An assault on our practices
Mary E. Kass, MD
I just returned from a meeting of the CAP House of Delegates, where passionate debate confirmed that direct billing is a huge issue across the country. I heard one story after another about efforts to seize and hold hostage our right to direct-bill patients and third parties for anatomic pathology services.
Arrangements that allow a referral source to bill for pathology services are Faustian at best and fraught with ethical problems. What happens to the pathologist’s independence and objectivity if one party controls not only the work that comes in but the payment received for it? No good can come of this.
Actions and attitudes speak louder than words, and in times like these our choices construct our legacy. This is a battle we cannot afford to lose. If we fail to act now, we teach residents and younger colleagues that our profession is not worth defending. If we don’t step up to the plate on this one, we may leave them precious little to defend.
Attempts to abrogate direct billing portend an enormous threat to our profession. For example, are you familiar with the "do-it-yourself pathology" movement? I refer to the disturbing assertion that clinicians have sufficient training in residency to read their own slides. If this came to pass, patients would lose the benefit of objective review by a trained pathologist who comes to the evidence with no preliminary diagnosis to defend and no initial position to support. And if the clinician missed or misinterpreted something? Neglected a necessary followup test? The cost to the patient could be incalculable.
While a handful of states do prohibit indirect payment, cytology and laboratory testing have been excluded from these protections in some state legislation. Proponents have suggested that cytopathology and laboratory tests are technical rather than professional medical services, a contention just shy of bizarre.
We have here a host of ethical and moral issues clothed in a financial wrapper. The task for the experienced pathologist is to get past all that bottom-line talk to the real bottom line, our integrity, our self-esteem, and our professional responsibility. We cannot accommodate unethical behavior. Every practice that does so makes it doubly difficult for the next target of these piranhas.
Winning this battle will be in many ways about attitude, so let’s begin by admitting that some of this is our own fault. Many of us have been content to know that we were doing great work for our patients. We weren’t especially concerned about whether others knew what we were doing. Well, now we’re paying for that.
Pathology needs to go public. We need to be perfectly clear about our role on the medical team, why we’re needed, how we contribute day-to-day. We need to be more active on our medical staffs and in our state medical societies. Pathologists who are not engaged in their pathology practices and their specialty undermine us all.
On March 6, the CAP House of Delegates passed a resolution calling on third-party payers and state licensure agencies to insist on direct billing for pathology services, a position consistent with our policy and with AMA policy as well. These statements are useful and important, but the real work here is going to be in the trenches. If individual pathologists on the frontline aren’t willing to take a stand, then all the principled talk in the world won’t protect our profession or our patients.
This assault must be met on multiple fronts, which is why I have called for a conference on the future of pathology to be held in Washington, DC, in June. We have invited the leaders of many of the pathology organizations to join us in forming a coalition to identify the most critical issues facing our specialty and develop strategies to deal with them. But I must repeat: Nothing that happens in a boardroom can salvage this situation if people don’t start to refuse to accommodate the pirates who would like to hijack direct billing for anatomic pathology services.
Right now we need intensive grassroots work. First, and today, we need the pathologists at ground zero, those who are being pressured to accept these arrangements, to stand up to these bad actors.
Second, and just as urgently, we need state-based action to prohibit nonpathologists from billing for pathology services. Please carry this message to your state medical societies, your state legislatures, and your colleagues. Get together with other pathologists and brainstorm with the CAP Division of Membership and Advocacy staff to bring up steam in your state capital. Get people talking about this. Help them understand why it matters.
Some people aren’t ready to make a move until they hear the horses’ hooves just behind them. I’ve been hearing those horses for a long time now. We are dealing with some people whose way of doing business could pick us off, one by one. Acting together, we won’t be trampled. And neither will our patients.
Dr. Kass welcomes communication from members. Send your letters to her at email@example.com