What is not illegal about it?

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Pathplanet

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My observation while setting up lab equipment in Private Labs vs Hospitals and also involved with Prostate cancer

Big laboratories setup small labs in Urologists offices so they can earn the technical component, which in turn gives an incentive to a Urologist to do more "million" core biopsies on anyone who walks in. Lab bills for "Professional component", performs unnecessary immunostains(triple stain, Pten, Erg) on multiple cores for no reason. It happens on multiple occasions to the same patient because they "just watch" and followup.

While in big hospitals, same twelve cores of prostatic tissue is put in two containers labelled "left" and "right". 88305x2. Rarely any immunostains(forget about Pten and Erg). Same information regarding diagnosis and tumor volume.

Then we read "overdiagnosing" and "overtreating" prostate cancer.

Am I missing something here?

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Prostate needle biopsy is a bundled CPT no matter how many sites the physician submits. They cut reimbursement by about 40% verses 12x 88305s.
The new coverage rules in Medicare LCD, they won't pay for a IHC on every core going forward. Prostate lab are screwed if the do a PC-split to get the work.
 
The structure is legal do to the ancillary testing Stark loophole.
Ultimately, it needs congressional action to stop.
Labs and physicians will find another way as long as there is any profit margin to kick back.
 
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The smart minds came up with Erg PTEN on every cancer core when they cut TC by 40%!!
 
Did you wake up one day, decide to register on SDN to post this nonsense?

Seriously do you have even the slightest clue as to what "illegal" is?

Illegal:
1.) Obamacare. Where CMS interpreted this to allow bureaucrats to ignore the RUC committee recommendations of our country's leading medical experts to deny coverage. This is well beyond "climate change-deniers" level of scorn for science.
2.) Any given day Hillary Clinton was Secretary of State.
3.) Any so-called Sanctuary City that allows illegal alien criminals to roam the streets.

On to what you said: No, big hospital lab do not as a general principle dump 12 cores into 2 containers. Those that do are idiots are best and committing medical malpractice at worst. Floating 6x4mm thin cores and seeing all lengths of all cores in a level section is stupidly hard to do from a HT standpoint. You would have to see like 15+ step sections to get all the cores confirmed negative. I would never work at your "Mr. Big Hospital" doing that crap.

Urologists do not do a million cores just because they have a small incentive to do so. Nor do dermatologists do a million biopsies on patients when they have a dermpath lab. Nor do Hematologists do a million CBCs when they have an automated hem analyzer. THAT IS A MYTH. Stop watching MSNBC.

Urologists who do more biopsies are more likely to in source pathology but physicians dont wake up and say now that they have a lab, they will biopsy everyone. Of course there are some very rare bad actors. And democracy has the Clintons too, but one wouldnt argue for Communism because of this.

PIN4 is INCREDIBLY necessary, in fact it is great. And I am saying that because I look at more prostate biopsies than almost any pathologist in the US outside some large commercial players and some prominent GU academics. I have used ERG but dont now so I cant comment on that other than I personally felt it wasnt a valued added to the Urologists I work with.

As someone said, they changed how they reimburse these cases anyway and they are given a set price regardless of cores so you are AGAIN a day late and a dollar short on your not so keen observations and outlandish delivery.

Everyone here needs to realize that is there is a large vocal element within the government that literally does not want ANYONE treated for prostate cancer. Take from that what you will, but they tend to, yes, be WOMEN. One could spin some conspiracy theories on this Im sure. This is heavily played in physician happiness surveys where Urology went from being one of the better fields to near the worst after 20 years of assault.

If we were talking about triple stains and tits, trust me the tone would be different. So excuse me if I couldnt just read your ignorant comments and let them slide.
 
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Urologists don't have a small incentive, they have a big incentive. PIN4 is an incredible test when its performed for diagnostic reasons, not for "raising the revenue" reasons. If you look at the number of slides you claim, you very well know what I mean. If the number was not capped, there were 24 cores and sometimes more increasingly done. If one or more core shows a clear tumor, there is no need to do triple stain on others. This is being seriously discussed at medicare.
Yes dermatologists do a million biopsies because they have skin in the game. Same true with GI's. How do I know? You have no idea!!
Once you get the diagnosis yourself and you find out that you are being used as a body to bill thousands of dollars when almost everyone has a cut, your point of view will change.
 
Im sorry, you "set up lab equipment" then post here how I have no idea...Im 100% positive "dude with 3 messages to your account", you have no clue.

But Im always happy to meet up and talk about this live. I am a patient too. Your Bernie Sanders Bros "All doctors are greedy" B.S. holds no sway here bud.

