DO NO HARM —Just Get The Facts

I recently responded (unpublished) to an article I found to be outside the bounds of credibility. The article was written by a pathologist who drew conclusions that were incorrect in my view of the world of in-office pathology laboratories. However, I did strongly agree with the author on one point --- DO NO HARM. That phrase should apply to articles written by the uninformed. Perhaps you can learn a few basic facts about in-office labs from this article and not stumble into the same holes as the pathologist-author.

The substance of the pathologist’s article is that a gastroenterology group had these specimen volumes according to a local pathology group that was providing services to the GI practice, labeled as “before” and dated 2005:

CPT 88305 Surgical Pathology – 5,729 billables
CPT 88342 Immunostains – 21 billables
CPT 88312 Special Stain A – 731 billables
CPT 88313 Special Stain B – 11 billables
CPT 88360 Morphometric Analysis – 0 billables

An “expert” consultant entered the scene and predicted that the GI practice should process the following volumes of specimens, labeled as “after” and, interestingly, undated:

CPT 88305 Surgical Pathology – 9,000 billables
CPT 88342 Immunostains – 2,000 billables
CPT 88312 Special Stain A – 200 billables
CPT 88313 Special Stain B – 600 billables
CPT 88360 Morphometric Analysis – 600 billables

The conclusion drawn by the pathologist-author is that this is “a splendid example of the enticing and succulent attraction of the these arrangements,” namely “the real victims of these self-referral practices, the same victims who have been the targets of a myriad of medical self-referral schemes throughout history, the patients who are unsuspecting and unknowing vital cogs of such tactics.” The author goes on: “It is the patient who is the victim of overutilization, misutilization, and increased morbidity. There is one fundamental concept of medical care that should be remembered by all professionals considering involvement in these schemes: DO NO HARM.” Who can argue with those statements? No one, if the facts are solid.

What we need are the facts by which to make reasonable judgments. I am not the “expert” referred to in the author’s article, at least based on a thorough search of my files for anything close to the data presented. Instead I am responding from what I see in the in-office pathology laboratory market after providing several hundred such financial analyses for specialty physician groups across the country interested in their own in-office pathology laboratory.

Why the difference in CPT code units in the “before” and “after” data? Surprising as it might sound, the most difficult task in providing a financial analysis is determining the number of specimens and CPT code units in a given specialty physician practice. For the most part the specialty physicians have no idea. Ask yourself this question: Do you provide such data to your clients on an unrequested basis? Don’t think too long about the answer, it is a resounding “no.”

So what do I do to get the data? The first option is to ask the specialty physicians to request the data from their laboratory services provider. That is usually an exercise in futility. Getting truly straight answers to that question is a challenge because the laboratory provider then knows something is up with its client. Those requests come back with partial data (88305 with nothing else), data that makes no sense (for a summer month or worse for December with its holidays), or no data (unavailable for whatever reason). My second option is to use average data per physician. For example, I would expect 1,000 CPT 88305 billings per year from each GI in the group practice, plus associated stains. From the tabular data provided in the author’s article I would estimate the “before” group at six physicians and the “after” group at nine physicians.

If your interest is piqued with the “before” and “after” data, let me offer these real-life situations:

The pathology group only got part of the specimens, those that were collected from patients at the hospital’s day surgery center. The rest of the specimens from the specialty group were collected at the local non-hospital endoscopy center and were shipped off to a reference laboratory.
Interestingly, the “before” data shows a date of 2005 but the “after” has no date. Was it a year or two later when the group of six physicians was considering or did merge with a group of three physicians? The single biggest driving force for explosive growth in specialty physician in-office laboratories is expanding merger activity within specialty practices.
If the specialty physicians also worked at a hospital not covered by the pathology group in the “before” case, then those specimens would have been retained by the pathology group at that other hospital but are now claimed as part of the total as the specialty physicians consider opening their own endoscopy center.

