Pathologists Roles in Clinical Utilization Management A Financing Model for Managed Care

Transcription

1 AJCP / UTILIZATION MANAGEMENT AND COMPENSATION Pathologists Roles in Clinical Utilization Management A Financing Model for Managed Care Jim Jian Zhao, MD, PhD, MBA, 1 and Aaron Liberman, PhD 2 Key Words: Pathologists; Utilization management; Financing; Compensation; Laboratory; Hospital; Managed care Abstract In ancillary or laboratory utilization management, the roles of pathologists have not been explored fully in managed care systems. Two possible reasons may account for this: pathologists potential contributions have not been defined clearly, and effective measurement of and reasonable compensation for the pathologist s contribution remains vague. The responsibilities of pathologists in clinical practice may include clinical pathology and laboratory services (which have long been well-defined and are compensated according to a resource-based relative value system based coding system), laboratory administration, clinical utilization management, and clinical research. Although laboratory administration services have been compensated with mechanisms such as percentage of total service revenue or fixed salary, the involvement of pathologists seems less today than in the past, owing to increased clinical workload and time constraints in an expanding managed care environment, especially in community hospital settings. The lack of financial incentives or appropriate compensation mechanisms for the services likely accounts for the current situation. Furthermore, the importance of pathologist-driven utilization management in laboratory services lacks recognition among hospital administrators, managed care executives, and pathologists themselves, despite its potential benefits for reducing cost and enhancing quality of care. We propose a financial compensation model for such services and summarize its advantages. During the past decade, the rapid emergence and predominance of managed care organizations (MCOs) has dramatically altered America s system for provision of health care. Changes have affected those who work in hospital settings and those in private medical practices, including specialty and primary care 1,2 (A.L., unpublished data, 1998). Fundamental outcomes of managed care, according to many advocates, have been reduced total cost for health care utilization and enhanced quality of care 3-7 (A.L., unpublished data, 1998). A major goal of managed care, which has been used for many years in health maintenance organizations, is utilization management. From the perspective of an MCO, there are 3 primary considerations: ancillary utilization; referral utilization; and hospital utilization. Utilization management in each of its forms involves using materials and human resources to make definitive judgments about the appropriateness of a prepaid treatment regimen. This service often is provided by a nonphysician, and pathologists rarely are involved, even if other physicians are participating. Pathology is unique in the medical professions, functioning as a bridge between clinical medicine and basic science. In routine clinical practice, pathologists often are referred to as a physician s physician whose job it is to provide tissue and body fluid diagnosis, as well as relevant clinical information to fellow clinicians, while assisting in the clinical diagnoses and treatment of patients. Moreover, the pathologist is involved much more in nonmedical work compared with most clinicians. This involves laboratory operations management, financial planning, technology development, and fulfilling miscellaneous duties. 8,9 In terms of level of reimbursement or compensation, a pathology service is considered to be somewhere between primary care and the majority of specialty services (eg, surgery, orthopedics, and cardiology). Therefore, using a pathology and 336 Am J Clin Pathol 2000;113: American Society of Clinical Pathologists

2 AJCP / SPECIAL ARTICLE laboratory service, when medically appropriate and indicated, is less costly than using most invasive procedures provided by procedure-oriented specialties. In an increasingly dominant managed care environment, the pathologist can have a substantial role in managing health care resources, especially pathology and laboratory services. Pathologists already serve as utilization managers in some settings. For example, it is not uncommon for a pathology resident to control laboratory utilization (serving as a gatekeeper) of blood products and sendout tests in a university hospital. The laboratory can, in these instances, produce substantial cost savings However, most pathologists practicing in community hospitals are largely neither proactive nor active in clinical utilization management (J.J.Z. and G. Pearl, unpublished data, 1999). Hence, the pathologists expertise and training in management has not been used fully by hospital administrators, MCOs, or other third-party payers. Two reasons seem fundamentally important. First, defining specific costeffective roles for the pathologist can be elusive. Second, determining how such work can be compensated within the current framework of the health care reimbursement system