Part 5 -

Organizational Models and Compliance Practices for Anatomic Pathology Black-Schaffer & Johnson

Introduction - Organizational Models and Compliance Practices for Anatomic Pathology Theory and practice of completely subspecialized diagnostic pathology Practical and applicable to any large practice, with Particular commentary on implications for academic practice Nuts and bolts of correct coding for reimbursement and compliance Established criteria, and Emerging/controversial areas Legal and regulatory framework of compliance Compliance planning for a pathology practice Why this makes sense to do How to do it efficiently Process Improvement - Organization for Compliance and Efficiency Pathology practice organization and operation => is complex Academic and clinical responsibilities => must be balanced Health care regulation and health care financing => are increasingly stringent How can the leadership of a pathology practice enhance compliance => even while responding to pressure to operate more efficiently? Efficiency in the Practice of Anatomic Pathology Clinical laboratories => factory industrial model => high fixed & low variable cost => high volume key to efficiency Anatomic pathology => cottage industry model => low fixed & high variable cost => low variability key to efficiency Decreased variability in anatomic pathology => subspecialization Two Causes of Variability Key concept - common vs. special cause variation: Common cause variations - show apparently random distribution - result from intrinsic causes - present in every occurrence of process Special cause variations - outside range of variability intrinsic to process - can be assigned to extrinsic events - can be controlled, reduced, or eliminated Subspecialization's Costs, Benefits, and Conditions Subspecialization => diagnostic process with reduced special cause variability Decreased specimen input variability => increased specimen throughput and diagnostic consistency Cost of decreasing service variability => increased operational overhead and decreased staffing flexibility Increasing operational scale and staff size => offer increasing opportunities to decrease service variability through subspecialization Benefits of Subspecialization Subspecialization in anatomic pathology can => increase productivity => decrease turn around time => enhance teaching of trainees => increase accuracy in diagnosis => promote clinical communication => facilitate faculty research involvement => align diagnostic work with academic interest => promote compliance in ordering and coding Subspecialization and Compliance How can a compliance plan be synergistic with enhanced operational efficiency? Align diagnostic work with subspecialty expertise => diagnostic and operational benefits => also compliance plan benefits. Subspecialization => conducive to understanding diagnostic issues => similarly conducive to understanding coding and regulatory issues for subspecialized: diagnostic entities; specimen types; special studies. Feasibility - Pathology Groups are Increasing in Size Since 1994, Groups with <4 pathologists decreased by 23% Groups with 5-20 pathologists increased by 14% And the largest groups, those with greater than 20 pathologists, increased the most, by 60% Desirability - is it Practically or Theoretically Sound to Subspecialize? Practically, Maybe yes => Surgical pathology is a clearly defined subset of anatomic pathology with well established clinical utility Maybe no => Surgical pathology is already most of what most pathologists actually do Desirability - is it Practically or Theoretically Sound to Subspecialize? Theoretically, In many large practices => general surgical pathology is already => whatever is left over after subspecialists have taken all the cases => on which generalist pathologists are no longer allowed to have the last word Economic Efficiency in Anatomic Pathology Practice is Professional Efficiency Attempts to decrease unit cost in anatomic pathology have typically focused on efficiency in technical (specimen processing and reporting) services These are economically a minor part of anatomic pathology operations The major part is the professional time, effort, and professional responsibility 70% of AP services in hospital setting, where less than 3% of