Anatomic Pathology: Are the vultures coming?" Janice M. Lage MD" Professor and Chair " University of Mississippi Medical Center"

Anatomic Pathology: Are the vultures coming?" Janice M. Lage MD" Professor and Chair " University of Mississippi Medical Center"

Presentation Agenda" Examine the changing landscape. " Discuss Staying Ahead through partnering academic medical centers with private practice pathology groups." Case study with step by step recipe."

Shortage of Pathologists Coming*" 2010: 17,600 fulltime pathologists (5.7/100,000 population)" 2010-2020, 4,700 will retire" 2021-2030 "5,700 will retire" 2030: 14,000 fulltime pathologists (3.7/100,000 population) " *Robboy et al. Arch Path Lab Med Vol 137, Issue 12, pp 1723-32 (Dec 2013)"

Net decrease in Pathologists in 2015*" Aging of patient population expected to increase need to 5.7/100,000 population" 75% active pathologists > 45 years old" 41% active pathologists > 55 years old" Incoming: 570 residents per year" 37 leave US each year" Net number of pathologists start" dropping in 2015" *Robboy et al. Arch Path Lab Med Vol 137, Issue 12, pp 1723-32 (Dec 2013)"

Most work in groups" Type of Practice! Community practice/ hospitals " Academics/medical school " "" Industry " " " " " " " Government, regulatory, public health " Distribution! 80%" 15%" 3%" 1%"

Academic anatomic Pathology is loosing market share" National pathology companies and pod labs" Hospitals buying up physician practices over " "60% physician practices now working for the "hospital/health system" Changing referral patterns, employed physicians and their hospital employer " Medicare and private health insurers:" 2012: Loss of TC grandfather clause" 2013: 88305-TC reduction and new molecular test CPT codes" 2014: New Medicare guidelines and pricing"

We need to adapt to maintain financial stability. " As they cut reimbursement we need to take on more testing/fte or reduce cost/test" Survive on your own margin " Prove that you deliver value" Model on clinical lab: some crossover" Decrease inpatient testing" Decrease cost per test" Decrease send out testing" Automation" Sticking with one company to get better pricing for reagents"

New Business Models for Anatomic Pathology" Pathologists employed by hospital/health care! Academic pathology groups partnering with rural hospitals to provide exclusive specialty pathology services (telepathology, couriers, frozen section coverage)" Academic pathology groups partnering with small pathology groups with various TC/PC arrangements" Academic pathology groups offering better, local service for needed ancillary testing such as flow cytometry, cytogenetics, molecular testing, immunohistochemistry: TC or TC/PC testing"

Academic pathology groups need to CHANGE GEARS and become very efficient " No experience running a business " Hospitality training not a part of pathology residency." Wallowing in town and gown issues for forever." Legal and compliance departments not used to dealing with outside businesses/hospitals, or, externally imposed deadlines." Speed/efficiency/flexibility/willingness to take on something new" Culture.I already have enough work! " Finance: whose budget is this going on?" Governance: who is in charge of the outside groups?" Logistics.what happens when you double the workload?"

CHANGE GEARS to provide efficient business services " Accreditation, CAP, CLIA," " transfer of ownership" Billing. Theyʼve never done this type of billing. What point of service do we use?" Accountability. Why should it start now?" Compensation, everyoneʼs"

Our example begins with The Phone Call " SOS Help us (pathologists) Our owners are terminating our contract in 3 months" Whoʼs calling?" Then the hospital calls: " The Demand:" We want our same pathologists at the same hospitals! We donʼt want to send specimens out of state! (The other hospitals in town have turned us down)! We want you to help us accomplish this!

How many of you are there?" 5 hospitals" 5.5 pathologists" Hospital system is being sold in the next 6 months" Blue Cross/Blue Shield in-network status gone" Lawsuits out of state"

Whatʼs in it for me?" Of course we would be delighted to help" Whoʼs in charge of your group now?" Could I get some particulars?" Set up a meeting" Where should we meet?" Who should I take to the meeting?" Will there be alcohol?"

"Time is running out!" So, we need you to take over in 3 months, on Dec 28, 2013" you said do what?" Academic practice.we will need:" Hospital credentialing/privileges for 5.5 pathologists" Malpractice coverage, do you have a tail?" Letters of recommendation" Review of medicolegal history of each pathologist"

The First Meeting" Took our new hospital CEO" Met with 6 pathologists, one lab" director" Hard times, facing contract termination" Distrust of universityʼs ability to handle transition" What about billing?" Histology, immunohistochemistry, flow cytometry, cytogenetics, molecular pathology, EM, etc to be performed in house" Couriers, transcriptionists, accessioners, registrars, histotechnologists, cytotechnologists "

How are you going to get a report out?" What are you using? Pathways" Us.Co-Path" What EHR do you have? McKesson Portal" Us..Epic" Do you have any interfaces?" Could we rent Pathways?" Need IT support"

Metrics" Annualized Sept 2013 TC and PC revenues, $3.2 million or so" Current volume: 11,000 surgical pathology specimens, hospital and outpatient, probably loosing some outpatient due to town and gown and original lab keeping some clients" All 5.5 pathologists want a job" Drew up a conservative business plan, did not include potential revenues for any ancillary testing"

The Budget" Use existing university facilities, no outside lab" Planned for additional staffing:" 2 histotechnologists" 2 transcriptionists" 2 couriers (PT and FT mix)" 2 call center employees " 1 cytotech (FNAs, nongyns)" 2 PAʼs (1 PA and 1 MD part time)"

Another meeting" Next meeting, same CEO" People started taking notes" Goals:" Keep same people at same hospitals" Courier to pick up specimens at 3 hospitals and transport them to the fourth hospital for grossing; 5 th hospital did its own grossing" Cassettes transported to university for processing" Slides sent out next AM, biopsies cut first, then large specimens" Differential numbering system/number wheel for each site" Different colored slide folders "

