affect academics?

If I were an academic urologists and wanted to setup a POD lab, I'd 1) Keep my academic job while diverting my well-insured patients to my newly opened biopsy clinic/histo lab across the street. 2) If my contract (or the law?) does not allow #1, I'd get all the urologists together, leave en mass to the nearest grateful community hospital, take all of our patients with us, and send our well-insured patients to our newly opened biopsy clinic/histo lab across the street. 3) Threaten to do #2, forcing the hospital to provide more money, which the hospital can "take" from Pathology anyway.
What, you don't think hospitals will take revenue from one department to give to another? Ask around.

So now that all your easy biopsies are going elsewhere, how will the hospital pay for your (lol) starting salary of 200K with benefits. The answer is they won't because pathology is a "cost center". They're not going to take money from a more productive department to support you- that would be communism. And if you don't like it, there's someone else out there who is better trained, with more experience, and is willing to work for 120K with fewer benefits. Even better, fire all the clinical instructors, and the less productive assistant profs- why should the full professors take a pay cut?? They've already earned their entitlements. Don't worry the workload will be covered by our 6 new "surg path fellows" who will be making 50K, covering all our call, and writing our papers. Welcome to the race to the bottom.

And by the way, you do realize that not all academic pathologists or academic hospitals were created equally right? Mediocre academic pathologists get spanked all the time by community practice pathologists that trained in reputable academic hospitals. You should also realize that some community hospitals have a far better reputation than the local academic hospital, and as a result have more patients (at least the ones with insurance), generating more money, thus attracting the good surgeons, good oncologists, maybe even good pathologists, which increases its reputation, drawing in more patients. It's really a virtuous cycle, unless you're in the academic hospital.

LOL, the "MAN in your area and making bank for consults". I FedEx my consults across the country. I prefer internationally recognized experts, because I'm not getting sued for vicarious liability because I picked Dr. Nobody, head of lung, pituitary, and placental pathology at Unknown University Hospital, who once co-authored a chapter in some book that's gathering dust in the substandard library of a mediocre training program. Well that, and I want the right diagnosis, not some descriptive hedge that I could have done myself.

We're in the same boat. The only people who are safe are tenured professors at major, financially-stable, reputable academic centers, preferably in an area with affluent, educated people. Good luck.

 

[2121115]

If pathologists were smart, we would increase our numbers for obtaining leverage by partnering with radiologists who lose their tech fees to clinician private groups who own their own CT scanner and whatnot to petition congress to make these types of practices illegal. The same thing happens to radiologists as well, its just that radiologists refuse to participate in as fast a race to the bottom. Numerous clinician private groups have tried to bargain radiology groups against each other (or even overseas groups) to get radiologists to read scans for $10 (or whatever). It doesn't work because a radiologist won't read them for that cheap- they just won't do it. However, it is only a matter of time before radiologists will begin to feel the brunt of this too. That may be what it takes to make meaningful change happen- because radiologists won't stand for it.

 

[2121115]

For those new in practice, I am curious how your practices are dealing with this issue. First, is it an issue in your area? If so, how is your practice managing the issue. If not, why do you think it hasn't permeated your area yet?

I'm curious. Does being in a state that permits client billing have an effect?

 

[pathstudent]

Think about it for a second if there were two spots of CA on your 12 biopsies, would it make a difference if they were from adjacent or disparate areas? Left and right? apex and base? or both from the right mid...

I don't know if it makes a difference. Staging is based on the prostatectomy not the biopsy. I have seen many prostates removed where 1 core out of 12 showed 5% gleason 3+3. I have seen many prostates that came out with extensive disease where only one prostate core out of 12 showed cancer and many which only had focal disease in the prostate under the same circumstances.

I have also been at places where they just did things Left prostate vs. Right prostate on the biopsies. I know of know study that has shown better outcome for patients that had their biopsies broken up into 12 containers versus 2. I think it is suspicious for "working the system" to make the most money possible.

On a different note, pathologists have some accountability for this. Back in the days when most groups had small pathology owned histo labs, pathologists griped and griped to medicare that the technical reimbursement was too low. This was in the time where the professional component was reimbursed higher than the technical component. Well medicare just took money from the PC and transferred it to the TC. So there was no benefit to pathologists because the global remained the same. But this made the TC very lucrative and drew the CP focused reference labs into AP, and eventually the GIs and Uros figured out that they could make some easy money too.