services generate technical component charges or payments 30% of AP services in commercial laboratory setting, where only ~1/3 of global charges or payments are for technical component 1/3 of 30% TC ~10%; 2/3 of 30% plus 70% PC ~90% Anatomic Pathology Practice Organization for Professional Efficiency Organizational change is necessary to leverage size and achieve efficiency by subspecialization in anatomic pathology practices The rationale for this is evident from basic business management principles but How does it work in practice: What are the obstacles? What is the benefit? Other outcomes? Subspecialization's Biggest Obstacle THE MEASUREMENT OF PHYSICIAN WORK The biggest single obstacle to subspecialized practice is ensuring equitable responsibilities among the pathologists in support of your practice mission The biggest single equity issue that arises from subspecialized practice is workload equity In a general diagnostic practice, if you work by weeks, this can be hard enough when a week is a week is a week (because sometimes it's not) But when it becomes an issue not just of time on service, but of how much time on which service How can you measure/assign work equitably? Measurement of Histopathologist Work - Both Volume and Complexity Specimens Number of specimens Type (group) of specimens CPT–4 total Slides Number of H&E slides Number of special stain slides Number of immunohistochemistry slides Reports Number of diagnoses Amount (items or units) of information reported Lines of diagnoses, templates, notes, gross and/or microscopic descriptions Measurement of Cytopathologist Work - Both Volume and Complexity GYN Number of specimens Source of specimens Nature of screened population Diagnostic threshold for cytopathologist review Non-GYN Number of specimens Type (group) of specimens Abnormality rate Special procedures Cytopathologist performance of FNAs Subspecialization - Actual Service Work Measurement Considering the need to count specimens and also to assess their complexity in various ways The first question is whether the work difference among the various services is worth measuring To see an answer, let's delve into the actuality of the last ten years of completely subspecialized diagnostic pathology at MGH We'll look at just how different the various subspecialties are in terms of work done, as measured one way, in physician work RVUs. We'll consider alternative measures of work shortly. Subspecialization - More Actuality Various services have very different amounts of work at any one time And these different amounts of work also change a great deal over time Subspecialization - The Requirement for Ongoing Measurement Services thus differ widely in amount of work And these differences also change over time Quantification can not be a one time thing So, to minimize the administrative overhead of a system to track the amount of work on each service, on an ongoing basis The system should do so as much as possible with existing data and processes And should be carefully examined for potential incidental benefits (Like compliance plan implementation) Subspecialization - Empirical Efficiency We have doubled the overall amount of AP work at MGH between 1995 and 2005 How have we coped with this increased volume? We have gradually worked out the intricacies of how to assign work fairly, and, as we have done so, we have also realized substantial increases in productivity. The following table and chart summarize this increased productivity as measured by a far lower rate of increase in our staffing than in diagnostic services as measured in RVUs. Subspecialization - Empirical Efficiency FY1/2 RVUs Staff FTEs Work Weeks Work FTEs RVUs/Wrk FTE Alternative Wrk FTEs Alternative Staff FTEs 95#2 75,188 30.4 32.0 18.7 4,018 18.7 30.4 96#1 80,491 30.4 34.0 19.9 4,048 20.0 30.6 96#2 87,667 30.4 35.0 20.5 4,283 21.8 32.4 97#1 111,842 31.4 35.5 21.4 5,216 27.8 40.8 97#2 99,408 31.4 36.0 21.7 4,572 24.7 35.7 98#1 105,430 31.4 36.5 22.0 4,782 26.2 37.4 98#2 111,010 32.9 36.8 23.3 4,766 27.6 39.0 99#1 114,416 34.1 36.8 24.1 4,741 28.5 40.2 99#2 122,613 34.1 38.2 25.0 4,896 30.5 41.5 00#1 128,493 33.8 38.2 24.9 5,170 32.0 43.5 00#2 127,203 32.4 38.0 23.7 5,368 31.7 43.3 01#1 135,055 31.3 38.0 22.9 5,898 33.6 46.0 01#2 139,750 33.9 38.0 24.8 5,646 