Car washes, crib sheets and surgical pathology: Sleaze, graft and corruption

Summers and a couple of winter breaks in college I worked at a car wash in suburban Chicago. This was after I learned auto body work and auto detailing. It seemed to make sense to me to learn how to apply bondo, fix bumpers, paint and buff and then understand how to keep a car’s finish looking like new, a natural evolution, or so I thought. Perhaps because I couldn’t really stand working any longer for the people who owned the auto body shop or auto detailing shop. Nonetheless, I learned about auto repair, auto detailing and met many different kinds of people over the years.

The goal at the car wash was to try to sell the “Super Package” or the “Super Package Plus”, comparable perhaps to a daily or manager’s special at your local car wash. The different options included additional polishes, waxes, sealers, rust protections and dressings. Part of my job was accounting for the cash at the end of the night from the car wash and gas station with convenience store. If a drawer came up short or some receipts were missing, you had to problem solve. Sometimes people would drive off without paying for gas or try to obtain something from the store without making a proper purchase. Sometimes folks who worked with me trying to upsell the super packages would figure out how to pocket the difference between the basic and the premium wash, provide a basic wash or the premium wash and then try to top of the tanks in the car wash to account for the appropriate amount of additional waxes and sealants. They figured out they could make more trying to game the system than they would have for the bonuses paid as a percent of the premium washes sold. Whether it was customers driving off without paying for gas or food or trying to pass counterfeit bills or phony credit cards or employees trying to alter the receipts themselves, it was pure sleaze and it usually caught up to the offender.

Back in college, there was no shortage of student colleagues trying to figure out how to steal an exam or pay someone to take an exam or design an elaborate crib sheet to get through an organic chemistry or economics examination. Some of the plans were quite elaborate, including involving workers from the local automobile factory in the adjacent town to sit for the earlier exam, steal the exam, pass that to another automobile worker who would then take the exam to a rendezvous spot to a student who would exchange money for the exam and then take the exam to another student, likely one involved in actually taking the exam, who would pay the student, and begin to look up the answers with a small group who pooled their financial resources to pull this off while creating a few layers between them and the person who actually stole the exam initially. The goal would be to get enough right answers to do well on the exam within the hour or two they had to look them up. It worked a few times then professors caught on and administered different exams to different sessions. Many of the students went on to medical, law or business school; some didn’t make it. If they had spent half as much time actually reading the material as they did planning the theft they may have done as well or better. Nonetheless, pure graft.

Despite growing up in the Den of Thieves, as I mentioned on Tuesday, and seeing first hand the creative ways the human mind works to cut corners for personal gain, nothing prepared me for what many of us have seen in the practice of medicine, in surgical pathology, in particular. And many of us I think are equally shocked and dismayed at both what pathology has become and perhaps how we have contributed to it.

2009 Updated Title Slide

In 2008, there was an American Society of Pathology (ASCP) companion meeting at the United States and Canadian Academy of Pathology (USCAP) as there is every year, along with many other companion and subspecialty companion meetings through the weekend and beyond dealing with everything from electron microscopy to more practical matters with ASCP and the College of American Pathologists (CAP). I think there were similar sessions held in 2007 and 2009 as well.

The session at the ASCP companion meeting was entitled “Controversies in Pathology: Sleaze, Graft and Corruption and Why a Surgical Pathologist Needs to Care” – designed, as the program said, “to help pathologists combat unethical business practices”. The program included a pathologist from Ameripath, Robert Michel from The Dark Report, Jane Pine Wood, an attorney familiar to many pathologists and laboratories and the president of ASCP. A prior post on this blog dealt with the matter and some comments on the issue back in 2008.

Without belaboring the points, the major issues discussed in the packed room with clearly different opinions from different pathologists, were about client billing arrangements, POD labs, “condominium” labs, mark-ups and more. There were cries for “Stop Pod Labs Now” and “We must counteract the perception of lab tests as a ‘commodity’”.

The Pathology Blawg has covered the issues of self-referral as well as anti mark-ups and the like for many years.

Recently, The Pathology Blawg has also mentioned a Medicare administrative contractor is also looking at the issue of potential fraud by pathologists related to many of the same issues we thought we were addressing directed at laboratories other than our own many years ago.

You see, the sad reality is that we as pathologists and laboratorians have also benefited from the practice of self-referral, the business of referring additional work to ourselves in the form of additional immunohistochemistry or special stains. I covered this a bit in 2008 with my post on “‘automatic’ GI stains’”.

A recent comment from another blog perhaps sum up the issue quite poignantly:

“Clinicians stopped caring about turnaround times when they profited from the pathology lab revenue. Turnaround time was the excuse used to pad the bills by pathologists who were going to be reimbursed for doing the wrong thing.”

Again, I refer to The Pathology Blawg post and assorted comments on many sides of the issue here.

I think the bottom line here is that we as pathologists have a unique place in medicine where we can and may benefit directly from ordering additional tests or studies that may fall outside the norm and potentially be inappropriate if not fraudulent. Is it any different for a physician who owns physical therapists and refers you to him/her or surgeons who own an imaging center and refer you there for a potentially unnecessary study? No, it is exactly the same thing.

Despite perhaps our attempt to do so, we did commoditize lab testing, and in the process we have commoditized ourselves. With a deliberate and intentional plan by some pathologists, laboratories, practice managers, business managers & hospitals we have orchestrated a perfect sequence of sleaze, graft and corruption through our own self-referral practices.

It puts the CAP in a difficult spot, because many of its members and their accredited laboratories for maintaining best practices, regardless of where they practice, be it pathologist, hospital or urologist/gastroenterologist-owned laboratory have perpetrated the problem. No doubts with some help from some self-referring clinicians but also likely from themselves and their administrators.

While I may not agree with routine special stains on GI biopsies or “routine” immunohistochemical stains on a tumor when a well-done H&E will do, I have watched and participated in this for more than the past 10 years and we as a specialty have to look at ourselves rather than what we perceive as inappropriate by others as appropriate for ourselves.

Furthermore, we are increasingly placing ourselves in a precarious position by subjecting our specialty, with our own evidence-based practices in terms of cost:benefit to have how we practice our trade further regulated by Medicare and third-party payors.

From Palmetto GBA:

“Only the pathologist may determine the medical necessity of a special stain. The vast majority of conditions of the stomach on biopsy can be diagnosed by the use of the routine hematoxylin and eosin (H&E) stain alone. There is potential for either over-utilization or under-utilization of these ancillary special stains. In most cases it is NOT reasonable or necessary to perform ‘special stains’ such as alcian blue (AB) – periodic acid schiff (PAS) to determine if clinically meaningful intestinal metaplasia is present. In addition it is not usually reasonable or necessary to perform special stains or immunostains (IHC) to determine the presence of H. pylori.”

Until now.

Scientific data demonstrates that the combined number of gastric biopsies requiring special stains is equal to or less than 20 percent of biopsies received and examined in a practice, laboratory, or hospital. Palmetto GBA agrees with the published data. To check utilization, Palmetto GBA encourages providers to perform a self-audit on the number of separate gastric biopsies (reported with CPT code 88305) as compared to ancillary stains (reported with CPT codes 88312, 88313, G0461, and G0462). The ancillary stain code group should be less than 20 percent of the total gastric biopsies (88305 codes) submitted. Providers that exceed the 20 percent criteria may be subject to additional action.

I think this is known as chickens coming home to roost.