I know you. You are 20-30s something guy who was "premed" in college, couldnt cut the grades and are meandering through life now renting some crappy apartment in a big city lucky to make 20 bucks an hour doing something healthcare related. In your mind the reason chicks wont talk to you at the bar on Friday nights is all the greedy doctors who have stolen your dreams and $. I get it. But this is a fictitious narrative to help explain why you cant cold approach that cute blonde at the bar without your knees shaking.


Move along.
 
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http://content.healthaffairs.org/content/31/4/741.full

" I found that self-referring urologists billed Medicare for 4.3 more specimens per prostate biopsy than the adjusted mean of 6 specimens per biopsy that non-self-referring urologists sent to independent pathology providers, a difference of almost 72 percent. Additionally, the regression-adjusted cancer detection rate in 2007 was twelve percentage points higher for men treated by urologists who did not self-refer. This suggests that financial incentives prompt self-referring urologists to perform prostate biopsies on men who are unlikely to have prostate cancer. These results support closing the loophole that permits self-referral to “in-office” pathology laboratories."

I realize this isnt from MSNBC but it does seem to contradict your opinion
 
I am 50 something guy who has sold almost a nine figure lab few years ago and own one of the biggest equipment business. Yes I joined yesterday and yes I have three posts. I thought Pathologists would be the group who will concur since they get the shaft most. LAdoc you assume a lot of things.
 
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I think the Wall Street Journal has raised more questions about overtreatment/overdiagnosis than MSNBC. Hardly a liberal publication.

Let's face it, we are creating a lot of eunuchs and miscarriages just to line pockets. We need LESS health care, not more despite what it will do to our job market.
 
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http://content.healthaffairs.org/content/31/4/741.full

" I found that self-referring urologists billed Medicare for 4.3 more specimens per prostate biopsy than the adjusted mean of 6 specimens per biopsy that non-self-referring urologists sent to independent pathology providers, a difference of almost 72 percent. Additionally, the regression-adjusted cancer detection rate in 2007 was twelve percentage points higher for men treated by urologists who did not self-refer. This suggests that financial incentives prompt self-referring urologists to perform prostate biopsies on men who are unlikely to have prostate cancer. These results support closing the loophole that permits self-referral to “in-office” pathology laboratories."

I realize this isnt from MSNBC but it does seem to contradict your opinion


This is bogus as the AUA White Paper on the subject and the NCCN guidelines show 12 core IS the scientifically proven "sweet spot" for detection of prostate cancer: "Expert panels in the United States, Canada, and Italy generally recommend initial prostate transrectal ultrasound (TRUS)-guided biopsy protocols involving 10–12 cores in men with an abnormal digital rectal examination (DRE) finding or a high prostate-specific antigen (PSA) level (7-10). The NCCN panel suggests an “extended-pattern 12-core biopsy” that includes the standard sextant; peripheral base, mid-gland, and apex; and lesion-directed palpable nodules or suspicious images (8). The other panels do not specify the regions of the prostate to sample, although the Italian panel recommends biopsy protocols directed to the peripheral-lateral zone (7). Only the Italian guidelines address biopsy specimen labeling with a recommendation to package biopsy specimens from different sides and different areas (e.g., base, mid-gland, and apex) in separate containers; however, core specimens from the same area should be packaged in the same container."


*Dont quote a health affairs article when talking about ACTUAL science.

Moving along, it is a complete and utter MYTH that in office pathology labs in urology setting took business away from local pathologists. That business was already gone in the 1980s and 1990s when large commercial labs like Ameripath, Bostwick etc sent into wave after wave of marketing personnel. When in office models appeared en masse after the big annual Uro meeting 5-6 years ago, this actually opened a window for local pathologists get this business line back.

Pathologists are getting the "shaft" DAILY from the following sources:
1.) no 1 source of the shaft is from other f'ing pathologists! re-read that.
2.) CMS post Obamacare
3.) Hospital Administration
4.) Our own trade society
5.) ABP
THEN other physicians siphoning cents off the margins.

And dont listen to the WSJ either then. Okay we need less healthcare, I agree lets start with government set prices for all drug companies that want to be carried by US insurance. Lets not pick on doctors because our lobbyists are lower rent and our attorneys less numerous.

My educated guess is Obama is not holding back in his war against ISIS because pathologists and urologists are requesting too many PIN4s. Just a guess though.
 
Did you wake up one day, decide to register on SDN to post this nonsense?

Seriously do you have even the slightest clue as to what "illegal" is?

Illegal:
1.) Obamacare. Where CMS interpreted this to allow bureaucrats to ignore the RUC committee recommendations of our country's leading medical experts to deny coverage. This is well beyond "climate change-deniers" level of scorn for science.
2.) Any given day Hillary Clinton was Secretary of State.
3.) Any so-called Sanctuary City that allows illegal alien criminals to roam the streets.

