A community pathologist asks "How can I survive?"

I am at a small community hospital and I feel like they do need a pathologist here. But my thought is that in order to support one, higher fees have to be charged. I do 3000 cases per year and take care of the lab. So I am diverse and busy but I am not a specialist. It makes the most sense to me that specialists like you should be reading all of my prostates and derm experts should be reading all my skins (etc). You are cheaper AND better at it. If I was a patient, that's what I would want. So how do I keep my job? The most efficient use of healthcare dollars would eliminate those of us at small places but we need to be here (I think). I am not trying to make a killing but I am trying to make a living. My hospital does do my billing but I have profit sharing and they listen to my input. The example of the 12 set biopsy is an extreme but I do know that ALL of my charges are high. So anyone without insurance is charged this. And insurance companies pay less. I didn't know that you were allowed to set up special fees for those who don't have insurance. I think we just wait for the patient to call and say they can't afford it, then we write some off.I just wonder if other small hospital pathologists have similar concerns about this.

The $8000 Prostate biopsy evaluation.

Mouse writes:

I believe that the hospital I work for (as an employee)charges over $300 for both the technical and the pro fee that they bill on my behalf. We do not get many prostate biopsies. When I do get them in a set of 12...um...that's over $8000. Just for the H and E (I have not needed special stains). I really doubt any insurance is paying this but it makes me sick to know that some guy without insurance would get a bill for such an amount. Have you ever heard of such huge fees? What can I do to make it right?

_________________________________________

Well, unless the patient does not have any insurance, he will not be paying the full $8000. If he has no insurance, and even if he does, then he can negotiate with the lab to pay less. He can advise his urologist to ask the lab about the excessive fees (My lab would charge a non-insured patient about $360 for this service). This might prevent other patients from being similarly ripped-off in the future. But the real question is this: What party do you want to "make it right" for ? Please clarify what type of insurance, if any, this patient has.

Have I heard of such huge fees? Unfortunately, yes.

J. Oppenheimer

Jane Pine Woods Esq. advises on Avoidance of Defamation

I ask any party who believes that this blog contains any defamatory statement(s) to notify me immediately so that they may be reviewed and if unsupported, removed at the earliest opportunity.

J Oppenheimer

Ms Wood today sent me the following communication.

______________________________________________________________
Amen! I am hearing many of the same concerns from virtually all of my clients. Like you, they want to be competitive and obtain new business, but they also want to comply with legal and ethical guidelines. That's hard to do when some pathology providers don't play by the same rules.

I also suggest, as an aside, that you be careful using the names of other laboratories to avoid possible claims of defamation. Use of the phrase "I believe" or "It is my understanding that" can also be helpful.

See you in Denver.

Thanks, Jane

Jane Pine Wood, Esq.McDonald Hopkins LLC 956 Main Street Dennis, MA 02638direct 508.385.5227 fax 508.385.4355 jwood@mcdonaldhopkins.com www.mcdonaldhopkins.com

Cytospins on Prostate Biopsies

Just thought I'd share an e-mail with you.

From: XXXXXXX
To: Jonathan Oppenheimer ; XXXXX
Sent: Fri Feb 01 14:35:59 2008
Subject: Another way to rip off the patients
I just wanted to let you both know some info that was passed along to me through XXXX this morning. We lost our biopsy business at XXXXX Urology in XXXXX, AZ.
We knew this was coming due to their merger with XXXXXXX, but this is the kicker.
The reason the group decided to go with XXXX Diagnostics on their prostate biopsies is because at XXXX after they extract the prostate core from the formalin vial, they do a cyto-spin on every formalin vial.
What way will they think of next to rip-off the poor patients?

Outrageous Examples of Pathologists Gone Bad

I received some slides for a second opinion today. Four immunostains (P63, -903, P504S, and CK 5,6) were performed on each of three prostate cores. That's a dozen IHC stains performed at a cost of over $1000. The letterhead of the report identifies the lab as based in the urology office. A hired pathologist reads cases in their office. Technical services (88305-TC and 88342-TC) are provided by the same laboratory which supplies the hired pathologist for the (88305-26 and 88342-TC) professional services.