Let’s forget all of those excuses, which are real-life experienced examples, and stick with the author’s implication that the consultant was pumping up the specialty physicians to over-biopsy their patients. After all, this is the usual cry from the College of American Pathologists ( CAP ). It is also nonsense from a database of hundreds of thousands of actual biopsies performed and billed by specialty physicians with their own in-office laboratories.

A key average ratio in the gastroenterology (GI) field is 2.2 biopsies per patient undergoing a biopsy procedure. A search of my database indicates GI practices with a low ratio of 2.0 and those with a ratio as high as 2.4, averaging 2.2 which is right on target with what the GI field in general experiences. Assuming the “before” example averaged 2.2 biopsies, the “after” example mathematically would have to be running at 3.5 (2.2 x 9,000 / 5,729) biopsies per patient. That is not happening based on the hundreds of financial analyses I have done for GI practices. My observation of the tabular data presented in the article is that there are now more specialty physicians in the group or the specimens are being consolidated under one roof or the expert was given incorrect data or assumed incorrect data. If the latter, the expert would have the GI practice build and staff a laboratory that is too large for the practice and find him/herself in a legal wrangle. There is no black magic here and no gouging of the patient or the health care system. Implying so is unfair to the thousands of specialty physicians with their own in-office pathology laboratories and the very large number of pathologists who work in those laboratories for specialty physicians.

Now let’s turn to one of my favorite topics, ordering of stains at in-office pathology laboratories by pathologists hired or contracted to specialty physicians to provide professional pathology services. In this analysis I am referencing actual Medicare data for 2006 (latest available and close to the 2005 date used in the article) courtesy of Jondavid Klipp at Laboratory Economics and comparing it to the “before” and “after” examples, as well as to a client with high staining percentages and staining percentages from the largest GI client in my database. This is what it all looks like in terms of stains as a percentage of CPT 88305s ordered:

	Actual Medicare 2006	Path Article - 2009		GI Database - 2009
CPT Code	Actual Medicare 2006	“Before” Example	“After” Example	High Client	Largest Client

88312	8%	13%	2%	28%	0%
88313	6%	0%	7%	50%	14%
88342	14%	0%	22%	0%	19%

% Total Stains	28%	13%	31%	78%	33%

What do I know from the above data? For one, I will not be the first to toss out the “U” word (utilization, if you missed the point). Let’s clearly note that it is pathologists who order special stains, not specialty physicians who own in-office pathology laboratories. This is in spite of protestations by CAP and others. I challenge any pathologist to explain and justify the actual data from the “before” example and the high and largest client data sets presented. These data are all from GI practices. I can also relate that the data shown here is no different in my urology database, basically all over the map and driven by pathologists.

Some of my thoughts on the above data are as follows:

The Medicare percentages relate to a broader range of tissue specimens than those seen at a GI in-office pathology laboratory and are not directly comparable. However, the number of stains ordered and reimbursed by Medicare is growing at more than double the growth of tissue diagnoses reimbursed.
H-pylori diagnosis is switching from 88312 to 88342, hence increasing the percentage of 88342 and decreasing the percentage of 88312. Is 88342 substantially better medically or is its reimbursement substantially better?
Some pathologists are not using 88342 (“before” example and high database clients). Are they ill informed or are they ahead of the curve and sensitive to keeping the costs down and, co-incidentally, their compensation low?
Organized pathology has not addressed standardization of protocols for staining. As a result you get the mess shown in the above table. Who’s right, who’s wrong? Who knows? Does the pathologist in the “high” database client get tagged for overutilization? Is a pathologist who orders few stains a genius who doesn’t need staining assistance or is he/she incompetent?

I maintain that if blatant overutilization of biopsy procedures is occurring by specialty physicians, it is the pathologists who should be blowing the whistle. They are closest to the action and know what is happening at in-office specialty pathology laboratories. Maybe they are taking to heart the author’s “DO NO HARM” message by deciding that saying nothing does no harm to them or the specialty physicians who own such laboratories, and the patients be damned.

Joe Plandowski

07/06/09