On to what you said: No, big hospital lab do not as a general principle dump 12 cores into 2 containers. Those that do are idiots are best and committing medical malpractice at worst. Floating 6x4mm thin cores and seeing all lengths of all cores in a level section is stupidly hard to do from a HT standpoint. You would have to see like 15+ step sections to get all the cores confirmed negative. I would never work at your "Mr. Big Hospital" doing that crap.

Urologists do not do a million cores just because they have a small incentive to do so. Nor do dermatologists do a million biopsies on patients when they have a dermpath lab. Nor do Hematologists do a million CBCs when they have an automated hem analyzer. THAT IS A MYTH. Stop watching MSNBC.

Urologists who do more biopsies are more likely to in source pathology but physicians dont wake up and say now that they have a lab, they will biopsy everyone. Of course there are some very rare bad actors. And democracy has the Clintons too, but one wouldnt argue for Communism because of this.

PIN4 is INCREDIBLY necessary, in fact it is great. And I am saying that because I look at more prostate biopsies than almost any pathologist in the US outside some large commercial players and some prominent GU academics. I have used ERG but dont now so I cant comment on that other than I personally felt it wasnt a valued added to the Urologists I work with.

As someone said, they changed how they reimburse these cases anyway and they are given a set price regardless of cores so you are AGAIN a day late and a dollar short on your not so keen observations and outlandish delivery.

Everyone here needs to realize that is there is a large vocal element within the government that literally does not want ANYONE treated for prostate cancer. Take from that what you will, but they tend to, yes, be WOMEN. One could spin some conspiracy theories on this Im sure. This is heavily played in physician happiness surveys where Urology went from being one of the better fields to near the worst after 20 years of assault.

If we were talking about triple stains and tits, trust me the tone would be different. So excuse me if I couldnt just read your ignorant comments and let them slide.


I've been told some urologists will tack on a nickel to what they pay you for each case if you pick up their dry cleaning on the way to their office to sign out.
 
I've been told some urologists will tack on a nickel to what they pay you for each case if you pick up their dry cleaning on the way to their office to sign out.

Wanna hear a true story? There was a fairly large pathology group in CA once run by a guy who bonus out extra $ to junior male staff if he could molest them.

Trust me, look no further than our dying field for fine examples of degeneracy.
 
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Guys with these long posts (pun intended)... do you dictate them or type them. where do you get time to type such long diatribes
 
Prostate needle biopsy is a bundled CPT no matter how many sites the physician submits. They cut reimbursement by about 40% verses 12x 88305s. The new coverage rules in Medicare LCD, they won't pay for a IHC on every core going forward.

It’s bundled for Medicare pts. only. You can still bill 88305 x 12 for private insurance. Same with IHC. If you do the cocktail, CMS caps you at 88344 x 5 only; but you can bill 12X with a “code 59”modifier which will get you more from private insurers. Don’t know if your LCD has fee schedules which supersedes this. Although somehow LA is raking it in by doing 88360s. Don’t know how it’s legit though…

I dont do 88344s anyway, I have swapped over to 88360s on prostate immunos, which I do alot of. CMS will pay for up to 6x88360s per G-code prostate.
This comes out to roughly 800+960 or 1760 per 6-part prostate at CMS reimbursement levels.
 
Prostate needle biopsy is a bundled CPT no matter how many sites the physician submits. They cut reimbursement by about 40% verses 12x 88305s. The new coverage rules in Medicare LCD, they won't pay for a IHC on every core going forward.

It’s bundled for Medicare pts. only. You can still bill 88305 x 12 for private insurance. Same with IHC. If you do the cocktail, CMS caps you at 88344 x 5; but, you can bill 12X with a “code 59”modifier which will get you more from private insurers. Don’t know if your LCD has fee schedules which supersedes this. Although, LA is raking it in by doing 88360s...

I dont do 88344s anyway, I have swapped over to 88360s on prostate immunos, which I do alot of. CMS will pay for up to 6x88360s per G-code prostate.
This comes out to roughly 800+960 or 1760 per 6-part prostate at CMS reimbursement levels.




On another note...

Stop watching MSNBC
I realize this isnt from MSNBC
I think the Wall Street Journal has raised more questions about overtreatment/overdiagnosis than MSNBC

This reminds me of an episode from CNBCs ‘American Greed’. It was about Dr. Michael Rosin: a Mohs-dermatologist in FL who had an in-office lab where he also read his own slides and would diagnose cancer 99% of the time. This way he could re-biopsy and do more procedures and keep raking it in. He used an office employee to make the slides and they looked like they came out of a blender. So even an actual pathologist would have difficulty making a read. Rosin turned this into a multi-million dollar practice and then lost it all and got thrown into the slammer…

 
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"It’s bundled for Medicare pts. only. You can still bill 88305 x 12 for private insurance. Same with IHC. If you do the cocktail, CMS caps you at 88344 x 5; but, you can bill 12X with a “code 59”modifier which will get you more from private insurers. Don’t know if your LCD has fee schedules which supersedes this. Although somehow LA is raking it in by doing 88360s. Don’t know how it’s legit though…"

I pretty sure your wrong here. All private insurance are using the CPT under national MC rules.
Now that there is national G code that bundles all prostate needle biopsies your bound to code it as such rather X12.
 