What would be good is if CMS slashed the TC to barely cover cost. It would take out the reference labs and make insourcing of pathology much less attractive to gastros and uros. Pathologists could at least keep the PC. Most young people don't realize that an 88305 at one time was reimbursed 80-90 for the the PC. Now it is down to 35-40. By continuing practices of biopsing the prostate 16 times and putting them in 16 different containers and billing 16 88305s, will just cause CMS to say F U and slash it more. What is even worse about the gastros and uros doing all these excessive number of biopsies so they can make money of the pathology is rules is that they will F it up for the rest of us. All 88305 specimens will be slashed. So while GI biopsies and Prostate biopsies will be the cause of the abuse, it will slash reimbursement for breast biopsies, lymph node biopsies etc....

 

[mcfaddens]

This post will probably not go over too well with some of you out there, but as a group Pathologist like to cry a lot and do little to fix the major problems in advance (we give prognostic info on patients daily but yet we cannot figure the same info out for our profession). If clinicians are moving in on your territory then move in on theirs, if reference mega labs are giving you trouble then get up off you ***** and bash them to your local community and clientele. You cannot let other people beat you to the punch, you have to strike first and strike hard, if they bend the rules then you bend them back, take a leadership position in you medical center while giving the impression that you are not a hospital employee. All of this can be done with some ease (and if all of your business is leaving then you obviously have some free time to go out and get it back). WE as a group have to stop being passive (this was hardwired into most of us during training, that was done for a reason a very selfish passive aggressive $hitty reason, you have to get over it and make moves on your own). Someone posted that we are just technicians well you might as well just roll over and die then, seriously these clinicians are way more tech like than we are, rarely do thoughts flow in and out their minds as opposed to how fast one can do a colonoscopy. Stop crying and do something on a local level instead of waiting for uncle Sam to bail you out (which will never happen to physicians in any field)

 

[2121115]

What would be good is if CMS slashed the TC to barely cover cost. It would take out the reference labs and make insourcing of pathology much less attractive to gastros and uros. Pathologists could at least keep the PC. Most young people don't realize that an 88305 at one time was reimbursed 80-90 for the the PC. Now it is down to 35-40. By continuing practices of biopsing the prostate 16 times and putting them in 16 different containers and billing 16 88305s, will just cause CMS to say F U and slash it more. What is even worse about the gastros and uros doing all these excessive number of biopsies so they can make money of the pathology is rules is that they will F it up for the rest of us. All 88305 specimens will be slashed. So while GI biopsies and Prostate biopsies will be the cause of the abuse, it will slash reimbursement for breast biopsies, lymph node biopsies etc....

The problem then is that we all lose money. There are still many pathologists that bill TC. I have heard this line of thinking before and many people feel that we should just ride this out until CMS addresses it and then bring TC billing back in house for pathologists. Any cut to the TC without an concominant increase in reimbursement for PC would hurt pathologists who still bill TC. However, it would probably bring back the volume that has been lost so maybe it would even out, I don't know. Personally, I would be fine with that if it would bring the TA's back in to the hospital-based pathologists.

Regardless, any movement to cut TC billing for 88305 will be actively opposed by the AGA and the AUA, not to mention the ACOG who are doing this with paps, and it will be extremely difficult to pass. And even if it did, uros and gastros would just make you sign the cases out at their office and take a portion of the PC. In other words, it doesn't fix the $10 per biopsy problem. The real problem, after all, is that it is legal for them to bill for services they do not perform. It is illegal in every situation except pathology.

 

[yaah]

I don't think it is illegal in every situation except pathology - some internal medicine groups own their own imaging equipment, for example, and have a radiologist come in to view the images. I suspect the same billing arrangements occur. It is easier to do this in pathology in part because the cost of setting up a histology lab is cheaper than buying a CT scanner. Other than that I agree with your post. Most of these things happen because of a neverending quest for money. Urologists used to have lupron injections to make money off of. Then reimbursement was cut, so many moved to insourcing pathology. These, of course, are physicians who give the rest of medicine a bad name. They exist in every field, including pathology. And they are never going to go away. You can pass whatever law you want, but sleaze always finds a way.

It was said above that this practice hurts private groups much more than academics (or something to that effect). Not true. I know of several academic programs (not usually large ones though) who lost prostate and/or GI biopsy volume. I talked to a resident at MCV who hadn't seen an in house prostate biopsy her entire residency.

