College of American Pathologists
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Achieving proper pay for clinical pathology

March 2005
Mary E. Kass, MD

You know how some kids just don’t like peas? And how they’ll play with the peas on their plate, hide them beneath the mashed potatoes, push them around in circles, anything but eat the darn things?

When my sons were small, I was never one to give in to them on the peas. There was a hidden message about the power struggle: Things don’t get better when they’re put off; they just get cold. Sometimes you have to swallow something you’d rather not. But eventually you have to deal with the peas.

It seems to me that compensation for clinical pathology is getting to be a bit like those peas. In some parts of the country, the argument has been pushed around the plate for so long that it’s gone cold. Some people have resorted to lawsuits, but even court decisions in their favor don’t always resolve the problem. In several places, agreements with insurers that have always paid for clinical pathology are beginning to unravel. And I suspect that a great many pathologists have given up, deciding that they might as well consider clinical pathology a pro bono activity.

Now, I’m all for charity. Pro bono has its place. But that place is not the clinical laboratory.

The problem with charity pathology is that when something is free people begin to believe they’re getting what they pay for. Then it’s no longer on the table. We’ve conceded much more than the dollars.

Clinical pathology is where the fiber of what we do gets stitched into the fabric of our institutions. It’s where the patient consultations occur, the testing menus are tweaked, the knotty cases where test results don’t match clinical evidence get sorted out. When we provide clinical pathology services, the rest of the staff is reminded that we are physicians, which is the best way to protect our patients from arrangements under which nonphysicians provide pathology services.

People understand anatomic pathology; that’s why there’s no trouble getting paid for it. But clinical pathology is a program that runs in the background and is often overlooked. Insurers balk and administrators hedge on payment for clinical laboratory services because they don’t understand what we’re doing in there. When it’s time to write the budget, what is not documented becomes what happened. Bottom line: Invisible services are not compensable.

About a year ago, I was responsible for the administration of a large integrated laboratory system in Baltimore. When I came into the job, it was told that no one at any local institute was getting Part A compensation. Shortly after I arrived, we promoted a talented young pathologist to serve as director of one of the clinical laboratories. When we sat down with the hospital administration to negotiate her contract, she made specific commitments. She would see that the pathologist under her supervision provided all appropriate clinical pathology services, which we enumerated. She would accept responsibility for conduct of the clinical laboratory. She would be the go-to person when administrators had questions.

The contract that resulted from these negotiations provided Part A compensation for clinical services. Once we engaged, made specific commitments, and accepted responsibility, the friction evaporated. Results were win-win across the board.

To receive the proper share of Part A Medicare dollars and reasonable compensation from private insurers, ever pathology group or practice needs to track its time on the clinical side. Administrators and insurers need to know precisely what activities fall under the clinical umbrella and who will be accountable for them.

The steps that individual pathologists can take to make a strong case for compensation for clinical pathology are fairly straightforward: document, educate, take responsibility, and engage in the dialogue. Less clear, however, is what the College should be doing.

There are as many points of view on this as there are current arrangements for payment, and I think we should develop a consensus. Too many signs suggest we should not let this drift any longer.

So I put it to the membership: How should clinical pathology services be compensated? Is there an idea measuring stick (per hour, per discharge, per test)? Should the College try to launch a pilot program with a group of hospitals and insurers to create a vocabulary to talk about compensation?

Everyone should be much better off if we can come up with a way to talk about this. If these peas get any older, the issue will be too cold to move and we will have ceded something of tremendous value to our patients, our specialty, and our institutions.

My email address appears each month at the bottom of this column. Please drop me a note and tell me what you think.

Dr. Kass welcomes communication from CAP members. Send your letters to her at