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Pⁿ Blog
The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Tuesday, August 05, 2014
It has been a relatively slow summer in terms of blog topics.  I depend on leads from colleagues so feel free to send me an article or topic that you think should be covered.  Much of the news these days is filled with stories of Ebola.  I have to admit that the press seems to be doing a reasonable job of reporting the facts and not feeding into the large body of misinformation.  Fortunately, this virus doesn't spread in an airborne fashion and requires direct contact with body fluids.  If it or a similar virus ever acquires that ability, we'll be in BIG trouble.  Imagine a virus with the infectivity of influenza and the mortality rate of Ebola!  Ugh. 
 
Which leads to one of my favorite morbid musings, regarding "how it will all end."  One end is absolutely certain.  In a few billion years when the sun runs out of hydrogen to burn it will become a bloated red giant star engulfing earth and reducing everything on it to a cinder.  We'd better have moved by then!  In the mean time we can consider the inevitability of the next substantial asteroid impact, something we could possibility alter if we could detect it in time, and my personal favorite, the next super volcano.  The Yellowstone hot spot has a history of erupting every 600,000 years or so and it's overdue.  The dome has been noted to be rising due to the accumulation of underlying magma, so it's just a matter of moments, in geologic time, before it happens.  When it erupts much of the midwest farm belt will be covered in feet of ash.... so much for farming!  But enough good cheer, let me deal briefly with two quite different medical topics.
 
First, the good.
Under a new law in my home state of Virginia, effective July 1, 2014, patients are protected from add-on fees to their medical bills for any form of biopsy or Pap test.  Prior to enactment of the law, a physician who ordered anatomic pathology services for their patients could include additional fees over and above the cost of the service, when performed by an outside laboratory or pathologist.  A physician who includes any markup charge to a biopsy or Pap test under the new law could be subject to disciplinary action by the Virginia Board of Medicine.
 
The bill unanimously passed the Virginia legislature and was signed into law this year by Governor Terry McAuliffe. American Medical Association ethics policies do not condone markup business practices, but until the new law was enacted there was no legal prohibition in the state. Virginia is now the 25th state to outlaw markup billing practices on pathology services.  The legislation, House Bill 893, was sponsored in the legislature by Delegate Christopher P. Stolle (R) of Virginia Beach and Norfolk, and supported by the Virginia Society of Pathologists and the College of American Pathologists.
 
As we all know, widespread markup practices by gynecologists led to the explosive growth of Pap mills and all the associated problems and regulations we'd like to forget. 
Now the bad.

Just when I was feeling good about the above and not contemplating asteroid collisions, another colleague sent me a copy of the United Healthcare Laboratory Benefit Management Program Administrative Protocol for the state of Florida, effective Oct. 1, 2014.  The web URL is too long for a hyperlink, so here it is in full form: 
 
 
This document outlines the requirements for reimbursement for laboratory tests in the state of Florida. I direct your attention in particular to pages 6 & 7.  Note that United Healthcare requires that in order to receive reimbursement, among other things, all malignant skin lesions must be signed out by a subspecialty certified dermatopathologist, all cytology specimens (not just Gyn), must be signed out by a boarded cytopathlogist, etc.  Following this subspecialty requirement table is a long list of pathologic diagnoses for which a documented second review is required for reimbursement.  This list is too long to even summarize here, other than to say that virtually every atypical, in situ, or malignant lesion requires second review, often by a subspecialty certified individual, before reimbursement will be allowed. 
 
Essentially, we have a third party payer attempting to limit reimbursement by setting arbitrary and irrational standards of care.  Part of the definition of any "profession," in addition to the requirent for special skills and often advanced training, is that it is a closed and self-regulating group.  Entry is gained by meeting appropriate training requirements and certification testing.  The profession is self regulating, setting its own standards and enforcing them.  I guess that doctors are no longer professionals.  Unfortunately, this argument could have been made on other grounds much earlier.
 