I see what you mean.
I am pretty sure that commercial insurance will recognize the code and require it shortly.
The tend to update their payment manuals and codes following national medicare payment rules.

The same is true for the MC LCD on IHC and SS. If it become national policy they will be right behind.

This is a game of cpt wack-a-mole. We are the mole.
 
I sign out about 500 prostate biopsies every year. PIN4 is done on about 5-10% of cases.

95% of the biopsies I get are at least 6 sites (each site is 2 cores typically) (more if it's an MRI-related biopsy or it's a patient with an abnormal area they want to sample). One guy sends just left and right (12 cores) but we limit to 2 cores per block.

In my experience reviewing outside cases large reference labs don't typically excessively order PIN4, but they do excessively order ancillary molecular or IPOX tests (like PTEN). The ones who excessively order PIN4 are insourced urology labs (usually smaller ones) or pathologists who rarely see them. I once saw a consult case from a pathologist who ordered PIN4 on every block.

I have no idea what is "illegal." There are a lot of exceptions to the stark law, many of which are meant to protect dermatologists who read their own slides but are abused by urologists. I know what is unethical but I don't know what is illegal.
 
I sign out about 500 prostate biopsies every year. PIN4 is done on about 5-10% of cases.

95% of the biopsies I get are at least 6 sites (each site is 2 cores typically) (more if it's an MRI-related biopsy or it's a patient with an abnormal area they want to sample). One guy sends just left and right (12 cores) but we limit to 2 cores per block.

In my experience reviewing outside cases large reference labs don't typically excessively order PIN4, but they do excessively order ancillary molecular or IPOX tests (like PTEN). The ones who excessively order PIN4 are insourced urology labs (usually smaller ones) or pathologists who rarely see them. I once saw a consult case from a pathologist who ordered PIN4 on every block.

I have no idea what is "illegal." There are a lot of exceptions to the stark law, many of which are meant to protect dermatologists who read their own slides but are abused by urologists. I know what is unethical but I don't know what is illegal.

My experience is different and I actually tabulated the data for this last month. 90% +of all prostate biopsies seen at academic centers where they had not already been done had PIN4s when seen in consultation there from my labs. So YMMV. We have had a 100% concordance rate btw, knock on wood.
 
My experience is different and I actually tabulated the data for this last month. 90% +of all prostate biopsies seen at academic centers where they had not already been done had PIN4s when seen in consultation there from my labs. So YMMV. We have had a 100% concordance rate btw, knock on wood.

I can't understand your statement.
Reads like "90% of baseball is half mental"
 
I can't understand your statement.

I think what he's trying to say is there's a more sizeable share of places doing PIN4's on every core rather than just insourced urology labs or the random pathologist as Yaah suggests. I would agree with the former. Don't be surprised if insurance does not reimburse for this anymore if cancer is not detected. And I'm talking about across the entire country, not just CMS and some LCD's.
 
I most definitely did not say that there aren't a lot of labs who order a lot of IPOX. I said some of the larger labs who you might think would be the worst offenders are not the worst offenders. In my experience academics can be the worst offenders. I did also say that reference labs tend to be the ones that order the extra flowery stuff that adds very little real clinical info but sounds impressive (molecular stuff). I would wager at least 10% of the 3+3 cases I sign out without IPOX that get reviewed at academic centers (because patient goes for second opinion) end up calling for the block to do IPOX. Occasionally they downgrade it to ASAP, at which point I send it to another academic center who confirms my original impression.

This is one of my favorite studies to quote: http://www.ncbi.nlm.nih.gov/pubmed/23273390

This is a large academic practice. They stained 40% of their cases and 12% of their blocks (1.8 blocks per case). That is astounding to me.

It's kind of similar to GI path - some labs do lymphocyte IPOX on every duodenal biopsy, and H-pylori IPOX on every stomach. Others do these stains <10% of the time.
 
I think what he's trying to say is there's a more sizeable share of places doing PIN4's on every core rather than just insourced urology labs or the random pathologist as Yaah suggests. I would agree with the former. Don't be surprised if insurance does not reimburse for this anymore if cancer is not detected. And I'm talking about across the entire country, not just CMS and some LCD's.

Don't be surprised if they just eliminate reimbursement at all for IPOX. They will say it should only be justified in 10% of cases which means it doesn't need to reimbursed specifically for an individual case.

I am no longer surprised about anything except for increases in payment for routine things.
 
