College of American Pathologists
Printable Version

  On client billing, a voice
  in the wilderness

  cap today

February 2005
Feature Story

Louis Wright Jr., MD, would make a lousy dance partner. In a profession where no one, as he puts it, wants to step on a colleague’s toes, Dr. Wright, the founder of Pathology Services Associates LLC, Florence, SC, doesn’t hesitate to mash a few digits. He might even give a swift kick to the shins while he’s at it.

The subject is client billing, one of the more flyblown topics to confront pathology. On some levels, the conflict feels epic, like a religious war. On another front, it’s a legislative struggle, besmirched as only politicians can besmirch things.

It’s also a family matter, and in the way of many familial discussions, there are burning issues that no one can quite bring themselves to confront. But Dr. Wright is ready to talk. He shared his views most recently in an interview with CAP TODAY and during a Washington G-2 Reports session.

Stripped bare of all the rhetoric, client billing allows clinicians to charge for pathologists’ services, which are performed by pathologists at a discount. Depending on your viewpoint, the practice is either wrong or a legitimate business arrangement; it can lead to overutilization and poor quality, or it saves money while boosting patient care. It violates Medicare regulations and AMA policy (though some unblushingly insist otherwise), and it was the subject of a strongly worded editorial ("An assault on our practices," CAP TODAY, April 2004) by CAP President Mary E. Kass, MD.

Into this maelstrom thumps Dr. Wright, who strides past the motley arguments and says, "The fundamental issue is, Are we peers with our clinical colleagues, or are we seen by them as simply some sort of supertechnicians?"

To Dr. Wright, the evidence is clear: More and more, he says, clinicians view pathologists as supertechs who manage projects in the laboratory, which spins out information for clinicians who then use it to make decisions without further input. Yet there’s no parallel universe between clinicians. Dr. Wright proposes as an example a urologist who detects a heart problem in a patient and calls a cardiologist for a consult. No clinician would dare say to a clinical colleague, "See my patient, and by the way, I want to negotiate what I’m going to pay you for the service. And when you’re done, send me the bill and I’ll price it however I want to." Says Dr. Wright, "That just doesn’t happen."

If it doesn’t happen among clinicians, why pathologists? Some argue that pathologists are just the first stop on the long client billing train, that clinicians soon will start targeting one another as well. Dr. Wright takes another tack, arguing it has become easier for clinicians to downgrade pathologists because pathologists’ own self-perceptions have changed.

It’s a daring view. While many pathologists feel they’re under attack by clinicians and are fighting client billing on local and state levels, Dr. Wright is calmly pointing inside the profession and asking pathologists to take a closer look at themselves. It’s like asking belligerents to set down their copies of Machiavelli’s The Prince and start flipping through I’m OK, You’re OK instead.

But Dr. Wright is adamant underneath the gentlemanly, Southern layers that wrap his words, insisting the profession needs to change what he calls its "personality model" if it wants to reclaim its peer status among clinicians. Those who typically seek pathology as a profession are "introverted and quiet, usually highly intelligent, and don’t want to fool with anything but doing what they do well as scientists," he says. "They don’t like having direct relationships with clinicians or with patients or with hospital staffs. They just want to go in their lab or office and hunker down and make interesting diagnoses."

This personality has had some 20 years to work its way into the collective conscious, says Dr. Wright, who links the transformation to changes in pathology postdoctoral education. That’s about four cycles of residents, he notes, and those who conform to this model have been practicing approximately 15 years.

Two decades ago, academic pathology decided an added year of pathology training was in order. At the time, pathology residencies were four years, with an additional one-year pre-residency clinical requirement in general medical training or pediatrics. Adding a fifth year of pathology created a six-year program—"and it didn’t take them very long to realize that the quality and number of applicants started to go down because of it," Dr. Wright recalls. The added year of pathology soon trumped the clinical year. "So in the last 20 years, we’ve gone from having postdoctoral clinical experience to not having any before you go into pathology. I think that’s the linchpin that’s driving all this."