Not a lot of confidence " How are you going to manage all of this?" Can you keep all of us?" What if we donʼt like how you do things?" What about IT?" What about billing?" What about CAP and CLIA?" You only have two months now to get this all done"

The Contract, or, will it ever end?" Legal and Compliance" Weʼve never done this before " Why do you want to do this?" You go ahead and draft a contract" Complications from TC and PC being " involved " "-Rent for frozen section space, grossing "- "- "-DRGs for government payers bill hospital for TC" Not registered in your system" Inpatient or outpatient?" Clinical ICD-9 codes " Doctors not listed in your directory unknown doctor "

How is IT doing?" We are going to rent Pathways and keep their interface to hospital EHR" IT will handle getting a rental contract signed" IT begins designing billing fields, separate CPT code designations (88305/88305h)" IT obtains permission to access hospitalʼs EHR and their network"

One month left " Pathologists interviewed, salaries negotiated, letters of" offer accepted, contracts signed" Credentialing still working on it" Malpractice insurance still in progress" Legal review. still in progress" At last, our contracts are out of Legal here, now to Legal at the hospital organization" Credential some of our pathologists at their hospitals, just in case" Ordering 4 cryostats, 4 microscopes, computers, monitors" Devising new requisition sheets, old requisition cards from the ancient past are exhumed just in case"

Two weeks left" No signed business contract " No signed IT contract between university and company" Cryostats will be here in 3 months!" Safeguards:" Install Co-Path there need more CoPath licenses. " Is CoPath on one of our GPOs? Purchase order?" Credential 2 of our pathologists at their hospitals" Strong push on university credentialing to get new faculty on staff" What about dictation? using companyʼs system." Who is taking call on the first day, Saturday, Dec 28?"

One week left" Still no signed contracts" Company moving out, removing their property, boxing up blocks and slides, pathologists ask, are they taking my chair? " Issues regarding cryostats" Have you decided if we could buy your equipment?" Credentialing close on 4 pathologists" Malpractice insurance in place" I go on a long planned vacation to Singapore"

3 days to D-day" Business contract signed by both sides on 12/24-27/14" IT contract signed by company on 12/24/14, now to legal " Citrix not working for IT, site to site VPN selected" Need access to hospitalsʼ networks to use our Co-Path" Still need more Co-Path licenses for transcriptionists, accessioners, PA, etc." Hired: One or two histotechs, one cytotech, 1 PA, 1 transcriptionist"

How are we handling their last day?" We handle all cases that are grossed or diagnosed on the last day" Leaving equipment for a month " They kept their IT system open to the pathologists with remaining cases in their system (immunos, etc)" Still no access to IT system for other pathologists, company still awaiting a signed contract" Four pathologists are credentialed at University on very last day, Friday, 12/27/13" Everyone on vacation for holidays" Frantic, in the middle of the night emails from Singapore"

Day 1-Saturday" No grossing" No frozen sections" Tissue blocks brought to university for processing" Ungrossed specimens brought to university for registration, accessioning, grossing" Couldnʼt print out results at hospitals since not on hospital networks so printers wouldnʼt work"

Day 3-Monday" Avalanche of cases to gross at University" Requisitions sheets faxed to university for patient registration and accessioning" All hands worked into the night for many nights" Slides went out via volunteer lead tech couriers" Remaining tissues picked up via courier" Dictation system not working hurry, take them our DocVoice system " Ask for larger IT crew" Hiring: Still lacking 2 couriers, 2 accessioners, 1 transcriptionist, 2 call center people" Had one very tired department business administrator registering patients into Epic, looking for help"

By one month" All cases registered in Epic" All cases signed out in CoPath, results faxed to medical records at hospitals and doctorsʼ offices, then scanned into their EHR" Co-Path still freezing up from time to time" Staffing:" Still short couriers, kept failing drug testing " Replaced call center people with registrars and accessioners" Turn around time need slides earlier"

By two months" Still on Co-Path, no interface to McKesson Portal" Investigating Mayo Access/Mayo Connect interface" 1 ½ couriers hired" All slides out by 12 noon, biopsies out by 9-10AM, immuno slides out by 3 PM" Hospitals still complaining about turn around time, though better" Pathologists cleared from credentialing by FPPE evaluation, billing hold released"

By 3 months" More histotechs hired (previously short 2 histotechs, so 4 hired with one additional temp)" Accessioners and transcriptionists in place at grossing hospitals" More detailed logs created for slide and specimen accountability" Passed CAP inspection at one site" Pathologists surprised it worked so well" Hospitals satisfied" Charges after 2 months exceed expectations"

A good business model" For the practice: Affiliating with university setting is ideal for small private practices free, timely consultations, ancillaries in town " For the university:" Keeping TC is a significant contribution to margin" AP testing in house: kidney biopsy, bone marrow, muscle biopsy" Ancillary testing in house: immunohistochemistry, flow cytometry, EM, cytogenetics, FISH" Connectivity: IT interface needed for this practice as well as adding additional practices" Considering outside billing company for efficiency" Professional component billing"

Support needed from all sides" Achievable for most academic pathology practices as long as:" Hospital/University administration " One entrepreneurial pathologist is willing to do the leg work " Lead histotechnologist " Cytology: Same day screening nongyn and FNA cases" Department business administrator "

You are now running a real business!" Takes a Team" Start credentialing and malpractice insurance on day one" Talk with IT on day one bring food" Nimble legal and compliance sections" How good is the regional pool of potential employees?" Hospitals need to be understanding" Accept your deficiencies, find ways to improve" Exit strategy: 30-day no fault out clause"