Making a play for Part A
What is Part A?
In his unflagging quest for Part A reimbursement for pathologists at Sentara Healthcare System, Richard Moriarty, MD, has stared down any number of obstacles. Hospital administrators unaware of what and how much pathologists do in the clinical lab, and trying to limit Part A payment. Tough contract negotiations. Well-trained, independent technologists wary of pathologists becoming more involved in the clinical lab.
But his biggest stumbling block was a bit surprising. "It was my colleagues," says Dr. Moriarty, medical director of laboratories at Norfolk, Va.-based Sentara Hospitals and president, Pathology Sciences
To be precise, colleagues who failed to record their Part A activities on the time sheets designed to track such efforts. "I can’t tell you the number of times I’ve taken the time sheets around, closed the door to the office, and said, ’Jim, did you call so-and-so about that liver biopsy and discuss the lab tests?’ And he’ll answer, ’Yes, yes, I did that.’ When I ask him if he’s the one who straightened out the fact that the GMS control didn’t work—’Yes, I took care of that.’ ’Did you speak to Dr. X about the workup of the patient with the prolonged PT and PTT?’ ’Yes, I did.’ ’Did you attend the planning session for the upcoming Joint Commission survey?’ ’Yes.’"
Invariably, Dr. Moriarty says, his final question was, "Then where is it reflected on the time sheet?"
"Some people are just not interested in this stuff," he continues. But Dr. Moriarty and his colleagues have decided they can no longer afford to be indifferent about Part A matters. In recent years they’ve negotiated not one but two contracts for Part A pathology services with Sentara Healthcare System, a five-hospital system with a large reference laboratory. Dr. Moriarty spoke about the tireless—and tiring—efforts that led to the group’s eventual success in a presentation at the 2001 Executive War College, held in Cincinnati in May, and in a followup interview with CAP TODAY.
The starting point in any Part A journey is a provocative question, Dr. Moriarty says: Can pathologists afford to give up 30 percent of their time—representing Part A activities—as pro bono work? "Many of us give up more than 30 percent, even those who do anatomic pathology," he observes.
"Every pathologist provides Part A on a daily basis," he notes. "Even if you go to the physician’s lounge, get a simple cup of coffee, you go down there and you talk with the clinicians. You interact with them, and they ask you a variety of questions about laboratory testing or test results. This is Part A."
When Dr. Moriarty joined Sentara in 1990, its pathologists were paid in a lump sum representing the total salary allotment for each physician. "There was no separate, recognized Part A allocation, and the pathologists did not separately bill for Part B activities," he recalls.
The laboratory setup at the time of Dr. Moriarty’s arrival had another glaring drawback: Apart from the laboratory medical director, pathologists were only marginally involved in the lab; the real movers and shakers were the administrative director of the lab and the senior medical technologists. "We were unhappy with our status and our perceived inability to have more control over technologic issues and influence in the laboratory," Dr. Moriarty says.
He shared his unhappiness with the system’s administrators, one of whom invited him to write a vision statement. "That was all I needed," Dr. Moriarty remembers. "A vision statement should always be looked on as an opportunity, not a chore." One vision statement later, he and some of his colleagues had an unstinting sense of where they wanted to take the system, how everyone—patients, technologists, administrators, and pathologists—would benefit from their actions, and how they would make themselves accountable.
Their first step was persuading the administration to let them hire a transfusion medicine expert. "We have a large transplant center, a busy trauma center, and we were spending a lot of money on blood and blood components. No one was exercising any control over transfusion orders," Dr. Moriarty says.
Dr. Moriarty and his colleagues proposed the hire would permit Sentara to save an amount equal to that person’s salary in the first year alone. Their predictions were more than met, with a savings of 1.7 times the salary in year one, and twice the amount the second year.
Such a clearly demonstrated cost savings, along with documented medical staff support for the pathology department, proved invaluable. "The technologists started to appreciate us more as pathologists," says Dr. Moriarty, who adds, "The techs and administrators were beginning to recognize we were willing to be more involved, and they came to us more and more often." Moreover, "We gained credibility with the administration. We delivered a product. We improved patient care. We delivered
All of which opened the door to further pathologist activity. The administrators were willing to listen to requests for additional staff, particularly in AP, and the pathologists won representation on hospital committees and growing recognition from the medical staff they now consciously catered to. "People were starting to ask the question, ’Jeez, how did we ever get along without this kind of input from pathologists?’"
These were much savored, though short-lasting, victories. In 1995, Sentara embarked on what became known as its "reinventing." The chief executive officer ordered a 25 percent reduction in the operating expenses of the system’s major clinical and business functions—including the laboratory—to take place over five years.
The laboratory’s cost-reduction goals were ambitious—to trim $1.1 million in calendar year 1996 and $5.5 million by calendar year 2000. The lab had baseline measurements for a range of services it planned to improve, ranging from quality (such as lab specimen identification and lab reporting errors and crossmatch-to-transfusion ratios) and service (turnaround times) to cost and utilization.
The laboratory reinventing team, which included pathologists, spent countless hours plotting and setting up centralized services (including AP); standardizing test menus and equipment across the system; and expanding its point-of-care testing program. It significantly boosted its units of service and market share and decreased its expense per units of service that first year and in subsequent years.
Despite all their efforts and successes, the pathologists’ compensation was cut. "We did not stress and document our involvement in the process as Part A activity," Dr. Moriarty says. To their disappointment, part of the cost savings to the lab was to be a decrease in pay from the hospital to the pathologists. "We had no time studies. I had not really written down everything my colleagues and I had done to contribute to this Part A activity," he says.
The administration’s position rallied the pathologists to seek a new contractual arrangement with the hospital. "It was a tough negotiation," Dr. Moriarty recalls, "because it was a new arrangement for the pathologists and hospital administrators. I got most of my gray hair that I now have during that time," Dr. Moriarty says.