34.8 47.6 02#1 142,884 32.5 39.0 24.3 5,870 35.6 47.4 02#2 144,758 34.4 38.0 25.2 5,755 36.0 49.3 03#1 146,632 33.5 37.7 24.3 6,032 36.5 50.3 03#2 147,174 34.3 39.0 25.8 5,713 36.6 48.8 04#1 150,940 33.4 38.0 24.4 6,188 37.6 51.4 04#2 151,040 33.7 38.5 25.0 6,046 37.6 50.8 05#1 149,256 35.9 35.0 24.2 6,176 37.1 55.2 Change 99% 18% 9% 29% 54% 99% 81% Weeks –Nominal and Assigned per FTE 05#1 theoretical 35.0 weeks per FTE nominal average 32.1 of 32.1 nominal weeks per FTE actual assigned work 30.6 Weeks –Assigned and Actual per Staff Member 05#1 at theoretical 35.0 weeks assigned average 24.8 of the 24.8 assigned weeks actual average work 23.0 Subspecialization - Various Quantitative Considerations As services become more distinctly differentiated => quantitative measurement of the work on each service becomes more essential. Limitations of CMS RVUs include: Absence of established values for autopsy services; Work contribution of, and supervisory effort for, trainees; Differential increase efficiency with subspecialization among: special study services, routine diagnostic services, and procedural / intraoperative services; Miscellaneous subspecialty specific factors. Quantitative Considerations - CMS RVU CMS RVU advantages: => specific physician work component; => most prevalent single basis of payment. Service work credited and allocated on RVU basis => close relationship between work credited and payment received => simultaneously track physician work for service credit and physician billing for compliance. Quantitative Considerations - Autopsy Based on levels of work that were accepted as equivalent by MGH staff on both the autopsy and surgical pathology services, relative values were established for staff activities on the autopsy services in multiples of 88309: Service Description CPT RVUs 88309s Necropsy; with brain 88025 20.52 9.0 Necropsy; without brain 88020 17.10 7.5 Necropsy; stillborn/newborn 88029 11.40 5.0 Necropsy; brain only 88037 6.84 3.0 Quantitative Considerations - Surgical Grossing Pathology services most conspicuously performed by trainees under staff supervision => grossing of routine specimens in surgical pathology. Equity with work directly done by staff in routine cytopathology => 50% increment in cytopathology credit. Quantitative Considerations - Routine diagnostic surgical pathology services CPT Narrative RVU 85060 Blood smear interpretation 0.45 85097 Bone marrow interpretation 0.94 88300 Surgical path, gross 0.08 88302 Tissue exam by pathologist 0.13 88304 Tissue exam by pathologist 0.22 88305 Tissue exam by pathologist 0.75 88307 Tissue exam by pathologist 1.59 88309 Tissue exam by pathologist 2.28 88321 Microslide consultation 1.30 88323 Microslide consultation 1.35 88325 Comprehensive review of data 2.22 Quantitative Considerations - Routine diagnostic cytopathology services CPT Narrative RVU 88104 Cytopathology, fluids 0.56 88106 Cytopathology, fluids 0.56 88107 Cytopathology, fluids 0.76 88108 Cytopath, concentrate tech 0.56 88112 Cytopath, cell enhance tech 1.18 88125 Forensic cytopathology 0.26 88141 Cytopath, c/v, interpret 0.42 88160 Cytopath smear, other source 0.50 88162 Cytopath smear, other source 0.76 88173 Cytopath eval, fna, report 1.39 Quantitative Considerations - Special Studies Greatest increase in subspecialization efficiency => services with most specialized procedures: which special studies to order; how to evaluate, interpret, and report on the results; how to code and bill for these services. We therefore decrement special study RVUs by 40% as a more realistic measure of their relative time, effort and professional responsibility on subspecialized diagnostic services. Prevalence of such special studies => differs widely among subspecialties. Quantitative Considerations - Special study services CPT Narrative RVU 88182 Cell marker study 0.77 88187 Flowcytometry/read, 2-8 1.36 88188 Flowcytometry/read, 9-15 1.69 88189 Flowcytometry/read, 16 & > 2.23 88291 Cyto/molecular report 0.52 88311 Decalcify tissue 0.24 88312 Special stains 0.54 88313 Special stains 0.24 88314 Histochemical stain 0.45 88318 Chemical histochemistry 0.42 88319 Enzyme histochemistry 0.53 88342 Immunohistochemistry 0.85 88346 Immunofluorescent study 0.86 88347 Immunofluorescent study 0.86 88348 Electron microscopy 1.51 