Part of the "solution" comes from a good relationship with the clinicians. This does not solve all problems, but it helps. A lot of the reference labs win business by appealing outwardly to "quality" (even if they depend more on monetary manipulation to win actual business) by having "experts" see all the cases. And to be frank, many private groups as well as academic groups do not do a great job with these cases. It doesn't mean that the reference labs do, of course (and I have seen ample evidence that it often doesn't), but that can be beside the point.

 

[malchik]

Is this essentially any different from working for an academic department, or any entity where the pathologist is just paid a salary, for that matter? As I understand it, reimbursements in academics end up just going through the department on upward to the hospital, where funds are redistributed as the leadership sees fit.

 

[pathstudent]

Is this essentially any different from working for an academic department, or any entity where the pathologist is just paid a salary, for that matter? As I understand it, reimbursements in academics end up just going through the department on upward to the hospital, where funds are redistributed as the leadership sees fit.

Yes it is absolutely different. In most academic places you are paid a base salary plus a bit more based on your productivity. Also any extra money in the department doesn't go to paying for the new BMW or private tuition of the chair's son or the vacation home of another pathologist like it is going to in the urology office.

We should collect a list of all pathologists doing POD lab work or insourcing pathology work and track them on the internet. Then when their job falls apart we blacklist them to keep them from ever getting a job again.

 

[Pathwrath]

Part of the "solution" comes from a good relationship with the clinicians. This does not solve all problems, but it helps. A lot of the reference labs win business by appealing outwardly to "quality" (even if they depend more on monetary manipulation to win actual business) by having "experts" see all the cases. And to be frank, many private groups as well as academic groups do not do a great job with these cases. It doesn't mean that the reference labs do, of course (and I have seen ample evidence that it often doesn't), but that can be beside the point.

This has not been our experience. We served as the reference lab for every local GI and GU mill, and all that gave us was first crack at being their in-sourced pathology service. I'm not sure how strong these relationships are in the face of immediate unearned profit that is theirs for the asking.

 

[Pathwrath]

A one-second Google search coughed up this rancid piece of fungus:

http://www.twincrestlab.com/

 

[Pathwrath]

This post will probably not go over too well with some of you out there, but as a group Pathologist like to cry a lot and do little to fix the major problems in advance (we give prognostic info on patients daily but yet we cannot figure the same info out for our profession). If clinicians are moving in on your territory then move in on theirs, if reference mega labs are giving you trouble then get up off you ***** and bash them to your local community and clientele. You cannot let other people beat you to the punch, you have to strike first and strike hard, if they bend the rules then you bend them back, take a leadership position in you medical center while giving the impression that you are not a hospital employee. All of this can be done with some ease (and if all of your business is leaving then you obviously have some free time to go out and get it back). WE as a group have to stop being passive (this was hardwired into most of us during training, that was done for a reason a very selfish passive aggressive $hitty reason, you have to get over it and make moves on your own). Someone posted that we are just technicians well you might as well just roll over and die then, seriously these clinicians are way more tech like than we are, rarely do thoughts flow in and out their minds as opposed to how fast one can do a colonoscopy. Stop crying and do something on a local level instead of waiting for uncle Sam to bail you out (which will never happen to physicians in any field)

At a local level, the choices are limited. When your local GI's and Uro's set up their free-standing mills and start in-sourcing, your group can either play or pass. That really is the sum of your options. The clinicians really don't care about your or the hospital's righteous anger because they are independent of both of you.

These issues have to be addressed by pathologists as a group. Look at how long and protracted the arguments on this board have been just getting a consensus that there is a serious actionable problem with pathology. Every criticism is minimized or relativized, every solution is endlessly debated. That's the problem.

 

[lipomas]

These issues have to be addressed by pathologists as a group. Look at how long and protracted the arguments on this board have been just getting a consensus that there is a serious actionable problem with pathology. Every criticism is minimized or relativized, every solution is endlessly debated. That's the problem.

I am not sure that is really true - there is no debate about whether pod labs are evil and unethical. But the "debate" seems to always come back to reducing the numbers of pathology residency spots, which while it might be helpful will really have no effect for at least 4-5 years, assuming it was enacted immediately. And good luck getting anything like that passed.

You are right that the issues have to be addressed by pathologists as a group. But many pathologists don't care, others are ignorant, and ones with money and time want to see the status quo continue. I don't know personally what CAP or ASCP is doing in regards to these in office arrangements. I get occasional emails about "pod labs" and "specimen markups" which relate to it, but the problem is these stupid rules are written by politicians who only respond to money and populist rhetoric. I don't think pathologists in general are very good at populist rhetoric - neither are most clinicians except maybe pediatricians.

