College of American Pathologists
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  President’s Desk


CAP Today

Stanley J. Robboy MD, FCAP
Stanley J. Robboy, MD




March 2013

Stanley J. Robboy, MD

Look to pathways for opportunities

Regular readers know that the CAP has spent the past several years exploring how we can ensure a bright future for pathology. The future, of course, as my adult children would quip, is “ours, but also ours to lose.”

As we embrace new tools that enable us to decipher the molecular code of life, unravel the essential causes of disease, and develop miraculous new therapies, payment models are also evolving in fundamental ways. It appears likely that fee-for-service will be replaced by schemes that more directly measure value in terms of improved outcomes and cost efficiency.

Some 70 CAP members developed the data that built our Case for Change. With that in hand, we commissioned G2 Intelligence to help us formulate practical new ways to secure our economic future. “Promising Practice Pathways,” an astute, arms-length view of our opportunities and challenges, is the product. Written by pathologist Eleanor J. Herriman, MD, MBA, who heads the company’s advisory services, the pathways document is available for download at

“Promising Practice Pathways” offers concrete advice for pathologists who are coming to grips with the uncertainties of an evolving health care environment. It sets out fundamental considerations, which include urgency, risk, and reward. The four pathways that have been developed focus on new and more extensive services in oncology, diagnostic services, coordinated population care settings such as ACOs, and ambulatory patient diagnostic service centers.

To my mind, fee-for-service has become unsustainable, if only because it is about thinking small. How did we come to a system where compensation is based on test volume? It’s not surprising that the public discourse about health care is now so often focused on shrinking resources and competing needs.

Health care payment is moving to a value-based model designed to reward care that improves quality and lowers costs. Those who step up and embrace risk will find themselves working more closely with other clinicians, administrators, and possibly policymakers, tweaking measures to improve population-based care, creating evidence-based treatment schemes, and putting an end to the perception that our expertise is limited to tissue analysis and test management. The vocabulary may have changed, but fundamentally this is a return to our roots.

Pathologists are uniquely positioned to provide knowledge services that will enable optimal patient care outcomes and improved efficiencies. We need to get the word out on that point, which calls for initiative, energy, and healthy risk-taking.

Our first task is to redirect the greater conversation by brainstorming within our practice groups about services we can provide that meet a need and create value. Richard Friedberg, MD, PhD, who chairs the Department of Pathology at Baystate Health in Springfield, Mass., tells me that his group held an evening retreat to discuss the “Promising Practice Pathways.” Four other pathologist leaders agreed to study one pathway each and then led a discussion with the entire group from the perspective of what their practice might look like if they were to adopt a plan along that pathway. From that discussion, it was a much smaller step to take the conversation to others on the medical staff. Dr. Friedberg tells me they have done that, and their strategic planning process has made real progress. Many of us are so busy that we forget how exciting it can be to brainstorm, and that’s exactly what we need to do with our clinical partners. What a great way to get everyone invested and engaged.

Pathology practices can adopt one or more of the pathways models and implement them as adjuncts to their current practices. The CAP Practice Management Committee is developing tool sets to help our members introduce the pathways in their practices. The plan is to begin with tool sets that demonstrate pathologists’ value, facilitate benchmarking, and support negotiation skills. Next, they contemplate tool sets to help pathologists address quality improvement, build entrepreneurial skills, conduct market assessments and pathology practice self-assessments, improve cost efficiencies, and overcome inertia.

Space constraints do not permit a discussion of all four pathways, but the “high-performance pathology for high-value oncology” pathway illustrates the scope of services these models present. The oncology pathway will reveal the strengths of precision medicine. Pathologists with molecular diagnostics expertise—both members of the group and outside pathologists with whom they have consulting agreements —can help to monitor treatment and evaluate patient care options. Services may be developed in partnership with community oncologists, institutions (hospitals, cancer centers, ACOs), and health plans. As fully integrated members of the patient care team, we can move beyond diagnostic and prognostic advice to tailored treatment algorithms and case-based knowledge services.

Providing services with measurable clinical value is the key to our economic future. Pathologists might develop databases that identify options for palliative care in specific circumstances. They might create a digital resource that offers current commentary on the care of patients with common cancer comorbidities. Comprehensive integrated pathology reports can be developed to facilitate test ordering and interpretation. These are the types of services that the pathways model envisions.

Pathology is uniquely qualified to manage the products of a knowledge explosion that holds great promise for our patients. Those with informatics expertise (or consulting arrangements for informatics resources) can build robust databanks and sit down with treating physicians to compare treatment results against national benchmarks. Initiatives like these can change perceptions about our interests and capabilities.

Science is our domain, and it is a driver that moves ever forward. Consider the speed with which progress in genomics has changed our definition of “possible.” Consider the critical agency of informatics in marrying scientific insight with clinical application. Consider the impact in our practice settings when we partner with clinicians to connect the dots between improved outcomes and thoughtful efficiencies. Consider the opportunities that the pathways model suggests. Then invite a small group of your clinical colleagues to a meeting where the only agenda item is how your practice can do more for them. In short order, you will know more about their needs, and they will know more about your capabilities. The pathways are win-win for us and for our patients.

Dr. Robboy welcomes communication from CAP members. Send your letters to him at