Without that clinical immersion, says Dr. Wright, pathology "became a wonderful place for people with personalities who really didn’t like talking to other people, who really didn’t want to have that interaction with a sick patient. Over time, pathologists have, as a secular group, become more and more introverted and less and less willing to participate in the general dynamics of patient care." He’s seen it in his own practice, he says: younger pathologists who don’t want to do floor consultations and who rarely want to participate in tumor boards, quality assurance and credentialing committees, and, yes, autopsies. Instead, they’re drawn to high-end, fine diagnostic work—and nothing else. "They’re much happier closeted in a small space with their microscope, solving very difficult diagnostic problems, dictating that into a transcription machine, and laying the report file out for the clinicians to use."

"So it’s easy to see," says Dr. Wright, "how our clinical colleagues have developed a perception of us that we’re not really doctors."

Dr. Wright doesn’t discount the other forces chipping away at pathology’s image, such as declining reimbursements across the board. "It’s natural that our clinical colleagues are trying to scurry around finding ways to offset those reductions. One way to do it is demand that you do their pathology and bill them at a discount, so they can then bill it up and recover some of the losses they have on the other side of their business. It adds a major obstacle to us changing the mindset of clinicians about client billing."

Less talked about—though not by Dr. Wright—are the disagreements within pathology that are sending fissures through the profession. "The issues need to be laid out candidly," he says. "The problem is, no one wants to step on their colleagues’ toes. We are inclined to be nice folks and we try to work collegially within the lab industry."

That makes it hard to discuss any number of issues, among them:

  • whether client billing should be capped, or banned outright;
  • how the battle should be fought—on the AP front, the CP front, or both; through state or federal legislation, or both;
  • the profession’s attitude toward pathologists who client bill;
  • whether pathologists should join forces with insurers and other physician organizations.

Make no mistake—any number of pathologists who’ve been involved in client billing issues consider this to be a war. But it’s been difficult to articulate against whom, especially since there are pathologists as well as clinicians who advocate the practice. But again, Dr. Wright blames pathology’s existential crisis, rather than a particular enemy. "Who are we?" he asks. "What are we?

"I sometimes worry that the College has a great deal of problems with these questions," he continues, adding that this isn’t surprising. "The College is in the business of dealing with regulators; getting products certified by agencies; selling products to hospitals, to large national labs, even to small pathology labs. So they deal across this whole industry realm, and those people are embedded in our membership. But so is the small community pathologist." The College’s inescapably broad perspective "leads to confusion by the rank and file as to what we’re all about," Dr. Wright maintains. "But as time goes on, the College may find it has to identify who it serves a little more clearly."

He applauds the ongoing efforts being made by various CAP councils to clarify the organization’s identity. "But there is still that nagging question: Can we serve a large, diverse group of masters? It’s going to take some real hard decision-making, that won’t always be popular, to resolve that."

Even less popular will be the discussions that acknowledge pathologists—including College members—practice client billing. To the consternation of many, some have publicly advocated the practice. Others are more quiet about their choice. "They’re reluctant to admit they do it," says Dr. Wright, "because their colleagues want to tar and feather them."

Such internal strife is like watching a clan struggling not to implode over a holiday meal. While some are hell-bent on making nice—not mentioning the absent spouse, the drunken cousin, the failed business venture—Dr. Wright is demanding that the skeletons finally be let out of the closet. "As long as we’ve got that sort of internal dynamic, it’s going to be hard for us to even get to where we’re comfortable sitting at the table and developing a consensus decision."

Does the College have the stomach for all this? "I don’t know. I really don’t," says Dr. Wright. "I think we have wonderful leadership. But they’re all human. And most of them are not people who want to be confrontational."

If troubled by confronting one another, pathologists have been willing to face legislators and, in some cases, clinicians. The bulk of their efforts have been focused on individual states, an approach that Dr. Wright views with mixed feelings. "I had always wished we would have the federal government legislate, in a Prohibition way, against client billing," he says. Because Medicare prohibits client billing to its beneficiaries, it makes no sense to ignore it on the private side, Dr. Wright contends. "I’m one who firmly believes that client billing is inflationary. It could be an incentive for the ordering physician, the clinician, to order maybe a little bit more than he really needs because he’s going to get a little pickup on it financially."