88349 Scanning electron microscopy 0.76 88355 Analysis, skeletal muscle 1.85 88356 Analysis, nerve 3.02 88358 Analysis, tumor 0.95 88360 Tumor immunohistochem/manual 1.10 88361 Immunohistochemistry, tumor 0.94 88362 Nerve teasing preparations 2.17 88365 Tissue hybridization 0.93 88367 Insitu hybridization, auto 1.30 88368 Insitu hybridization, manual 1.40 Quantitative Considerations - Intraoperative and Procedural Services Time, effort, and professional responsibility of some services => minimally decreased by subspecialization. Particularly intraoperative and procedural services: => performance and immediate evaluation of fine needle aspiration biopsies; => intraoperative gross examination, touch preparation, and frozen section examination. Quantitative Considerations - Intraoperative and Procedural Services We therefore increment special study RVUs by 40% as a more realistic measure of their relative time, effort and professional responsibility on subspecialized diagnostic services. The prevalence of such services => also differs widely among subspecialties. Quantitative Considerations - Intraoperative and procedural services CPT Narrative RVU 10021 Fna w/o image 1.27 10022 Fna w/image 1.27 88161 Cytopath smear, other source 0.50 88172 Cytopathology eval of fna 0.60 88329 Path consult intraop 0.67 88331 Path consult intraop, 1 bloc 1.19 88332 Path consult intraop, add'l 0.59 88333 Intraop cyto path consult, 1 1.20 88334 Intraop cyto path consult, 2 0.59 Quantitative Considerations - Service Impact of Systematic Adjustments Subspecialties differently affected by => special studies and/or => intraoperative & procedural services => credit adjustments for services most affected => renal and hematopathology (down) and => FNA and FS (up). Quantitative Considerations - Miscellaneous Factors Miscellaneous work factors: Call coverage (transplant, neuropathology, &c.), Interdepartmental subspecialty clinics and conferences (breast multidisciplinary conferences, &c.), Changes in practice from those prevailing when RVUs were established (synoptic reporting generally, and for excisional breast biopsies in particular; outside case consultations with new NCCI edits, &c.), and Uniquely specialized services (obstetrical pathology flotation of specimens with dissecting microscope examination for identification of villi, &c.). MGH AP Subspecialty Services - Service Credit and Staffing – 100% RVUs Subspecialty Credit Staff Autopsy Path 0.61 1 Breast Path 0.89 2 Bone & Soft Tiss 0.85 1 Cardiac Path 0.36 1 Non-GYN Cyto 2.33 2 GYN Cyto 0.53 1 Dermatopath 1.11 2 Electron Micro 0.13 * ENT Path 1.28 1 FNA Clinic 0.47 1 Frozen Sect Lab 0.77 1 GI Large Path 0.81 1 GI Small Path 2.44 1 GU Path 1.10 1 GYN Path 0.80 2 Hematopath 1.54 1 Neuropath 0.91 1 OB Path 0.47 1 Pulm Path 0.51 1 Renal Path 0.30 1 All Path 23.13 23 *Electron microscopy staffed as add-on service. Quantitative Considerations – Weighting of both Duration and Intensity of Service As above, based on intensity of service work as measured in RVUs per week, we had a greater than 8:1 ratio of service work credit between the highest credit service and the lowest credit service (GIS @ 2.44 : Renal Path @ 0.30) Staff signing out subspecialties with high weekly credit had fewer weeks on service Staff on low weekly credit services acknowledged their work was of lower intensity, but they also perceived they had less time free for academic pursuits This led to the conclusion that we needed to weight both the duration of service and the intensity of the service to achieve equitable distribution of work We therefore needed to blend the credited work between the simple duration of assigned coverage, which would provide the same credit per staff person for regularly scheduled services, and the intensity of the work, which had become too extremely variable Achieving a 4:1 maximum ratio of service work credit between services for our mix of services meant weighting the duration (the weeks of coverage) at 30% and the intensity (the RVUs per week) at 70% MGH AP Subspecialty Services - Service Credit and Staffing – 70% RVUs and 30% Weeks Subspecialty Credit Staff AUTOPSY PATH 0.73 1 BREAST PATH 0.92 2 BONE & SOFT TISS 0.90 1 CARDIAC PATH 0.55 1 NON-GYN CYTO 1.93 2 GYN CYTO 0.67 1 DERMATOPATH 1.07 2 ELECTRON MICRO 