The thing that has to happen though is not reducing patholgy residency spots - as said above that is basically irrelevant currently (even if it might help way down the road). What has to happen is serious reformation of legislation to end sleazy business practices. The major problem is that there are legitimate enterprises which are not unethical. There are huge, standalone urology and GI groups which do treat the pathologist as a relative equal (they may be outnumbered by sleazy ones though). There are also dermatologists who read their own slides.

However, I fail to see how it is legal in anyone's book to bill for the work that someone else does. If we need healthcare "reform" in this country, that should be part of it, along with the insane practice of how clinical medicine is reimbursed (procedures first, then all else). The problem is that politicians neither understand this nor do they care.

 

[lipomas]

I thought there were some interesting blurbs here http://www.pathologyoutlines.com/management/management.html

The thing that pisses me off is that I always hear about how "new rules will make it tougher for pod labs!" but yet they seem to continue to proliferate. Reading through these articles, I have no earthly idea how it is legal for a urologist to bill for interpretation of a test if they are not interpreting it. I guess it all boils down to whether the pathologist agrees to work as a contracted employee for the uro group, and the uro group bills for the interpretation since processing and interpretation were done in their office. But that's such bull****. It's just sneaking around the law! Why don't they pass laws that actually prevent what they are supposed to prevent?

 

[Pathwrath]

But the "debate" seems to always come back to reducing the numbers of pathology residency spots, which while it might be helpful will really have no effect for at least 4-5 years, assuming it was enacted immediately. And good luck getting anything like that passed...The thing that has to happen though is not reducing patholgy residency spots - as said above that is basically irrelevant currently (even if it might help way down the road). What has to happen is serious reformation of legislation to end sleazy business practices. T

I'm glad you wrote this, because you nicely illustrated my point.

The glut drives these arrangements. You eliminate pod labs by congessional fiat (easy), the clinicians then switch to in-housing with pathologist employees or independent contractors. Getting rid of these arrangements will not be as easy, and even if you could pull it off, something just as exploitive will take its place.

You have a $hitload of pathologists ready to work for peanuts. You think new laws are somehow going to correct this?

 

[2121115]

I'm glad you wrote this, because you nicely illustrated my point.

The glut drives these arrangements. You eliminate pod labs by congessional fiat (easy), the clinicians then switch to in-housing with pathologist employees or independent contractors. Getting rid of these arrangements will not be as easy, and even if you could pull it off, something just as exploitive will take its place.

You have a $hitload of pathologists ready to work for peanuts. You think new laws are somehow going to correct this?

I agree. The long term solution is to cut residency positions. In the short term however something needs to be done about these in-house lab arrangements.

 

[malchik]

However, I fail to see how it is legal in anyone's book to bill for the work that someone else does.

Again, this seems not unlike academic pathologists or hospital employees. If a pathologist is paid less than the cases they sign out bill for, which frequently happens in academics, then someone else is getting paid for work they didn't do. Any rule to proscribe insourcing pathology will have to clearly distinguish between large hospitals and these pod labs.

 

[pathstudent]

Again, this seems not unlike academic pathologists or hospital employees. If a pathologist is paid less than the cases they sign out bill for, which frequently happens in academics, then someone else is getting paid for work they didn't do. Any rule to proscribe insourcing pathology will have to clearly distinguish between large hospitals and these pod labs.

This is true. Or like when one joins a private group before he is made partner. He is being paid a salary while the group bills for his work. That is no different than the in-sourcers of pathology.

BTW, there is zero percent chance of residency positions ever being cut. Academic departments are now in the mix going after private practice domain so they/we will need ever more residents/surg path fellows to gross and write up cases.

 

[Pathwrath]

Again, this seems not unlike academic pathologists or hospital employees. If a pathologist is paid less than the cases they sign out bill for, which frequently happens in academics, then someone else is getting paid for work they didn't do. Any rule to proscribe insourcing pathology will have to clearly distinguish between large hospitals and these pod labs.

Exactly. Try crafting such a convoluted rule and getting it passed.

That's why CAP is still continuously patting itself on the back over its pod lab work, even though pod labs are completely irrelevant at this point. CAP has got nothing but pious position statements on in-office pathology services.

 

[ABC789]

The good news is that there are leaders in pathology who are actively trying to get anatomic path removed from this exception by talking with congress during these reform talks (check out statline). The bad news is that I can only assume that pathologists are probably the only docs that want it taken out (obviously) so every time they try to do so, other specialty organizations oppose it and pathology becomes a lone voice. That is just the way that the democratic process works, for better or worse.

