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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, July 16, 2013
Self-referral.
Congressional Quarterly recently reported that the GAO (Government Accountability Office) has become increasingly concerned about the dramatic increase in self-referred biopsies.
 
As reported at CQ.com (a subscription-based publication), the number of times doctors order biopsies when they have a financial stake in the testing is increasing dramatically, with the Government Accountability Office estimating that in 2010, Medicare paid $69 million it could have saved had the number of self-referrals not been so high. 
 
Several days ago, a bipartisan group of lawmakers including Senate Finance Committee Chairman Max Baucus, R-Mont., ranking member Charles E. Grassley, R-Iowa; House Ways and Means Committee ranking member Sander M. Levin, D-Mich.; and House Energy and Commerce ranking member Henry A. Waxman, D-Calif met to discuss this topic.  The group berated physicians for over-ordering such procedures.  The GAO report indicated that three specialties: dermatology, gastroenterology, and urology accounted for 90 percent of self-referred anatomic pathology services in 2010.  How this number was derived is unclear, but we all recognize these as "biopsy rich" specialties.
 
This is, of course, far from the first time that this concept has been brought up in Washington and elsewhere, and it doesn't take a crystal ball to see where it's all going in today's cost reduction driven world.  Those who order any lab tests, ranging from clinical chemistries to biopsies, should not benefit financially from them.  Human nature being what it is, if you benefit, you order more tests than you need to, even if you're not conscious that you're doing so.  Clinicians should not be farming out their laboratory work to the lowest bidder and then marking up the price and collecting from patients and their insurers for this work.  And yet there are physician groups who not only seek out this sort of arrangement but view it as a substantive source of ancillary income. And as pathologists, some of us are guilty of going along with these arrangements.  If you think this is a good idea, think back to the direct billing of marked up Pap smears by gynecologists, which led to the growth of poor quality Pap mills and ultimately the massive government regulations surrounding gynecologic cytology.  It's deja vu all over again! 
 
If you're in a dermatology, gastroenterology, urology, or other clinical practice and thinking about starting your own lab and reaping a financial windfall, think again.  The end of this practice is very near.  You may have your own favorite pathologist whose diagnoses you undersand and trust. They may even rent space in your building.  That's OK, but you had better keep the financial arrangements completely separate.  You cannot benefit financially from the specimens you're providing.  Do your job, bill for your services independently, and let the pathologists do the same.  It's just good medicine.  But, then, unfortunately if you're a dermatologist, gastroenterologist, urologist or other "high biopsy" clinician, you're not reading this blog anyway.
 
 
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.