A state-by-state approach could also take longer and will meet with uneven success. "It’s harder to build that road one pebble at a time," says Dr. Wright. His own state legislators passed a direct billing law for anatomic pathology last year, and in mid-January they overrode a gubernatorial veto of the law. "We’re a small state," says Dr. Wright. "Our governor has a very close relationship with some pathologists, and he has some close relationships with some OB-G’s."

At the same time, Dr. Wright has nothing but praise for one outgrowth of the state efforts. "It has brought the College full force into pathology issues on the state level. The Washington office is doing an incredible job of growing that initiative." In the long run, he says, this CAP-sponsored nation-building of small state pathology societies may be what keeps the College front and center among pathologists.

Unlike some hardliners, Dr. Wright isn’t an anti-client billing purist, for lack of a better phrase. He says legislative approaches that permit client billing, but prohibit markups, are palatable to him. Teaming with insurers—an obvious if somewhat unorthodox ally—also makes sense to him, as does aligning with radiologists. He even evokes a bit of understanding toward pathologists who are tempted to client bill, acknowledging the competitive pressures they may feel.

On the other hand, he’s drawn the line hard and firm for himself and PDPA, his practice. If there are legitimate reasons to client bill, he says, he hasn’t found any during his nearly 30 years of practice. He notes that LabCorp’s corporate offices are 120 miles from his; likewise, Quest Diagnostics has a large lab in Atlanta, 160 miles away. "They’re all over us, just like everyone else in the nation," he says. "And we’ve elected to compete with them.

"But we don’t client bill."

The clinicians in his marketplace know this. Occasionally, Dr. Wright says, a client will succumb to this Delilah and take its business elsewhere. But in every case, he says, the clinicians have eventually returned to his fold. "Sooner or later they realize it’s important to have a pathologist close by, helping them understand their patients."

When they return, they find the door open to them. It’s likely Dr. Wright and his colleagues are passing through the door themselves, meeting clinicians, talking to them, and working alongside them—practicing point-of-care pathology, as he calls it.

Would that all pathologists did the same, he says. "If you talked to all 10,000 or so fellows of the CAP, every single one of them would look you straight in the face and say, ’Oh, we do that all the time.’ But they don’t. They may somehow pay a little lip service to it, but they don’t really do it." More realistic, he says, are the stories about the pathologist who goes on vacation, leaving three difficult cases for when he returns. "He wants the time away to clear his head a little bit, and then he’ll come back and work on them," says Dr. Wright. "Clinical medicine doesn’t wait on our vacations."

If pathologists want to regain their peer status, it will require a prompt and thorough response, says Dr. Wright. "We can’t wait."

Returning to a four-year basic pathology residency and reinstituting a year of clinical medicine after medical school top his list. But even if that occurs, it will be decades before the profession’s peer personality re-emerges. In the interim, Dr. Wright suggests:

  • turnarounds on frozen sections. "They want them, you get them. I don’t care when it is."
  • Clinical bedside consultations. He knows they’re unpopular with pathologists. But to stand alongside clinicians, "We’re going to have to interact with them much more aggressively, and we need to start doing that immediately."
  • Be a joiner— "whether it’s a tumor board or quality committee or insurance committee, even doing autopsies, which is sort of the ultimate quality assurance tool."

His finger having come full circle, Dr. Wright again points directly at his own profession. "A lot of pathologists like to close the door of their office when they go in and instruct their secretaries not to let those doctors in," he says. "It’s a vicious circle that we’ve created."

Dr. Wright knows that critiquing his own profession, let alone physicians in general, is not a popular thing to do. "Managing criticism is difficult for physicians. Period. We know a lot of stuff, and we make really difficult decisions affecting people’s lives. So don’t tell us we did it wrong," he says.

"But as long as I have an opportunity to have a voice, I’m going to keep talking."

Karen Titus is CAP TODAY contributing editor and co-managing editor.