represents a daunting challenge. This article aims to clarify several issues about these challenges through a review of the current pattern of clinical pathology practice, including clinical utilization management and reimbursement mechanisms. Recommendations about what can be done to resolve the current dilemma are followed by suggestions about how pathologists and laboratory physicians can be used to reduce the cost of care and enhance its standard of quality. Roles of Pathologists in Clinical Services and Utilization Management: Current Compensation Mechanisms In general, the primary roles of pathologists in clinical practice can be classified in 3 general categories: clinical pathology and laboratory services; laboratory administration; and clinical utilization management. 8,13 An additional role is basic or clinical research, which originates from grant support or personal interest and often involves experimental work, product development, or clinical trials. Clinical Pathology and Laboratory Services Tissue or Fluid Diagnosis or Surgical Pathology Diagnostic Services The service mainly involves evaluating tissue biopsy, fine-needle aspiration, and surgical resection specimens. These are traditional tasks that most surgical or anatomic or general pathologists perform routinely. The service or surgical pathology professional component is reimbursed under Medicare part B, using approximately 30 Current Procedural Terminology 14 (CPT) codes (CPT codes between and 89399) with the modifier -26. Physician Interpretation of Laboratory Test Results Pathologists routinely interpret electrophoresis patterns, hematology smears, blood crossmatching, and coagulation test results. The results are then correlated with a particular clinical situation and sometimes are followed by direct communication with the patient s physician. This service also is reimbursed under Medicare part B, and there are approximately 20 CPT-coded tests with a laboratory physician interpretation component with the modifier -26 representing approximately 2% of the total CPT-coded tests. A large portion of laboratory tests, representing almost 1,000 CPT-coded tests, do not have an interpretation component. 3,14 Physician-to-Physician Consultation Service Included are consultation services provided by a pathologist to other clinicians on behalf of individual patients. Such consultation services are not applicable to routine physicianto-physician conversations, and they are reimbursable only if the services meet the following criteria: (1) requested by the patient s attending physician; (2) related to a clinically significant abnormal test result; (3) result in a written narrative report that is included in the patient s medical record; and (4) result in an interpretation requiring a medical judgment by a laboratory physician. The consultation does not have a technical component (ie, modifier -26 is not included). Two CPT codes are used for clinical pathology consultation under the Medicare fee schedule: CPT code is for a limited clinical pathology consultation without review of a patient s history and medical records; CPT code is for the comprehensive clinical consultation of a complex diagnostic problem with review of a patient s history and medical records. 14 In addition, there are 3 CPT codes for blood bank physician services that have neither a technical component nor attached modifiers: CPT codes 86077, 86078, and are used for interpretation and to generate a written report for specific blood bank services. 14 An additional physician-to-physician service, which has not been explicated and coded by the CPT codes, is the consultation about appropriate selection or utilization of specific tests for medical (as well as financial) reasons, including introduction of new state-of-the-art technologies for clinical diagnosis and treatment. For example, introduction of molecular diagnostic testing, such as HIV genotyping and phenotyping and polymerase chain reaction for the factor V Leiden mutation may provide a more cost-effective outcome for management of AIDS and for thrombotic risk American Society of Clinical Pathologists Am J Clin Pathol 2000;113:

3 Zhao and Liberman / UTILIZATION MANAGEMENT AND COMPENSATION assessment, respectively. This service will be become even more important in an increasingly dominant managed care environment. 10,11 Physician-to-Patient Consultation Service The pathologist rarely participates in a direct patient consultation service. Consulting clients primarily are clinicians. The medical opinion or judgment of a pathologist about diagnosis, treatment, and follow-up to an individual patient always is given through clinicians surgeons, oncologists, or others. In some situations, however, direct consultation services may be more appropriate for patients or their families, in part because many pathologists, particularly those with a subspecialty, may be more knowledgeable than are other clinicians about a specific topic of interest to a patient. For example, pathologists who specialize in prostate and urologic pathology may be in a better position to interpret the correlation between the prostate-specific antigen level and biopsy results than a general surgeon or a urologist. They also may lend a greater level of objectivity about treatment options based on the latest and best medical knowledge, rather than offering options based on a specialty bias or a financial motivation. Moreover, in the emerging areas, such as risk assessment for cancer and other diseases, and in preventive medicine, the pathologist specializing in molecular genetics is likely to become one of the most appropriate specialty physicians for direct patient and family counseling for the selection of specific diagnostic tests and interpretation of results. Compensation for a patient consultation includes many CPT codes, such as through 99404, 99411, 99412, 99429, and 99429, that are designed for evaluation and management (E/M) services. 