Yet, fortunately, "We were able to capitalize on the goodwill we had built up over the last five or six years with our medical staff and on our record of past achievement—though not entirely recognized—of our Part A activities." They signed a new contract with the hospital in 1997 and won the first ever "reasonable, but significant Part A payment, allotted by FTEs—that is, the pathologists said they would provide and document x amount of FTE activity in clinical pathology, and were given that sum as Part A payment," Dr. Moriarty explains. The additional money was used to hire more clinical pathologists. "The days of putting Part A money into your pocket are over, and I think they should be over," Dr. Moriarty says.
The contract was notable for its performance standards—a challenge pathologists should embrace rather than fear, Dr. Moriarty insists. "If we can’t deliver this kind of turnaround time, if we can’t deliver this quality, we don’t deserve the contract."
Though some of his colleagues initially were upset by accountability standards, "I think it showed good faith on our part to be accountable for the money the hospital had given us," Dr. Moriarty says. "Again, it’s an opportunity to prove you are worth your salt."
The pathologists also embarked on time studies, which, in part, helped them successfully negotiate a mid-contract increase. Another increase came this past spring, when they negotiated another contract.
Looking back on the events that led to the contracts, Dr. Moriarty offered a handful of lessons learned.
"You need to educate everyone"—medical staff, administrators, lab staff, colleagues—"as to what you do and offer," he says.
Laboratories also need to document their activities with a system that is understood, recognized, and accepted by the administration prior to its adoption. "Make sure you and your administrators sit down and say, ’Look, this is the measurement we’re going to use,’ and have them review the numbers. We made sure from the beginning that our administrators were happy with how we were measuring what we’re doing."
Also ripe for documentation: cost savings. "I have a file in my desk and every time I know we saved some money, every time we helped with a policy that I can document a savings—even if it’s just a ballpark estimate—I put it in the file. When I meet the administrator I bring that file with me, and at the end of the year I can make a summary report. It lets me demonstrate what we’ve done.
"You’ve got to promote yourself, because no one else will," he adds.
Time studies are critical. Dr. Moriarty and his colleagues developed a one-page form that essentially serves to remind pathologists exactly what they do under the Part A umbrella. Pathologists can access the form on
"Somewhere around 40 percent of our activity can be documented by Part A," he says. That figure climbs higher for those whose work is strictly clinical, of course, and drops—though never disappears—for those whose focus is primarily anatomic.
Dr. Moriarty and his colleagues document Part A activity for a near-epic list of endeavors that might leave some to wonder, What isn’t Part A activity?
In education, this includes resident/student teaching, lectures, supervision, and signout. Other Part A-related activities include attending lectures and CME conferences, participating in medical staff education conferences, and teaching/overseeing technologists and other hospital personnel. Administrative tasks, such as attending committee meetings, answering e-mail/mail, traveling among the system’s various hospitals, project and budget planning, and personnel/staff recruitment, are likewise counted as Part A activity.
The Sentara pathologists also track Part A activity in an area known as AP/CP laboratory management. This includes informal consults with medical staff—which often take place in the physician lounge, Dr. Moriarty notes—as well as determining the need for specific CP/AP procedures; pinning down appropriate diagnostic methods for analytes; evaluating clinical relevance of results; creating test reference values and levels of precision, accuracy, specificity, and sensitivity; assessing the effects of other analytes, medications, and disease states on test results; and interacting with medical staff on laboratory issues.
"I get several calls a day where clinicians say, ’Hey, I’ve got a problem.’ I deal with it, or I give them to someone in our laboratory who can deal with it. Again, this is all Part A," Dr. Moriarty says.
AP/CP lab management also includes designing test protocols, turnaround times, deferral criteria, stat procedures, panic values, and data collection and storage criteria; sizing up clinical reference laboratories; developing and monitoring utilization guidelines; and evaluating test and QC performance.
All aspects of autopsy fall under Part A as well. "Not just when you are downstairs doing the prosection. Not just when you come upstairs and dictate. But also when it’s a couple of days later, when you have to get the special stains, when you go around showing it to your colleagues, when you’re calling the clinicians for more history," he says.
And finally, he says, take note of direction of POC testing, accreditation activities, and clinically oriented research. "All can be included as Part A activity, and all are on the form that we use."
Just as important, he says, pathologists "need to revel in accountability. Don’t run away from it. Ask to be accountable, then be able to demonstrate what you accomplish. I look forward to being able to explain why we should get Part A."
Cooperate with and respect administrators and technologists, Dr. Moriarty urges. "We work with bright and talented hospital personnel, and cooperation and mutual respect are key ingredients in a win-win relationship between the hospital and pathologists."
Pathologists need to represent themselves at meetings and during negotiations with the administration—don’t let that role fall to the administrative director, he warns. Joint meetings that include the administrative director are fine. "But I’ll speak for myself," Dr. Moriarty says.
And speak he does, all the time, about Part A, with a fervor that borders on proselytizing. Such doggedness, ultimately, has been the key to his group’s successes. His administrators are probably tired of hearing him mention Part A, he admits. "But it’s on their radar screen. And sometimes they’ll call and give a little dig, saying, ’Rich, we need you to do this—and consider it Part A.’ And that’s great to hear."
Dr. Moriarty has no patience for pathologists who are unwilling to take the time to educate administrators about the Part A activity hospital pathologists are performing, and no patience for those pathologists not willing to be aggressive in seeking "appropriate, reasonable, fair, and deserved Part A payment.
"It’s about time we stop being wimps about this. We have a lot to offer," he says. "But if you’re going to roll over, you’ll roll over and lose your Part A"—a loss pathologists can ill afford.
Colleen Siver is a freelance writer in Chicago.