This is true. The only way to remove Anatomic Pathology from the loophole is to become POLITICALLY
ACTIVE through your pathology organization(s) of choice and individually. The CAP's yearly "Advocacy School" addresses many of these issues. The ASCP's Day on the Hill does does too.

You cannot sit back and complain about how unfair the system is unless you actively do your part to address these issues.

 

[HESC]

This is true. The only way to remove Anatomic Pathology from the loophole is to become POLITICALLY
ACTIVE through your pathology organization(s) of choice and individually. The CAP's yearly "Advocacy School" addresses many of these issues. The ASCP's Day on the Hill does does too.

You cannot sit back and complain about how unfair the system is unless you actively do your part to address these issues.

Excellent to know.

Also, I found this in the most recent CAP Statline that addresses the in office ancillary exemption which is the loophole that allows in-sourcing anatomic path. Looks like this is one of the major topics in stark law reform.

Most participants agreed that the Stark Law was enacted under the assumption that financial incentives skew a physician’s judgment, increases utilization, undermines competition, and potentially compromises quality. Several participants were also critical of Stark Law’s in-office ancillary services (IOAS) exception, however, which they felt is inconsistent with the articulated purposes of the legislation.


Suggested reimbursement reforms proposed at the Convener Session to combat these potential lapses included:

• decreasing reimbursement for all ancillary services provided through a physician’s group practice
• adopting a declining reimbursement formula for particular modalities tied to volume on the theory that the provider’s margin increases dramatically above a certain volume threshold
• decreasing payments for high margin services
• limiting the number of entities that are eligible to bill for certain lucrative services by implementing stringent credentialing requirements or
• bundling the payment plans that promote shared risk among providers involved in an episode of care.

 

[pathstudent]

Excellent to know.

Also, I found this in the most recent CAP Statline that addresses the in office ancillary exemption which is the loophole that allows in-sourcing anatomic path. Looks like this is one of the major topics in stark law reform.

Why can't they just say it in plain English

1) No more in sourcing of pathology.
2) No more pod labs.
3) Only pathologist can bill for global.
4) Only academic departments or private groups can hire pathologists as employees.

I have no idea what those other statements mean above.

 

[exPCM]

Why can't they just say it in plain English

1) No more in sourcing of pathology.
2) No more pod labs.
3) Only pathologist can bill for global.
4) Only academic departments or private groups can hire pathologists as employees.

I have no idea what those other statements mean above.

Excellent ideas. Unfortunately the current CAP leadership is probably a bit too passive and weak to come out directly for these specific goals.

 

[Pathwrath]

Also, I found this in the most recent CAP Statline that addresses the in office ancillary exemption which is the loophole that allows in-sourcing anatomic path. Looks like this is one of the major topics in stark law reform.

Good luck with that. This is how non-pathologists view the issue:

http://www.twincrestlab.com/pdf/verdict_web.pdf

 

[TMZ2007]

Good luck with that. This is how non-pathologists view the issue:

http://www.twincrestlab.com/pdf/verdict_web.pdf

Wow, that's pretty harsh.

 

[Pathwrath]

Actually, the only legitimate argument against these arrangements is self-referral--mill docs incentivized to perform unnecessary biopsies.

All the rest--clinicians setting up their own pathology labs with their own techs for their own profit, pathologists agreeing to work as parttime employees or independent contractors for cut-rate fees--is good capitalism. No one outside pathology is gonna cry us a river over this.

 

[malchik]

Actually, the only legitimate argument against these arrangements is self-referral--mill docs incentivized to perform unnecessary biopsies.

Agree, and it seems to me it is a very compelling argument that could only be lost by inaction or incompetence.

 

[pathstudent]

Actually, the only legitimate argument against these arrangements is self-referral--mill docs incentivized to perform unnecessary biopsies.

All the rest--clinicians setting up their own pathology labs with their own techs for their own profit, pathologists agreeing to work as parttime employees or independent contractors for cut-rate fees--is good capitalism. No one outside pathology is gonna cry us a river over this.

Well it is against the law for a group of internal medicine people to open up an endoscopy center, hire some gastro to endoscope all day long, send all their patients there and bill for it.