14 Theoretically, these codes apply to all physicians. We contend that compensation based on these CPT codes for direct patient consulting services should apply to pathologists, as long as such counseling has been given properly. Laboratory Administration A pathologist customarily holds the directorship of the clinical laboratory of a hospital or independent laboratory. According to the College of American Pathologists, the pathologist is responsible for the selection and implementation of laboratory test procedures that will fulfill the mission of the laboratory, which includes the reporting of test findings, proper performance of tests, and employment and training of properly qualified personnel. The laboratory director is responsible for establishing and modifying test procedure manuals and general laboratory policies. A number of pathologists participate actively in the daily operation and management of the laboratory. These activities include dealing with important laboratory-related problems, quality control and quality assurance issues, and inspection, accreditation, and regulatory issues. Daily or regular laboratory rounds with residents, fellows, and the chief technologist are among the responsibilities of the laboratory director. Many pathologists also are involved directly in the development and introduction of new tests or methods in the laboratory according to advances in technology and the needs and expectation of clinicians. Teaching residents and technical staff is one of the primary jobs of academic pathologists. This includes tutorials, lecturing, conferencing, and other forms of learning. The aforementioned services usually are compensated through a fixed portion of the annual laboratory budget specifically allocated for medical directorship of the laboratory. In the community hospitals in which the pathologist is not a hospital employee but has a contractual relationship with the hospital s laboratory administration, the hospitalemployed nonpathologist laboratory administrator is largely responsible for daily laboratory management, including important managerial decisions such as human resource management, operational planning, and budgeting and financial management. As a consequence, the pathologist has become more passive in the administrative activities (J.J.Z., personal observations and communications, 1999). Clinical Utilization Management During the past several decades, several publications and a study have addressed the utilization management role of pathologists, particularly for laboratory test utilization (J.J.Z. and G. Pearl, unpublished data, 1999). Generally speaking, these roles largely involve specialized clinical pathologists in the areas of microbiology, hematology, and molecular pathology. Surgical pathologists, however, rarely are involved in management in a community hospital setting. Despite the fact that it has not been widely practiced in most pathology practices, utilization management of laboratory services, conceptually and practically, can be divided into 2 basic elements: general management and individual case management General Management of Clinical Utilization of Laboratory Services This is the process of planning, organizing, directing, staffing, and controlling for effective utilization of laboratory testing. Specifically, a pathologist can serve actively as a general manager and will establish policies and procedures for the effective utilization and control of laboratory services. The specific goal is to deal with test- and disease-specific issues having medical and financial variables that may affect the cost and quality of care. To achieve effective utilization management of laboratory services, the pathologist must be an effective manager and participate in the primary activities any effective manager should be able to perform, including 338 Am J Clin Pathol 2000;113: American Society of Clinical Pathologists

