TC/PC, split billing, etc in Pathology

[Anonymous]

Interested in opinions of sales reps, technical staff, pathologists and the clinicians who take the biopsies in these arrangements.

I am starting to see major problems with these arrangments such as:

1) Urologists/GI docs/Dermatologists are beginning to take more biopsies in situations where income increases with each biopsy taken.

2) Lab directors encouraging pathologist to order more ancillary studies than usual in order to increase profit
-- Classic example is the PIN-4 (triple stain) in prostate biopsies. This stain is ordered way too often by pathology groups specializing in prostate biopsies. I have heard of an in office lab in which the pathologist orders a PIN-4 on every single prostate biopsy (12/12 cores) prior to reviewing the H & E. In another lab I hear the lab director encourages staff pathologists to order exactly 3 PIN-4 / 12 part prostate bx core on medicare patients because medicare will only pay for 3 thus 3 PIN-4/extended core maximizes profitability.

3) Pathologists who are not qualified for a particular specimen type are signing them out in office labs
-- Urine FISH interpreted by pathologists with no molecular training at all, some
of them only boarded in Anatomic Pathology
-- I have seen other posts claiming that Flow Cytometry is being signed by pathologists who are not boarded in hemepath?? Is this true?


Do sales reps really feel comfortable offering such a product? Do you really think this is good for patient care. Seems to me this is a patient care issue and this practice is driving up the cost of laboratory medicine. As an academic pathologist I review a lot of material signed in office laboratories. Some of the material and diagnoses are of high quality and others are deficient. One particular lab produces slides of such low quality that diagnoses ar more difficult to make. I even advised a family member who was scheduled to get a prostate biopsy to ask his urologist what lab processes the material and to ask me about the quality before the biopsy occurred. This is the current state of laboratory medicine and is quite concerning.

Academic Pathologist

 

[Anonymous]

I have a hard time believing you're a pathologist, but personal doubt aside I'll address your points:

1. I have no doubt this occurs on some scale. Unfortunately, the data (from CMS) doesn't support the drastic increases in biopsy volume implied. A mere 2.5% increase in the three years between 2005 to 2008 (see article linked below). Furthermore, the number of biopsies taken is not as significant as the number of vials they are submitted in - and therein lies the number of 88305 charges.

2. The data does support your second point, and remember that special stains are ordered by the pathologist (not the lab director) and most frequently in hospital (including academic), private, and commercial labs - according to CMS. The link below documents a 9.2% increase in special stains ordered in the same interim; 3.5x the growth of the general biopsy rate.

3. What specimen types is your average pathologist "not qualified" to sign out? Wasn't yours a four year residency including hematology, microbiology, blood bank, cytopathology, molecular pathology, dermatopathology, forensics, and a dozen other subspecialties? Didn't your boards include both AP & CP (unless those in question choose or pass only one, in which case you might have an argument specific to that particular individual). But in general, isn't your average pathologist is perfectly qualified to sign out FISH? I'll even go a step further and suggest that the AP-only pathologist is perhaps more qualified in that the morphology skills to interpret FISH are stronger among those who focus on anatomic pathology, and I don't think it's been determined yet whether many of these molecular techniques are exclusively the domain of AP or CP.

What next? Only a fellowshipped cytopathologist is qualified to sign out a pap smear? Requiring all pathologists to additionally fellowship 1-2 years after a four year residency, and then to only sign out work that falls under the category of their fellowship is NOT going to reduce the contribution of the laboratory industry to the overall cost of healthcare. I furthermore doubt it would have an appreciable impact on the quality of patient care: most pathologists are happy to consult with a fellowshipped expert inside or outside of their own facilities (such as those at academic institutions) before they sign their name on the report for a difficult case.

4. I agree regarding quality of technical work performed in some TC-only labs. And that's a CLIA issue. A CMS issue. An issue perhaps CAP should get more involved in? From the link:

"The fact that CMS allows technical-only anatomic pathology laboratories to operate outside of CLIA (no CLIA registration) is more than “nonsense,” it is criminal. I have written to CMS regarding this issue on several occasions to no avail. All laboratories processing tissue should be required to be CLIA registered and regularly inspected. And, they should all have a pathologist as medical director to review laboratory procedures. There is no wiggle room on this position."

5. Finally, I don't know why you are asking sales reps why they offer this or if they think it is good for patient care? As long as anyone is offering it legally it's going to be required selling if you want to operate in GU, GI, and derm. If you as a pathologist want these arrangements to go away due to a concern for patient care and/or cost, then you and your peers should approach CAP to make those cases and lobby CMS and Congress to make them illegal.

For your reading pleasure:

http://www.g2reports.com/issues/advisory/advisory/joe_plandowski/657-1.html

 

[Anonymous]

First of all I AM a pathologist. A couple of your points require comments.

2) You did not read my comment carefully. Lab directors at speciality labs are encouraging individual pathologist who work in the lab to order more stains and to order exactly the number that will be re-imbursed. Of course I know the ordering comes from the individual pathologist to whom the case belongs (any pathologist would know this). I have had conversations with staff pathologists at PLUS dx and every staff member is aware of the fact that medicare will only re-imburse 3 triples / extended core biopsy and that is why they tend to order exactly 3 even if they need more (provided cancer is diagnosable) or less. This action is deplorable.

I am in process of comparing the frequency of ancillary PIN4 stain and jars/patient in these three groups
1) needles signed by academic pathologists on in-house cases
2) needles referred for prostatectomy signed out by pathologists in split bill arrangements and
3) needles signed by pathologists billed globally at GU speciality labs (i.e. PLUS, OurLab, etc)
I absolutely believe that TC/PC arrangements and to a lesser degree GU speciality labs "run up" the bill. Initial data shows that group 2 orders significantly more triples and has more jars than either group 1 or 3. More numbers needed to split group 1 and 3, but it is trending toward more triples for the speciality labs. Cant wait to publish this paper.

Other large academic centers are gathering similar data (MMSK, for one).

3) Again you didnt read my post. Molecular diagnostics is NOT a grey area it is a CP discipline, as any trained pathologist knows. A pathologist not holding CP boards or a PhD in molecular diagnostics is thus not qualified to sign out FISH. If you deem AP-only pathologists as capable for this task, you may as well let urologists sign them out. I am actually more concerned about Flow cytometry being interpreted by pathologists not boarded in hematopathology. This is bordering on criminal behavior, no matter how good of a "general pathologist" you are. Suggesting that hematopathology training is NOT necessary to sign out flow confirms to me that you are NOT a pathologist.

Anyways pathologist are taking action and check out this link from South Carolina

http://www.mhbh.com/documents/news/Jane Pine Wood, Steve Harris Dark Report 1.pdf

If this doesnt work google TC/PC + 2010 + south carolina

Briefly this report details that SC board of medicine just sent a message to all licensed physicians in the state to not engage in TC/PC if they are thinking to do this because of ethical and legal issues. It goes further implying that the practice will likely be prohibited completely in the state.

The days of TC/PC are numbered and I for one will be popping champagne when it ends.

Academic Pathologist

 

[Anonymous]

I think that CAP's approach on this issue is not producing the desired results. They should be promoting revenue sharing models instead of employing their current strategy of getting account billing ( third party billing ) banned in all states. This model allowed for revenue sharing and allowed for small laboratories to provide high quality pathology services. Now that CAP is systemically trying to eradicate this business model ...urology practices and others have become increasingly interested in starting their own laboratories. The result has you have pointed out is questionable usage of special stains and TC quality when these practices open their own laboratories.