I sign out about 500 prostate biopsies every year. PIN4 is done on about 5-10% of cases.

95% of the biopsies I get are at least 6 sites (each site is 2 cores typically) (more if it's an MRI-related biopsy or it's a patient with an abnormal area they want to sample). One guy sends just left and right (12 cores) but we limit to 2 cores per block.

In my experience reviewing outside cases large reference labs don't typically excessively order PIN4, but they do excessively order ancillary molecular or IPOX tests (like PTEN). The ones who excessively order PIN4 are insourced urology labs (usually smaller ones) or pathologists who rarely see them. I once saw a consult case from a pathologist who ordered PIN4 on every block.

I have no idea what is "illegal." There are a lot of exceptions to the stark law, many of which are meant to protect dermatologists who read their own slides but are abused by urologists. I know what is unethical but I don't know what is illegal.


As the manager of an in-office CAP accredited urologic pathology lab, I assure you that the work we complete here is neither illegal nor unethical. Using the most up to date technology available to them, my urologists find even the most minute cancer (our positive rate is over 60%.) and they could be taking more without question, but don't perform procedures they don't deem necessary. Our authorizations department strives for the most coverage for the patent for necessary testing so they will have no out-of pocket and we send the specimens to reference labs that are contracted as so. The in-office lab cannot accept some insurances, such as Cigna, because they will only contract at a capitated rate with the big-box reference laboratory. I call them that because there is nothing extraordinary about the sometimes questionable and overall substandard results obtained there. I have HTs trained to process urology- specific specimens, a uropathologist on staff ordering the testing he is expected to run to back his diagnosis (ususally around 10-15% of cases). Our TAT is 24-36 hours, not 7-10 days like the reference labs where your prostate slides are read by a general pathologist. We offer molecular testing upon request and run ERG/PTEN/Ki67 in house. (usually around 20% of our cases combined) The 12-part PBx is standard and necessary for tumor location specificity.


By the way, PIN4 is billed at CPT 88344(IHC multiplex) for all insurances and is reimbursed at a much lower rate than 88342 x 4. CPT 88360 is for IHC cellular analysis. The Medicare fee schedule is the basis for most payers and as of November 2017, the 88305 code is reimbursed by Medicare at the same rate it was in 1992, for any biopsy, not just prostate. Nobody thinks twice about in-house labs for GI, Breast or Derm because they don't have a standard number of billed specimens.
 
As the manager of an in-office CAP accredited urologic pathology lab, I assure you that the work we complete here is neither illegal nor unethical. Using the most up to date technology available to them, my urologists find even the most minute cancer (our positive rate is over 60%.) and they could be taking more without question, but don't perform procedures they don't deem necessary. Our authorizations department strives for the most coverage for the patent for necessary testing so they will have no out-of pocket and we send the specimens to reference labs that are contracted as so. The in-office lab cannot accept some insurances, such as Cigna, because they will only contract at a capitated rate with the big-box reference laboratory. I call them that because there is nothing extraordinary about the sometimes questionable and overall substandard results obtained there. I have HTs trained to process urology- specific specimens, a uropathologist on staff ordering the testing he is expected to run to back his diagnosis (ususally around 10-15% of cases). Our TAT is 24-36 hours, not 7-10 days like the reference labs where your prostate slides are read by a general pathologist. We offer molecular testing upon request and run ERG/PTEN/Ki67 in house. (usually around 20% of our cases combined) The 12-part PBx is standard and necessary for tumor location specificity.


By the way, PIN4 is billed at CPT 88344(IHC multiplex) for all insurances and is reimbursed at a much lower rate than 88342 x 4. CPT 88360 is for IHC cellular analysis. The Medicare fee schedule is the basis for most payers and as of November 2017, the 88305 code is reimbursed by Medicare at the same rate it was in 1992, for any biopsy, not just prostate. Nobody thinks twice about in-house labs for GI, Breast or Derm because they don't have a standard number of billed specimens.

This is INCREDIBLY UNETHICAL and in violation of the STARK LAWS! Plus you insult the entire profession insinuating that a general pathologist is somehow substandard to your EMPLOYED, SUBSERVIANT, "Uro"pathologist. There is NO reason that you need 12 part prostate biopsies!!! LMAO you CHEATS!!!
 
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You resurrected a thread from 2016 to tell us indeed prostate pathology is not illegal. Umm, thanks...I guess...

That being said, I would be interested if Yaah has actually done a look back analysis on negative cores or even better a prospective study of PIN4 IHC usage in his own practice to assess for realignment of false positive and false negative rates, because I have. And my series of total prostate cores reviewed is now standing at around 50,000+. The article you quote is a mere 748 biopsy sets, Im sitting closer 4000+.