4 AJCP / SPECIAL ARTICLE interpersonal, informational, and decision-making activities. For example, a pathologist can chair a clinical utilization committee composed of representatives from various clinical departments, such as emergency and internal medicine services, and from administrative departments, such as finance, operations, and marketing. The committee must have specific goals and an action plan with measurable objectives for service quality and financial performance. Moreover, the pathologist must establish a utilization management program that may include preauthorization, concurrent review, and retrospective review of laboratory testing. This requires a substantial effort and the time and resources necessary for establishing a cost-effective professional activity. An effective cost-control mechanism requires that utilization management be separated from general laboratory operations. A financial process providing positive and negative incentives should be established to encourage responsible performance. Individual Case Management of Laboratory Service Utilization This service includes 2 parts: one deals with individual requests for specific tests ordered by clinicians, and another involves coordination of laboratory services for individual patients in case and disease management. A common service is the pathologist-conducted concurrent review of sendout tests. When an expensive or rare test is ordered (often by clinical residents), the pathology resident reviews the medical necessity of the request based on established policies and medical knowledge and then decides whether the request should be rejected or approved. This has been an effective approach for reducing the cost of laboratory sendout testing. 10 (J.J.Z. and G. Pearl, unpublished data, 1999). Surprisingly, many of the inappropriately ordered tests were related to typing errors, with a rate of approximately 40% of total orders (J.J.Z. and Gary Stack, MD, PhD, unpublished data, 1995). The application and expansion of medical informatics, such as a computerized physician order entry system to modulate, guide, and monitor utilization of pathology and laboratory services, will have a substantial role in optimizing ancillary services provided to individual patients. This may relieve the time-consuming burden for personal utilization monitoring by a pathologist and, instead, permit focus of the pathologist s time on operating a more efficient clinical utilization management system. Furthermore, this will become especially important when ambulatory patient classifications are implemented in the near future 15,16 ; these classifications will establish a prospective payment mechanism for hospital-based outpatient services. Unfortunately, the utilization management of laboratory services, for general and individual case management as described, does not exist in the majority of pathology practices. Thus, we suspect that the lack of such pathologistinvolved utilization management has contributed substantially to the overutilization of laboratory services in many hospital systems and MCOs, resulting in a significant cost increase. Two main reasons are likely. First, pathologistdriven utilization management is far from well-defined, including specific roles and outcome measurements. Second, there is no financial mechanism for compensating the contributions pathologists have made, even if they involve such work. Hence, it is important to rectify the problem to optimize the utilization of laboratory services. Proposed Financial Model for Compensating Pathologist-Driven Utilization Management As previously noted, compensation for the administrative responsibility of a laboratory director (eg, pathologist) commonly is generated as a fixed salary or from a portion of the annual budget or revenue of the laboratory, which customarily is determined by the hospital administration (when the pathologist is an employee) or by contract (when the pathologist has a contractual relationship with the hospital). In addition, utilization management of a laboratory service generally is not specified or required by the hospital or by contract. In some instances, compensation for laboratory management represents a fixed percentage of annual revenue for laboratory testing. In this scenario, the consequences of a reduction in total utilization may lead to a decrease in a pathologist s compensation, although the financial effect could be positive for the hospital, the MCO, and the purchaser (employer) 1,2 (A.L., unpublished data, 1998). There are several potential financial mechanisms to be considered for compensating a pathologist-driven utilization management program. The methods chosen will depend on the working or contractual relationship between providers (hospital or physician service) and payers (health maintenance organization or MCO). Two typical examples would be capitation vs fee for service. However, before considering either, one must determine whether a pathologist-driven utilization management program can be effective without compromising the standard of care and without increasing the total cost of care. Total cost of care is the expense associated with managing a patient, a disease, or an episode. For example, laboratory service is considered a part of inpatient care costs for a specific diagnosis-related group. Thus, the total cost and total revenue must be carefully measured, calculated, and analyzed for each given situation. For example, performing a molecular test would cost much more than performing a routine test (eg, $200 vs $20, respectively), but rapid and American Society of Clinical Pathologists Am J Clin Pathol 2000;113:

