Why is my biopsy going to Yawkey, West Virginia?
In the old days, family practitioners and other physicians used their own reliable networks for referring patients who required specialized clinical care. A network would consist of individuals regarded by the practitioner as particularly competent, trustworthy and responsive. The network would also include a facility to which they preferred to send biopsy specimens. It could be that a laboratory was conveniently situated, or that a surgical pathologist in the group had a good reputation, or that the laboratory had a special appeal because of its academic profile. However, with the burgeoning of third party insurance and managed care, things have changed dramatically. The intermediate agencies (1) came to act as clearing houses and gateways for physician payments, and (2) converted doctors into “providers” of medical care, and patients into “customers.” Unless a physician agreed to sign up as a “provider” for a given third party payer, few patients registered with that insurance company would receive significant coverage for a visit to a doctor not registered on the company’s panel. Many doctors, although not all, scrambled to get themselves listed on as many panels as possible, rendering them eligible to receive a wide range of patients, and to be paid for their services. Much the same happened among laboratories, which also needed to become eligible for business across the board. I am now personally empanelled with 39 insurance plans, without whom my term of employment would cease. By my reckoning, that is 38 too many.
It is probably safe to say that most people undergoing a biopsy procedure have no idea where their specimen is going and, even if they did, would have no way of expressing an informed opinion on the subject. Unless one can pay out of pocket, or there happens to be a flexible provision in one’s insurance plan, the biopsy will go to a facility designated by one’s insurance company, where it will be examined by an anatomic pathologist employed by that facility.
Anatomic pathology services are offered by many for-profit laboratories, some of which operate nationwide. It could be that one’s biopsy will travel thousands of miles by overnight express, where it will be attended in a fully-staffed 24-hour laboratory, the result being transmitted to one’s doctor the next day. When I was working in Washington D.C., I noticed that clinicians with whom I enjoyed close professional contact would walk into the department with slides diagnosed elsewhere, asking for an informal (free) second opinion. The biopsies had been taken a block or two away, but the slides had been diagnosed on the other coast. These clinicians were seeking additional reassurance about the diagnosis from me, namely from someone with whom they already enjoyed a trusting professional relationship. I was dismayed, both by the ease with which they were willing to shop elsewhere, and by their comfort in secondarily approaching me when they already had a committed diagnosis in hand. I asked a colleague why he was sending his specimens to a distant laboratory. He said: “We like working with you, but the fact is we get a much faster turnaround from the other lab. And, what’s more, they make it really easy for us. They pay for overnight express, and give us materials to perform the biopsy procedure. Your last pickup is at 3:00pm, but with them, I can take a biopsy at 6:30 in the evening, bang it into Fedex, and get the result by the next afternoon.” To him, price and turnaround were supreme, and aced anything I could do for him. That commercial ripple has, over the years, evolved into a tsunami.
Some surgical groups, to improve income because of falling Medicare reimbursement, have made arrangements whereby they would send their biopsies to a “cooperating” laboratory, and issue the pathology bill on behalf of their own surgical practice, paying the pathology laboratory a percentage of the takings. A variation on this theme is where the clinical group employs and pays its own pathologist, yet again issuing a marked up bill from the practice. These activities represent an attempt by clinicians to maintain revenue in the face of declining payments from Medicare and other intermediate payers, but they also show the degree to which some specialists are willing to “capture” pathologists, whose work they assimilate under their own umbrella, issuing reports from their own “departments” of pathology.
The question of exactly where one’s biopsy is going, and why, is complex and might best be addressed to one’s physician. What one will discover is that the playing field is uneven and that the dollar talks.