Liberal PIN4 usage is one of the most cost effective interventions in preventing false positives while simultaneously significantly increasing the sensitivity in the entire profession of pathology. Every dollar spent is a massive societal gain to prevent unneeded treatment and create an opportunity for earlier intervention.

The main issue why this is so opaque is that prostate cancer itself is so biologically diverse with a subset of patients just dying of other causes. There is a prevailing mythological narrative that prostate carcinoma doesnt matter because older men get it, it sometimes grows slowly and therefore they have plenty of chances to die of other causes. That is about as cynical as you get.

A vast group of patients DO die of metastatic prostate carcinoma and are being heavily underserved by the "Pennywise but pound foolish" approach.
 
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This is INCREDIBLY UNETHICAL and in violation of the STARK LAWS! Plus you insult the entire profession insinuating that a general pathologist is somehow substandard to your EMPLOYED, SUBSERVIANT, "Uro"pathologist. There is NO reason that you need 12 part prostate biopsies!!! LMAO you CHEATS!!!

Holy crap, dial back the caffeine or crystal meth you are doing in the morning as a pick me up:)

There actually is a reason to do a 12 part, it is well studied that even up to 22 separate site core samples increases biopsy sensitivity. Remember, prior to MRI Fusion Guided Biopsy of the Prostate, all prostate biopsies were essentially blind. Do a geometric relational analysis of the success rate of a blind breast biopsy for a mass (taking into account size differential from prostate to breast of course) and you would be shocked how many needle attempts you need to hit a singular breast lump firing blind, it is insane like 100+ given mean report mass sizes on mammogram.

I have no clue why folks are so militant about prostate cancer, let's just get it diagnosed and treated. Hopefully cured one day too.
 
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This is INCREDIBLY UNETHICAL and in violation of the STARK LAWS! Plus you insult the entire profession insinuating that a general pathologist is somehow substandard to your EMPLOYED, SUBSERVIANT, "Uro"pathologist. There is NO reason that you need 12 part prostate biopsies!!! LMAO you CHEATS!!!


It is NOT in violation of Stark Laws, as you are obviously not a lawyer, and certainly not a medical professional. Perhaps you work for Medicare? By the way, I said reference labs are substandard. Specialized services are hardly unethical, nor is having prostate biopsies read by trained UROLOGY SPECIFIC pathologists.
 
It is NOT in violation of Stark Laws, as you are obviously not a lawyer, and certainly not a medical professional. Perhaps you work for Medicare? By the way, I said reference labs are substandard. Specialized services are hardly unethical, nor is having prostate biopsies read by trained UROLOGY SPECIFIC pathologists.

Correct this is not a STARK violation. I also agree that most reference labs suck. However, on your other point, GU pathology is probably the easiest of all AP disciplines to learn and perform.
 
I like how people throw out Stark Laws or Stark violation like it has any meaning at all, like its in the Bill of Rights or the Magna Carta.

Pete Stark himself was a senile hyperliberal politician from Berkeley who actually was thrown under the bus the second the Democrats went with the mantra that "All old white men are toxic."

His law was never meant to protect pathologists only to engender well moneyed special interests in free standing non-physician owned business basically you guessed it...QUEST DIAGNOSTICS and LAB CORP (which has a large facility in Stark's old congressional district..interesting see? they also gave TONS of $$ to him).

Lab Corp and Quest both saw the threat of physician owned and ran clinical labs in the outpatient setting and saw this as a way to shut those down. The anatomic stuff got pulled in for the ride, but that wasnt the focus at all, it was CP.

But the CMA/AMA was quite powerful, specifically Oncology. Oncology had been running quick TAT labs for hematology for decades and demanded to be exempt, once again for their own purposes not ours.

The CAP got drawn in by large mega groups, many of which were directly financially linked to Quest through Ameripath. The CAP wanted the original legislation to get passed with no exceptions, giving Quest literally carte blanche to destroy any independent lab operation who dared compete with them.

The tide was turned however when Kaiser got in the mix. See Kaiser is literally the poster child of self referral. They self refer everything. The American Hospital Association also had a vested interest in trying to prevent doctors outside its walls from building labs to compete locally, but honestly no one can really compete with a juggernaut like Quest.

Dermatologists got roped in as well, mainly because they realized this would affect their wonderful in house referrals of skin biopsy bliss...

In the final legislation, you ended up having such a stupid and utter monstrosity of exceptions that the entire process was worthless, but this is completely emblematic of Pete Stark the politician's wretched career.

But at the end of this trail of tears there always was and now is almost nothing for the average community pathologist.
 