5 Zhao and Liberman / UTILIZATION MANAGEMENT AND COMPENSATION accurate results provided by the former may save 3 days of hospital stay, which in turn would save more than $1,200. In the meantime, the standard of clinical care must be closely monitored with an outcomes-oriented quality assurance program to prevent underutilization or overrestriction of laboratory testing. 3 To achieve such decision-making, the pathologist s involvement in utilization management is necessary. If utilization of laboratory services can reduce total cost to the most effective level, without compromising quality, utilization management would be considered effective and worthy of payment. This may include appropriate compensation for a pathologist who organizes and performs the service. Based on available information and analysis, we offer a financial model for compensating the work of the pathologist. The purpose of this model is to make the pathologistdriven utilization management model financially feasible and justifiable so that it can be tested in the world of clinical practice with the ultimate goal of controlling the total cost of care and enhancing the overall quality of care. The model is predicated on 4 assumptions: (1) The pathologist who participates in the management of laboratory utilization service will possess proper training and skills in laboratory management including medicine, technology, and business administration. (2) The utilization of laboratory and pathology services is a necessary part of controlling the total cost of care. (3) Utilization management as an additional management service in laboratory administration should have a specifically defined compensation mechanism. (4) The CPT codes for evaluation and management of individual patient services are applicable to the clinical utilization management of individual patients or cases attended by pathologists, if properly coded and based on the rules of Medicare part B physician services. 2,3,14 The proposed financial compensation model combines a fixed level of compensation for conducting the utilization management service program with a variable compensation component for individual patient billings. Fixed compensation would be provided through the entity financing the laboratory services to the pathologist who directs the utilization management of laboratory testing. The variable component would be billed to payers, eg, MCOs, Medicare or Medicaid, or Blue Cross/Blue Shield, using a CPT code fee schedule. The following formula would apply: Total Pathologist Compensation = Fixed Level of Compensation + Variable Level of Compensation For general utilization management, it is very important first to define the specific and measurable goals, such as what percentage of the tests, including in-house and sendout, is likely to be controlled and reduced and how much effort or time will be required to achieve the goals. Certainly it would be difficult to set a realistic goal at the beginning, and many assumptions need to be made according to specific tasks, benchmarking data, historical data, and published literature. After determining basic estimates on the potential target of utilization reduction and the time or effort to be spent, the amount of a fixed compensation (or cost) for performing the work can be calculated. Incentives or penalties should be considered for exceeding or falling short of the expected and agreed-upon targets. For example, if it is expected, according to retrospective experience or studies, that a reduction of 5% of total ordered tests should occur with utilization management, the pathologist should be recognized with a bonus or a penalty depending on the amount of the withhold (the amount and percentage of reimbursement held back until the end of a contract year pending conformance with utilization objectives) and the deviation of the results. The variable compensation component can be matched by Medicare part B physician service. The case-specific billable services include the following: (1) concurrent review and gatekeeping of the physician-requested tests (sendout and in-house) for individual patients with followup telephone calls, written reports for interpretation, or both; and (2) conducting case management services through medical conferencing or telephoning physicians or other health care professionals. Several sets of CPT codes may be applicable for these services. One set includes CPT codes and that are used specifically for clinical pathology consultation (see Physician-to-Physician Consultation Service ). However, these codes are designed for requested interpretation of abnormal results. At a minimum, therefore, these codes may be applicable (1) when the pathologist performs standard clinical pathology consultations and while the pathologist participates in case or disease management; or (2) when, after reviewing and rejecting an original order, an alternative test is suggested and performed, abnormal results are obtained, and a written report is entered in the patient s medical record. For example, suppose an expensive molecular genetic test is ordered by a family physician, and the order is rejected by the pathologist because the test is still at an experimental stage. The pathologist suggests another simple molecular test, and an abnormal result is obtained and interpreted by the pathologist who writes a follow-up report. In this circumstance, the services provided by the pathologist should be billed and compensated by Medicare or another payer for the pathologist s work and contribution to cost reduction. A second set of CPT codes includes those for case management services applicable to all physicians. E/M generally is divided into broad categories, such as office visits, hospital visits, and consultations. According to published guidelines, the basic format of the levels of E/M 340 Am J Clin Pathol 2000;113: American Society of Clinical Pathologists

