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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
Summer Musings....
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. I'm back thinking about asteroid collisions.  :-)
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.