My two cents. I have more probably seen more prostates than most people.
(1) Only Epstein, Bostwick, and people like him think 12 or more cores increase sensitivity because they benefit(once upon a time, myself included) from it. We are overdiagnosing prostate cancer. Most people just get labelled, and die with it, not because of it(emphasis on most).
(2) Liberal use of PIN4 just because we treat each core as a "specimen", and feel compelled to render a diagnosis is STUPID. You wouldn't do it if it were multiple lung biopsies, breast cores, or a TURP. Prostate is not such a multi dimensional organ, where some sort of targeted nano therapy is administered. If you have cancer, they just hiroshima your prostate, take it out, or leave it alone.
(3) Nothing useful is gained by doing ERG, PTEN, or KI67. I have talked to many urologists.
(4) THERE is nothing but MONEY which drives "in house labs". GI's, Derm's, and GU's have nailed it down to last dime they can squeeze because they have the patient.
(5) "Mr Manager" your view is biased.
(6) There is nothing legal, or ethical in doing H pylori immunostain, AB/PAS, or any other lymphocytic marker on every GI specimen. People who advocate it, benefit from it.
(7) Diagnosing 30-40% of urine cytologies as atypical because they can be urovysioned is also seen only in "in house" labs.
 
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My two cents. I have more probably seen more prostates than most people.
(1) Only Epstein, Bostwick, and people like him think 12 or more cores increase sensitivity because they benefit(once upon a time, myself included) from it. We are overdiagnosing prostate cancer. Most people just get labelled, and die with it, not because of it(emphasis on most).
(2) Liberal use of PIN4 just because we treat each core as a "specimen", and feel compelled to render a diagnosis is STUPID. You wouldn't do it if it were multiple lung biopsies, breast cores, or a TURP. Prostate is not such a multi dimensional organ, where some sort of targeted nano therapy is administered. If you have cancer, they just hiroshima your prostate, take it out, or leave it alone.
(3) Nothing useful is gained by doing ERG, PTEN, or KI67. I have talked to many urologists.
(4) THERE is nothing but MONEY which drives "in house labs". GI's, Derm's, and GU's have nailed it down to last dime they can squeeze because they have the patient.
(5) "Mr Manager" your view is biased.
(6) There is nothing legal, or ethical in doing H pylori immunostain, AB/PAS, or any other lymphocytic marker on every GI specimen. People who advocate it, benefit from it.
(7) Diagnosing 30-40% of urine cytologies as atypical because they can be urovysioned is also seen only in "in house" labs.

Thank you for your 2 cents. Might I add...

1. My pathologist trained with Epstein. Bostwick is a crook. Specificity in location helps to localize treatment and keep it minimally evasive and one major reason for this is to prevent metastases.

2. Individual biopsies of lung or breast are stained the same way, they are individual biopsies. Stains for TURP are completed per block. Although the “Hiroshima process” is one the physician will try to avoid, urologists look for Gleason and CA% of each core to determine treatment plans. Which leads us to…

3. ERG, PTEN, or KI67 is a prognostic tool to help the physician determine aggressiveness of the disease. Not all urologists are sold on NGS or molecular analysis, but ongoing clinical studies have shown its usefulness in determining the probable outcome of the chosen treatments.

4. In my lab, we perform tests that give the most accurate result and report it in such a way that the physician is confident offering the patient the best possible treatment options.

5. That’s “Ms Manager”. I’ve been in GU specific pathology for 15 years; I’m not biased, I have a good comprehension of what it is I’m writing about.

6. I don’t run GI here. I don’t run stains on every case and I only run specials for AFB and fungus.

7. The only time FISH is run on my cytologies is when findings are suspicious but not diagnostic for carcinoma.

My lab is not Bostwick. We do not reflex diagnostic or prognostic testing. We don’t get paid by ANY other labs to send testing to them. The information we provide for the patient is accurate and consistent. Stark laws are in place to make sure the little guy doesn’t interfere with the big money to be made by those that make the rules. It’s seems too much for some to grasp that some of us are doing it right, and for the patient, not just the bottom line.
 
GI and GU are self proclaimed specialists. I have looked at thousands of unnecessary GI immunostains every year for a decade and a half, and never been able to justify their usage. You don't need to be a fellowship trained specialist for anything except hemepath, and derm.
All the path mills who claimed to be specialists in GI, and GU are gone because they just took the fraud to another level under the direction of their "specialists". Look at Strata, Bostwick, Caris, Plus, Miraca etc.
 
GI and GU are self proclaimed specialists. I have looked at thousands of unnecessary GI immunostains every year for a decade and a half, and never been able to justify their usage. You don't need to be a fellowship trained specialist for anything except hemepath, and derm.
All the path mills who claimed to be specialists in GI, and GU are gone because they just took the fraud to another level under the direction of their "specialists". Look at Strata, Bostwick, Caris, Plus, Miraca etc.

So, you think any specialists in the field GI or GU are frauds because??? Perhaps you should do your homework when commenting on GU fellowships. You obviously didn't do your research.
 