 

[exPCM]

I met a pathologist at a conference about 3 years ago who told me that his path group in the early 1990s built an endoscopy center and the group hired two gastroenterologists to work there. They had a steady stream of GI biopsies to read from the center. However their GI docs quit the path group after a couple of years and they could not find replacements because of the shortage of GI docs and the unwillingness of most of them to work for pathologists. So after 2 years he said they had to sell their endoscopy center.

 

[Entgegen]

I met a pathologist at a conference about 3 years ago who told me that his path group in the early 1990s built an endoscopy center and the group hired two gastroenterologists to work there. They had a steady stream of GI biopsies to read from the center. However their GI docs quit the path group after a couple of years and they could not find replacements because of the shortage of GI docs and the unwillingness of most of them to work for pathologists. So after 2 years he said they had to sell their endoscopy center.

Now if only we had a shortage of pathologists...

 

[Pathwrath]

Now if only we had a shortage of pathologists...

You mean letting simple supply and demand correct the problem, rather than passing more legislation? CAP begs to differ.

And while we're on the topic of our pathology leaders and their priorities, consider this food for thought:

http://www.g2reports.com/issues/advisory/advisory/joe_plandowski/227-1.html

 

[pathstudent]

Now if only we had a shortage of pathologists...

THere might be a shortage of pathologist one day, but it won't be through reducing residency spots. If anything residency spots will continue to rise.

When a program I was at was trying to increase the number of resident spots our PD said pathology is unlike optho or ENT which carefully restrict the number of spots to keep the number of practicing professionals low. In contrast he said the ABP would let him have as many as he wanted, but the main challenge is getting CMS to fund the spots.

One possibility of healthcare reform is that maybe they will decrease funding for residency spots in non-primary care specialties and take that money to increase primary care physicians.

When the residency went from 5 to 4 years, I wonder why the number of slots didn't decrease 20%. Wouldn't that have made sense?

 

[2121115]

THere might be a shortage of pathologist one day, but it won't be through reducing residency spots. If anything residency spots will continue to rise.

When a program I was at was trying to increase the number of resident spots our PD said pathology is unlike optho or ENT which carefully restrict the number of spots to keep the number of practicing professionals low. In contrast he said the ABP would let him have as many as he wanted, but the main challenge is getting CMS to fund the spots.

One possibility of healthcare reform is that maybe they will decrease funding for residency spots in non-primary care specialties and take that money to increase primary care physicians.

When the residency went from 5 to 4 years, I wonder why the number of slots didn't decrease 20%. Wouldn't that have made sense?

My program could get by just fine with half as many residents.

 

[Entgegen]

So I'm a 3rd year currently in rotations and I've been down to the path lab a couple times at the hospital I'm rotating at. Turns out that this particular hospital (and several others in the area) has contracts with AmeriPath, and the 3 pathologists that work in the hospital are AmeriPath employees. I had no idea until I did a little digging, as they each have their own little office in the lab, and it's just the 3 of them covering all the cases from this hospital while they rotate weekend call, grossing responsibilities, etc.

Is this how the big labs usually work? Contract out pathologists to hospitals? When thinking of pathologists employed by these huge labs, I just envisioned a warehouse with rows of tables and tons of pathologists lined up side by side behind microscopes while burly, hairy men with whips paced behind them.

 

[pathstudent]

So I'm a 3rd year currently in rotations and I've been down to the path lab a couple times at the hospital I'm rotating at. Turns out that this particular hospital (and several others in the area) has contracts with AmeriPath, and the 3 pathologists that work in the hospital are AmeriPath employees. I had no idea until I did a little digging, as they each have their own little office in the lab, and it's just the 3 of them covering all the cases from this hospital while they rotate weekend call, grossing responsibilities, etc.

Is this how the big labs usually work? Contract out pathologists to hospitals? When thinking of pathologists employed by these huge labs, I just envisioned a warehouse with rows of tables and tons of pathologists lined up side by side behind microscopes while burly, hairy men with whips paced behind them.

Many private practices have been sold to Ameripath, LabCorp, and others.

in the 80s and 90s there were many small groups of pathologists that would serve one or more community hospitals. Ameripath and others "bought" these groups and turned the pathologists into salaried employees. While it was a huge wind-fall for senior partners near the ends of the careers (on the range of 2-3 million for partner) in the long run it screws over all the young pathologists in the group and any future employees. As Ameripath will will pay the 1/2-2/3 what they would have made had they stayed independent. I heard about one group that was being bought by labcorp that the young people in the group wanted to fight it but the older in the group out numbered them and announced that whoever didn't vote for it would not receive any of the money. It's a tough world out there in the private practice. Another reason to consider academics.