6 AJCP / SPECIAL ARTICLE services is the same for most CPT codes: First, a unique code number is listed. Second, the place and/or type of services is specified (eg, office consultation). Third, the content of the service is defined (eg, comprehensive history and comprehensive examinations). Fourth, the nature of the presenting problem(s) usually associated with a given level is described. Fifth, the time typically required to provide the service is specified. The portion of the E/M services that is aligned most closely with the clinical pathologist s work is counseling. This term is defined as a discussion with a patient, family, or both about one or more of the following subjects: (1) diagnostic results, impressions, and/or recommended diagnostic studies; (2) prognosis; (3) risks and benefits of management (treatment) options; (4) instructions for management (treatment) and/or follow-up; (5) importance of compliance with chosen management (treatment) options; (6) risk factor reduction; and (6) patient and family education. The CPT codes for case management services that may apply directly to clinical utilization management provided by a pathologist or other physicians are E/Mrelated CPT codes, 14 such as CPT codes through for team conferences, through for telephone calls, and through for care plan oversight services. All these codes may need further exploration to determine whether they are applicable for clinical utilization management of laboratory services under specific circumstances. Furthermore, one likely applicable option for individual patient CPT code billing is the unlisted service code for unlisted evaluation and management services. This is unusual, variable, or may require a special report demonstrating the medical appropriateness of the service. The report should include pertinent information with an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. 14 The CPT codes for consultation may or may not be applicable to the pathologist performing the utilization management service. By definition, this is a type of service provided by a physician whose opinion or advice about the evaluation and/or management of a specific problem is requested by another physician or other appropriate source, and a physician consultant may initiate diagnostic and/or therapeutic services. However, these CPT codes are used for clinical specialty consultation in 4 subcategories: office, initial inpatient, follow-up inpatient, and confirmatory. By applying the model as proposed, the clinical utilization management directed and performed by pathologists becomes financially compensable through the current Medicare part B reimbursement CPT coding system. With laboratory compensation for general utilization management, clinical pathologists could then have a financial incentive for their contribution, as an effective cost-reduction resource, to utilization management of laboratory services that in turn will lead to a reduced total cost of care while at the same time raising the standard of care. What we recommend is basically a risk-adjusted payment method in which the level of compensation is tied inextricably to utilization and cost. Because the pathologist is in a unique position to observe utilization and assess its outcomes, the risk-adjusted payment method will provide a mechanism for the pathologist to successfully reconcile the issues of utilization and cost. Overall, we suggest that the risk-adjusted payment method may create opportunities for new plans to use pathologists as key players in clinical utilization management. 17 Conclusion Utilization management is one of the cornerstones of a managed care system. In our view, the laboratory pathologist represents an ideal physician specialty to organize, plan, lead, and direct these services. 3,18 A pathologistdriven clinical utilization management program would serve as an effective means for reducing the total cost of care and enhancing the quality of care for a hospital, an MCO, a medical practice, and, ultimately, the patient. All parties, including pathologists, may be able to use the financial mechanisms we propose to operate a pathologistdriven utilization management system. In the managed care environment, the pathologist should interact more proactively with physicians, patients, and families Moreover, hospital administrators and MCOs should recognize the clinical knowledge and management experience that pathologists can contribute toward controlling the total cost of care and enhancing the cost-effectiveness of clinical services. The cost of pathology services certainly is less than that for procedureconcentrated clinical specialists. Although they may not be as familiar with specific clinical interventions (eg, medication vs surgery) as are specialists, the pathologist almost certainly will be more objective in medically necessary advocacy. 