So, you think any specialists in the field GI or GU are frauds because??? Perhaps you should do your homework when commenting on GU fellowships. You obviously didn't do your research.

Unless you are a pure academic, GI, GU,GYN, breast fellowships are pointless. Good path programs who have adequate surg path volume and variety give you more than adequate training to sign out 90-95% of everyday cases in those areas. The other 5%-10% you send out to those academics. Non boarded fellowships are a waste of time.
 
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So, you think any specialists in the field GI or GU are frauds because??? Perhaps you should do your homework when commenting on GU fellowships. You obviously didn't do your research.
Anyone who has couple of years in private practice has more exposure to GI, GU, and Cytology than you get in fellowship. Most of directors of path mills who head these departments, themselves have no fellowships!! Experience and good diagnostic skills matter more. Non boarded fellowships are good to gain experience , but don't make you special.
 
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Anyone who has couple of years in private practice has more exposure to GI, GU, and Cytology than you get in fellowship. Most of directors of path mills who head these departments, themselves have no fellowships!! Experience and good diagnostic skills matter more. Non boarded fellowships are good to gain experience , but don't make you special.

Could not have echoed my sentiment better.
 
If you use ThinPrep and have good procedures your UROVYSION FISH ordering should be less than 10%
If you have competent histotechs and cut prostates at 2-3 microns with correct stainer settings, your PIN-4 rate should be less than 8% at most. This is from personal experience. Many people over order stains and tests not solely due to greed/inexperience/insecurity.... THey have not optimized the processing. GI, GU can be cut at different thicknesses and stained differently to optimize efficient diagnosis by H and E. Many people do not have this experience and overcall under call based on crappy histotechniques.
 
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If you use ThinPrep and have good procedures your UROVYSION FISH ordering should be less than 1% .
If you have competent histotechs and cut prostates at 2-3 microns with correct stainer settings, your PIN-4 rate should be less than 8% at most. This is from personal experience. Many people over order stains and tests not solely due to greed/inexperience/insecurity.... THey have not optimized the processing. GI, GU can be cut at different thicknesses and stained differently to optimize efficient diagnosis by H and E. Many people do not have this experience and overcall under call based on crappy histotechniques.
I have heard so called Fellowship trained experts GU's say their atypical rate and reflex Urovysion is 30%..
 
If you use ThinPrep and have good procedures your UROVYSION FISH ordering should be less than 1% .
If you have competent histotechs and cut prostates at 2-3 microns with correct stainer settings, your PIN-4 rate should be less than 8% at most. This is from personal experience. Many people over order stains and tests not solely due to greed/inexperience/insecurity.... THey have not optimized the processing. GI, GU can be cut at different thicknesses and stained differently to optimize efficient diagnosis by H and E. Many people do not have this experience and overcall under call based on crappy histotechniques.

Less than 1 percent reflex FISH testing on urine? Isn't that a little low? When they came out with the new signout system years back, I remember someone saying "you mean there will be a different category besides atypical cells?" It made many of us laugh. In my experience both "experts" and community pathologist call a high percentage of those abnormal.
 
Less than 1 percent reflex FISH testing on urine? Isn't that a little low? When they came out with the new signout system years back, I remember someone saying "you mean there will be a different category besides atypical cells?" It made many of us laugh. In my experience both "experts" and community pathologist call a high percentage of those abnormal.
Sorry typo.... less than 10% and that is if you have good ThinPrep slides. Some labs use crappy preparations on purpose to drive cases to FISH.
 
Correct this is not a STARK violation. I also agree that most reference labs suck. However, on your other point, GU pathology is probably the easiest of all AP disciplines to learn and perform.
GU is not easier or harder than any other specialty in pathology. Decent training and experience can make any specialty “easy.”
 
There is no question you MUST start with EXCELLENT H&E histology.
As I am sure most folks here can attest to, I (we) have seen LOTS
of real garbage that I would be mortified to let anyone see if it came out of MY lab. Great histo solves lots of problems.
 
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Sorry typo.... less than 10% and that is if you have good ThinPrep slides. Some labs use crappy preparations on purpose to drive cases to FISH.

Catheter lubricant screws up many Thinprep I have found over the years. Thinprep is a flawed technology using filters that get clogged up, leaving less cells to look at.

Fixation is the key regardless of how the slides are prepped back in the lab. I really really hate urine cytology. Seems like so many cells are degenerated.
 
Catheter lubricant screws up many Thinprep I have found over the years. Thinprep is a flawed technology using filters that get clogged up, leaving less cells to look at.

Fixation is the key regardless of how the slides are prepped back in the lab. I really really hate urine cytology. Seems like so many cells are degenerated.
If you have a good tech they can mitigate this (Looking at specimen and diluting when necessary) urine cyto is not a great test I agree but it can help catch cancer. It is what it is. OverFishing is not necessary.
 
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