Interesting thing is that the tumor is easily recognizable on the routine H&E slide. All the money and effort spent on the secial stains were unneccessary. BTW, I have heard that the Urology group has an investment in the Pathology Services Company that manages the laboratory.

It would be interesting to hear of other Pathologists-gone-bad examples as comments to this post.

Pathologist owned Laboratories

Is it necessary to do triple IHC stains on multiple prostate cores in order to have Absolute Confidence? Do urine cytologies routinely require Giemsa staining in addition to Pap staining? Is it necessary to separate the six cores that some urologists put in one container and give them separate diagnoses so that twelve diagnoses and twelve charges result from the two containers sent to the lab? Is it necessary to perform standard cytology on each FISH UroVysion?

Sure it requires money to compete with Quest and LabCorp so that you can compete with their donations of EMR software. But no one expects publicly traded commercial labs to be concerned with anything other than their bottom line. Laboratories that are owned by pathologists have the opportunity to demonstrate leadership and fiduciary responsibility to the patient. If one does not have any external investors that require a certain return on investment, why squander the rare possibility to show leadership in this industry?

Do we not have a responsibility to use our education and expertise to perform service FOR PATIENTS. Or must we look for every opportunity to do some procedure TO PATIENTS to extract the most revenue from their bodies?

Who pays for the lab-clinician "Relationship" ?

Each laboratory needs to foster a relationship with the clinician who supplies specimens. The desire for a lasting relationship encourages competing laboratories to kick-back as much of their excess profits as necessary to form and retain this relationship. Supplying attractive sales reps (who routinely make over $150K, and often over $250K/yr) with company credit cards for expensive meals and fishing/golfing outings ease the relationship as do charitable donations, reimbursements for expensive computer systems, payments to office staff, in-office placement of nurses and phlebotomists, free office and medical supplies, continuing education credits, free management and recruiting services, etc. The cost of these perks is considerable and can be generated by performing unnecessary medical tests (excessive IHC stains including triple prostate stains on multiple cores, Giemsa staining of urine cytology, routine FISH Urovysion testing in addition to urine cytology, etc.)

Excess profits are needed to pay for this "Relationship" which then leads to more specimens and more perks. The clinicians have learned to wait for the best offer and play one lab off the other. In this environment, only the most aggressive will survive.

What is Ethical Pathology?

I'm not sure. That's what I hope to explore in this blog.
This admission hopefully will give contributors pause before they post screeds and rants against yours truly and the lab I have been managing since 1996.

I am open to criticism, am willing to listen to it, and be improved by it if I perceive it as constructive. I have never claimed to be a paragon of virtue, but I do intend to live a meaningful and ethical life as far as I am able in the years I have left. I certainly have room for improvement and aim to get as close to the mark as I can, knowing full well that I will always fall short to some degree.

That said, the purpose of this blog is not for my moral education (although I do hope to improve from editing its content), but to serve as a forum where those who wish to improve the current environment may come to lurk or contribute. If visitors to this blog assist patients to get better healthcare without undergoing unnecessary testing, if medical costs are lowered, if professionism (ie, fiduciary duty to patients) is fostered, if regulatory agencies can create a more level playing field on which competition leads to better service to society, this blog will have succeeded.

Corruption Vice and Sleaze in Pathology Marketplace

Increasing attention to a dysfunctional industry will soon to change the face of commercial pathology. Folks in the industry know the game is about to end. Like the housing bubble recently burst, everyone knew it would happen, the only surprise is WHEN.

A conference on March 2 in Denver (www.ascp.org/511live/Timssnet/News/TNT_news.cfm?action=long&primary_id=USCAP08) will be a good time to expose additional schemes that threaten pathologists' ability to take care of patients.

Problems that my own lab has dealt with will be addressed in subsequent posts. Whether you are a patient who has been overcharged or subjected to unnecessary tests, whether you are a physician who knows of practices that run counter to good medical care, or whether you are an employee of a lab company that engages in questionable conduct, your observations are welcome here. They may be added to those that surface during the conference.

I admit to not being perfect. In the course of the past decade, I have adopted some practices that I thought were necessary to stay competitive in the increasingly cut-throat out-patient pathology industry. Some of these practices, whether longstanding or relatively new, have the potential of being abused and I look forward to eliminating them entirely once a level playing field has been created by upcoming changes, long overdue.