College of American Pathologists
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CAP Today




June 2012

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ACOs and pathologists: a close-up look

In its recently released white paper on accountable care organizations, the CAP identifies how pathologists can help an ACO achieve its goals of improving care and reducing health care costs.

To learn how pathology practices have taken leading roles in ACOs, CAP staff visited in February with pathologists, other physicians, and administrators at Geisinger Health System in Danville, Pa.; Methodist Health System and Nebraska Medical Center in Omaha; and Catholic Medical Partners in Buffalo, NY. Each of these coordinated care models was more a natural outgrowth of an existing business model than a response to health care reform or the Medicare Shared Savings Program in particular.

Four examples of how pathologists and laboratory medicine departments have added value:

  • Setting up test-ordering protocols. While pathologists contributing to order sets is not unique to ACOs, the paper notes, ACOs are unique in that there is opportunity to apply similar standards across a wide range of health care settings, and financial incentives can be put in place to reward pathologists for their contributions.

  • Helping ACOs to develop standards for identifying and managing chronic illness in the population enrolled in the system. Geisinger, for example, has reduced the median number of days it takes for renal patients on EPO to reach a target hemoglobin level, from 62.5 days to 35.

  • Improving physician access to laboratory data. As “owners” of the laboratory data, pathologists in these organizations have taken, or are looking to take on, a leadership role in making lab data more accessible to and actionable by physicians. Pathologists at Catholic Medical Partners are looking at how to use the EHR to identify diabetic patients who had not been getting the necessary HbA1c tests.

  • Collaborating with clinicians, the opportunities for which include not only creating test-order protocols and improving treatment of chronic disease but also providing post-test consultation for complex tests, pharmacogenomic testing, and followup disease-risk genomic testing.

What are the challenges the pathologists and other organizational leaders face?

One of the most important: how to pay for the pathologist’s contributions. At Geisinger, all providers are salaried and eligible for substantial incentive payments for cost savings and care innovations. At Nebraska Medical Center and Methodist Health System, pathologists are salaried and the pathology department gets a bonus based on cost reductions and quality targets. Pathology will be one of the specialties eligible for sharing in cost reductions from greater efficiencies under shared savings agreements in the physician hospital organization in which the Methodist pathologists participate, but the share going to pathologists and all other PHO physicians had not been determined at the time of the CAP visit.

At Catholic Medical Partners, pathologists are not employees of the hospitals or ACOs and therefore not compensated directly for the quality improvement services they provide. Under their IPA arrangement, pathologists are eligible for incentives based on performance measures. Under CMP, the formal ACO, how pathologists should be paid for efficiency gains was “not yet fully resolved conceptually or specifically,” the report says.

The other main challenges: health IT systems that aren’t bidirectional and the “substantial amount of time, effort, and behavior change” it takes to move to an ACO model.

David J. Gross, PhD, of the CAP Office of Transformation and director of the CAP Policy Roundtable, is the author of the paper. Find it at under Advocacy.

Agilent to acquire Dako

Agilent Technologies and Sweden-based private equity group EQT on May 17 agreed to buy Denmark-based cancer diagnostic company Dako for $2.2 billion. The all-cash deal, the largest ever for Agilent, is expected to double the company’s reagents business and increase its growth in life sciences and diagnostic markets.

“In the rapidly growing diagnostics market, Dako’s products and capabilities are a strategic complement to Agilent’s existing offerings,” Agilent president and chief executive officer Bill Sullivan said in a statement. “Agilent’s strategy in acquiring Dako is about strengthening the company’s presence in life science and about revenue growth.”

During a May 17 conference call to discuss the transaction, Sullivan said that because more than 90 percent of Dako’s business is in reagents and services, “we expect to see an immediate increase in Agilent’s recurring revenues from 25 percent to 30 percent of total revenues.”

The merger is expected to increase Dako’s penetration into emerging markets. Dako’s CEO Lars Holmkvist said in a statement, “Our combined companies will have complementary strengths. Like Agilent, Dako has a long history as a leader in scientific advancement and a culture that values discovery and innovation.”

Tool prompts a rethinking of the CT scan order

An electronic medical record tool that queries ordering physicians helps reduce potentially unnecessary CT tests in emergency room patients with abdominal pain, according to a study presented May 11 at the Society for Academic Emergency Medicine annual meeting. Conducted by researchers at the Perelman School of Medicine at the University of Pennsylvania, the study showed that when the tool was in use, ER patients were 10 percent less likely to undergo a CT scan. The number of patients admitted to the hospital did not increase.

The tool, which is embedded in patients’ EMRs, walked physicians through a series of questions that served as checks and balances for their decision to order a CT scan to investigate a patient’s abdominal pain. Physicians were queried, for instance, on what diagnosis they were trying to look for (from appendicitis to colitis to an ovarian cyst or tumor), and how likely they thought it was that the patient actually had that problem. If a medical resident ordered the test, it had to be approved by an attending physician before the patient could have the scan. Those steps, the researchers said, appeared to play a role in prompting the care team to rethink its choice of tests.

The Penn researchers studied 11,176 patients seen in two Penn Medicine emergency rooms between July 2011 and March 2012. Before implementing the new accountability tool, 32.3 percent of patients seen received CT scans. After its use was adopted, the number dropped to 28 percent. After adjusting for various confounding factors, the researchers determined that patients were 10 percent less likely to undergo a CT scan after the tool was built into the EMR. The patients were no more likely to be admitted to the hospital after adoption of the tool.

Molecular subtype of prostate cancer reported

A subtype of prostate cancer has been uncovered and it’s one that appears to account for up to 15 percent of all cases, say researchers at Weill Cornell Medical College, the Broad Institute of MIT and Harvard, and the Dana-Farber Cancer Institute.

In the study, published online May 20 by Nature Genetics, investigators describe how they discovered novel mutations in the SPOP gene in numerous patient tumors, saying this alteration is thus far unique to prostate cancer and represents a distinct molecular class.

This finding adds to the discoveries of other genes linked to prostate cancer by this team of investigators, led by Mark A. Rubin, MD, the Homer T. Hirst professor of oncology in pathology and vice chair for experimental pathology at Weill Cornell Medical College, and Levi Garraway, MD, PhD, a senior associate member of the Broad Institute of MIT and Harvard, and assistant professor at the Dana-Farber Cancer Institute and Harvard Medical School.

The latest study focused on the one to two percent of DNA in the genome that codes for proteins, and, as such, is one of the largest whole exome sequencing studies published on prostate cancer to date, according to Dr. Garraway.

Broad Institute researchers, led by Dr. Garraway and Sylvan Baca, MD, PhD, completed exome sequencing of 112 prostate tumors and normal tissue pairs. The findings were verified in another 400 prostate cancer patient samples from other institutions.

The teams found three genes significantly altered in the prostate cancers, but not in non-cancerous tissue. In addition to SPOP mutations, which occurred in six to 15 percent of tumors across multiple independent cohorts, they found mutations in the FOXA1 and MED12 genes, each of which are found in about four percent of patient tumors.

The mutations the team discovered all occur where the SPOP protein binds to the other proteins it should tag. “That suggests that there might be an accumulation of proteins in the cell that aren’t cleaned out and this might lead to cancer growth, or the mutations could be removing proteins that help prevent unchecked cell growth,” says Dr. Rubin. “We are working hard to understand what is happening.”

The researchers suspect SPOP mutations occur early in development of the cancer. They do not yet know if SPOP mutations define a more aggressive type of prostate cancer.