...now I'm back thinking about asteroid collisions.  :-)
 
 
 

Tuesday, July 15, 2014
If you've followed this blog for a while, or if you scan the backlog of my posts, you'll find that in the past I have discussed the issue of telepathology across state lines and the varying ways states have interpreted interstate medical consultations.  A review of the complex state interpretations can be found in an on-line review article in the March 2014 issue of the American Journal of Surgical Pathology.
 
Virtually all states interpret the practice of medicine as occurring where the patient is located, rather than where the physician (pathologist) is located.  It is clear, therefore, that primary pathologic diagnosis requires a license in the state where the material and patient reside.  As discussed previously, though, whether one needs a medical license to render a physician requested consultation on a patient's material obtained in another state is highly variable and often poorly defined in the state's medical rules.
 
On big step in the right direction would be the possibility of multistate licensure.  The Federation of State Medical Boards (FSMB) has begun an initiative in that direction and it appears to be gaining tremendous support at both the state and federal levels.  A recent article on MedPage discusses this initiative.
 
The details of such a multistate compact for licensure are not yet clear and are still in a state of flux.  In the current draft, it would be required that the applicant be board certified, not traditionally a state requirement, and be free from active disciplinary action.  Licensure in a primary state would be required first, followed by application for the interstate licensure.  The state of principal licensure would evaluate the physician's credentials for participation in the multistate compact and, once approved, other states would license the physician across the compact without further review.
 
One unanswered question, likely to remain so until this intiative becomes final, is the fees involved.  Anyone who maintains multiple state licenses (I have three), knows that these can be recurring non-trivial expenses.  Would this interstate license have a single fee, or would it only serve as a credentially vehicle with the physician still required to pay state licensing fees for every state in which he/she wished to practice?  I suspect the latter. 
 
Regardess, given the non-bounded, interconnected world in which we live, this is an idea that is long overdue to be enacted. If this passes it will clearly be a step in the right direction, improving medical care overall, especially in sparsely populated and underserved areas where direct patient care and expert consultations, clinical or pathologic, may be hard to obtain.

Thursday, June 26, 2014
One of my colleagues sent me an excellent article by Dr. Ben Brown examining the real adjusted income of physicians, taking into account accumulated debt and interest, earning time lost during 20+ years of educational training, long work hours, lack of overtime pay, etc. 
 
Click HERE for article link.
 
Dr. Brown begins his article:
 
"Physicians spend about 40,000 hours training and over $300,000 on their education, yet the amount of money they earn per hour is only a few dollars more than a high school teacher. Physicians spend over a decade of potential earning, saving and investing time training and taking on more debt, debt that isn’t tax deductible. When they finish training and finally have an income, they are taxed heavily and must repay their debt with what remains. The cost of tuition, the length of training and the U.S. tax code places physicians into a deceptive financial situation."
 
The author leads the reader through a calculation of adjusted net hourly wages for an internist working almost 60 hours a week, starting after training at age 29 and retiring at age 65 with a gross income of about $205,000/year and paying off over $600,000 in debt and interest over 20 years.  It works out to $34.46/hr over their career. 
 
Similar calculations applied to a high school teacher assuming debt for a bachelors degree, 10 weeks off for summer and 2 weeks off for Christmas yields a figure of.....wait for it....... $30.47/hr!
 
While most would agree that teachers are greatly underpaid an even larger percentage of the general population would argue, I suspect, that physicians are grossly overpaid.   Against this background, the author also discusses the effect of ever present Medicare fee reductions. 
 
By the way, when similar calculations are applied to dentists, the adjusted gross pay is $61.91/hr! ( I KNEW I picked the wrong medical profession!).  For nurses it comes out to $24.43/hr.  Should nurses really be paid less than teachers?  Food for thought.
 
Finally the article ends with an interesting table listing the USMLE scores, %AOA, and number of publications of residents according to subspecialty.  Pathology is in the middle of the pack.  The brightest seem to be attracted to plastic surgery, dermatology, and otolaryngology.   Interesting!  Keep this article in mind the next time one of your neighbors makes a snide comment about your income! :-)

Tuesday, May 20, 2014
You have cutaneous basal cell carcinoma.  You have pancreatic adenocarcinoma.  Both contain the word "carcinoma," ie. CANCER, yet the clinical difference is as great as the distinction between a lightning bug and lightning.  (Apologies to Mark Twain for twisting his original quote, "The difference between the right word and the almost right word is the difference between lightning and a lightning bug.")  Pathologists understand the distinction, as do most clinicians, but patients not so much.  Sadly, given the shortened exposure many current medical students have to pathology, I fear that their level of sophistication in this regard is likely to approach that of the general public over time. 
 