3,18 Finally, as ambulatory patient classifications 1 (A.L., unpublished data, 1998) become part of the reimbursement matrix in the very near future, the need for active involvement on the part of pathology practitioners in clinical utilization management will be increased, and the opportunities to be included in the reimbursement chain should be enhanced. However, the fruition of that goal will depend largely on the concerted efforts of pathologists to alter a heretofore disproportional expectation of work without proper compensation. American Society of Clinical Pathologists Am J Clin Pathol 2000;113:

7 Zhao and Liberman / UTILIZATION MANAGEMENT AND COMPENSATION From the 1 Laboratory of Diagnostic Molecular Pathology, Department of Pathology and Clinical Laboratories, Orlando Regional Healthcare System, Orlando, FL, and 2 Health Services Administration, University of Central Florida, Orlando. Address reprint requests to Dr Zhao: Oxford Diagnostics for Surveillance Care, Lake Underhill Rd, Orlando, FL Acknowledgment: We thank Gary Pearl, MD, PhD, for reviewing and providing valuable suggestions for the manuscript. References 1. Kongstvedt P. Essentials of Managed Health Care. Gaithersburg, MD: Aspen; Becker S. Physician s Managed Care Success Manual: Strategic Options, Alliances and Contracting Issues. St Louis, MO: Mosby Year Book; Vance RP. Outcomes management: new opportunities in a shrinking pathology market. Arch Pathol Lab Med. 1997;121: Halm EA, Causino N, Blumenthal D. Is gatekeeping better than traditional care? survey of physicians attitudes. JAMA. 1997;278: Blumenthal D, Epstein AM. The role of physicians in the future of quality management. N Engl J Med. 1996;335: Clancy CM, Kamerow DB. Evidence-based medicine needs cost-effectiveness analysis. JAMA. 1996;276: Bodenheimer T, Grumback K. The reconfiguration of US medicine. JAMA. 1995;271: Laposata M. What many of us are doing or should be doing in clinical pathology. Am J Clin Pathol. 1996;106: Lambird PA. Practicing pathology through multiple hospitals at multiple sites: practice management issues. Arch Pathol Lab Med. 1995;119: Kirby EJ Laposata M. The nature and extent of training activities in clinical pathology required for effective consultation on laboratory test selection and interpretation. Arch Pathol Lab Med. 1997;121: Valenstein P. Managing physician use of laboratory tests. Clin Lab Med. 1996;16: Jones J. A method for developing outcome measures in the clinical laboratory. Clin Lab Manage Rev. 1996;10: Hardwick FD, Morrison IJ, Cassidy AP. Clinical Laboratory: past, present, and future: an opinion. Hum Pathol. 1985;16: American Medical Association. Current Procedural Terminology, CPT th ed. Chicago, IL: American Medical Association; Connelly PD, Aller DR. Outcomes and informatics. Arch Pathol Lab Med. 1997;121: Tuthill M. Pathology informatics to the rescue. Adv Med Lab Prof. 1999: Glim M, ed. Faulkner & Gray 1999 Medicare Managed Care Sourcebook. New York, NY: Faulkner & Gray; Goldberg-Kahn B, Sims KL, Darcy TP. Survey of management training in United States and Canadian pathology residency programs. Am J Clin Pathol. 1997;108: Winkelman JW, Brugnaara C. Management training for pathology residents, II: experience with a focused curriculum. Am J Clin Pathol. 1994;101: Skootsky SA, Oye RK. The changing relationship between clinicians and the laboratory medicine specialist in the managed care era. Am J Clin Pathol. 1993;99(4 suppl 1):S7- S Friedman BA. The challenge of managing laboratory information in a managed care environment. Am J Clin Pathol. 1996;105(4 suppl 1):S3-S Miler TE. Managed care regulation: in the laboratory of the states. JAMA. 1997;278: Kricka LJ, Parsons D, Coolen RB. Healthcare in the United States and the practice of laboratory medicine. Clin Chim Acta. 1997;267: Leverone JP. The hospital-based group in a managed care environment: reading the terrain. Arch Pathol Lab Med. 1995;119: Ross SJ. New roles for pathologists in the 21st century. Hum Pathol. 1998;29: Elevitch FR. Practicing pathology as a healthcare contractor: business planning for managed care. Arch Pathol Lab Med. 1995;119: Sodeman TM. Managing opportunities under managed care. Arch Pathol Lab Med. 1995;119: McDonald JM, Smith JA. Value-added laboratory medicine in an era of managed care. Clin Chem. 1995;41: McDonald JM. The value-added laboratory: an opportunity to merge research and service objectives. Clin Lab Manage Rev. 1997;11: Keith DM, Garza D. Utilization management in hospital clinical laboratories: a local analysis. Clin Lab Manage Rev. 1996;10: De Cresce RP, Lifshitz MS, Logue LJ. Managed care and the hospital laboratory: survival of the fittest. Clin Lab Manage Rev. 1994;8: Wilding P. The changing role of the clinical laboratory scientists: coming out of the basement. Clin Chem. 1995;41: Vance. RP. Resource utilization and outcomes management: opportunities for the entrepreneurial pathologist. Clin Lab Manage Rev. 1997;11: Am J Clin Pathol 2000;113: American Society of Clinical Pathologists