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
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,
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
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
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
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
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,"
"But as long as I have an opportunity to have a voice, I’m going to keep
Karen Titus is CAP TODAY contributing editor and co-managing editor.