We have discussed this topic before, but like a bad relative looking for a handout, it keeps coming back!  A recent personal view article in Lancet Oncology [www.thelancet.com/oncology Volume 15, e234-e242, May 2014.]  discusses a National Cancer Institute (NCI) expert committee's recommendations in this regard.  In brief, the panel recommended that the word "cancer/carcinoma" be eliminated from indolent, slow growing lesions with little or no impact on mortality.  Instead the group recommended that such lesions be labelled as "IDLE,"  indolent lesion of epithelial origin.   Setting aside my extreme dislike for the confusion of "origin" with "differentiation," the authors' hearts are in the right place.  However, it strikes me that this is essentially a diagnostic "dumbing down" to deal with the lack of understanding of both patients and, increasingly, clinicians.  In some cases, many examples of carcinoma in situ for example, it may well be appropriate to eliminate the word "carcinoma" as has been done in gynecologic pathology and other areas as well. 
 
It is also clear that increased use of screening is going to preferentially detect more and more indolent cancers, since more aggressive tumors pass through this phase and become symptomatic much more rapidly.  Imagine, for example, the futility of trying to screen the general population for acute leukemia.  The related issue is whether screening and early detection leads to significant improvement in patient survival when balanced against the significant cost and morbidity of overtreatment.
 
Overall, though, this is a thought provoking paper that provides brief and well-written reviews of the prime offenders in the world of overdiagnosis and overtreatment.  Included in this list are:  thyroid carcinoma, prostatic carcinoma, Barrett's esophagus, ductal carcinoma in situ, atypical nevi, and several others. 
 
There is also a very cogent discussion, with a flow chart, addressing the factors from both the patient's and clinician's perspectives that tend to reinforce the use of overly aggressive therapy. 

Monday, April 28, 2014
In case you missed it, on April 24th the FDA approved the cobas human papillomavirus test, manufactured by Roche Molecular Systems, as a primary screen for cervical carcinoma.  The cobas HPV test detects DNA from 14 high-risk HPV types. The test specifically identifies HPV 16 and HPV 18, while concurrently detecting 12 other high-risk HPVs.  Women who are negative with the cobas test to not require a Pap smear.  Women who test positive for HPV 16 or HPV 18 should have a colposcopy.  Women testing positive for one or more of the 12 other high-risk HPV types should have a Pap test to determine the need for a colposcopy.  Health care professionals are advised to use the cobas HPV Test results together with other information, such as the patient screening history and risk factors, and current professional guidelines.
 
Data supporting the use of the cobas HPV Test as a primary screening test for cervical cancer included a study of more than 40,000 women 25 years and older undergoing routine cervical exams. Women who had a positive Pap test or whose cervical cells screened positive for HPV, as well as a subset of women whose Pap and HPV tests were both negative, underwent a colposcopy and cervical tissue biopsy. All biopsy results were compared to the Pap and cobas HPV Test results. Data from this study, which included three years of follow-up on women who went to colposcopy, showed that the cobas HPV Test is safe and effective for the new indication for use.
 
Although this may not be the death knell for the Pap test as a primary screen for low-risk patient populations, it is certainly a large step in that direction. 
About the Author

Stacey E. Mills, MD
Stacey E. Mills, MD, a graduate of University of Virginia (UVA) and the UVA Medical Center, has authored nearly 230 articles, 20+ books, atlases and monographs—including the renowned Sternberg's Diagnostic Surgical Pathology. He has been a practicing Professor and Staff Pathologist at UVA for 30+ years and is Director of Surgical Pathology and Cytopathology. His clinical specialty is general surgical pathology with emphasis on neoplasms and neoplasm-like lesions. Dr. Mills is also Editor-in-Chief of The American Journal of Surgical Pathology.