0.13 * ENT PATH 1.20 1 FNA CLINIC 0.63 1 FROZEN SECT LAB 0.84 1 GI LARGE PATH 0.87 1 GI SMALL PATH 2.01 1 GU PATH 1.07 1 GYN PATH 0.86 2 HEMATOPATH 1.38 1 NEUROPATH 0.94 1 OB PATH 0.63 1 PULM PATH 0.66 1 RENAL PATH 0.51 1 ALL PATH 23.13 23 *Electron microscopy staffed as add-on service. Other Measurement Systems - Kim Units Few other systems to measure pathologist (rather than pathology) work. Kim Units (KUs) For routine surgical specimens, KUs roughly parallel the RVU physician work component at a conversion factor of 1 KU = 1.8 RVUs However, using this conversion factor: Specimen Type KUs RVUs Difference NON-GYN Cytology 1 1.0 88104 KUs = RVUs GYN Cytology 2 2.7 88141 KUs >> RVUs Autopsy Pathology 10 2.5 88309 KUs << MGH* *KUs << than MGH (KP) values by factor of 3.7 (3.9) Other Measurement Systems - Autopsy KUs At 10 units, KUs assign roughly 2.5 times the relative credit to the physician work of an autopsy as CMS RVUs assign to an 88309. Service Description CPT RVUs 88309s Necropsy (KUs) N/A 5.70 2.5 KU Other Measurement Systems – Kaiser Permanente & Kim Units for Histopathology "efficient and proficient ... pathologist" (KP) 250 autopsies per year 2,500 pathologist work KUs (10 KUs/autopsy) 7,500 surgicals per year 15,750 pathologist work KUs (~2.1 KUs/surgical) "whole time equivalent consultant" (KU) ~10,000 pathologist work KUs 1,000 autopsies per year 4,760 surgicals per year Other Measurement Systems – Kaiser Permanente & Kim Units for Cytopathology "efficient and proficient ... pathologist" (KP) "review and sign out" 6,000 fine-needle aspirates per year 8,340 physician work RVUs (1.39 RVUs / FNA) "whole time equivalent consultant" (KU) microscopy and reporting of ~5,000 GYN cytology specimens 2,100 physician work RVUs (0.42 RVUs) microscopy and reporting of ~10,000 non-GYN cytology specimens 5,600 physician work RVUs (0.56 RVUs) Other Measurement Systems - Royal College of Pathologists, London , England (RCP, 1992 & 1999) The 1992 and 1999 RCP workload guidelines were based on annual case load: a combination of 4,000 surgical cases, 6,000 cytology cases, and 600 autopsy cases per FTE direct clinical care pathologist in a district general hospital and half that in a teaching hospital department A Special Advisory Committee on Histopathology meeting in 2002 reconsidered these guidelines and determined they required substantial revision to take account of the effects of increasing subspecialization, increasing use of more detailed minimum data sets on cancer cases, increasing participation in multidisciplinary team meetings, and a general increase in requirements for clinical governance, continuing professional development, and appraisal Other Measurement Systems - Royal College of Pathologists, London , England (RCP, 2003 & 2005) The sum of the Macroscopy and Microscopy scores from the matrix below is considered to be the relative work of the service Macroscopy Microscopy Low 1 Intermediate 3 High 5 Very High 10 Low 1 2 4 6 11 Intermediate 3 4 6 8 13 High 5 6 8 10 15 Very High 10 11 13 15 20 The expected rate of pathologist work is 10 of the above units per hour, counting both Macroscopic and Microscopic work for cases where the pathologist does both, and Microscopic only in cases where a resident or technician does the gross under the pathologist's supervision A typical FTE direct clinical care pathologist would be expected to provide approximately 40 weeks per year of diagnostic services, at 24 hours per week of diagnostic services, which amounts to 9,600 units of diagnostic service Other direct clinical care activities would typically include preparation for and participation in multidisciplinary team meetings, case reviews, and second opinions Other supporting professional activities would include teaching, continuing professional development, clinical governance, and research Specific examples of diagnostic services include the following: Service description RCP workload units acro+micro=score CPT code CMS professional component RVUs Single small bx no level stain immuno 1+1=2 88305 0.75 Single small bx 1-4 levels stains immunos 1+3=4 88305 to 88305+4*88342 0.75 to 0.75+4*0.85 = 0.75 to 4.15 Single small bx >4 levels stains immunos 1+5=6 88305 to 88305+>4*88342 0.75 to 0.75+>4*0.85 = 0.75 to >5 Needle core bx no immuno 1+3=4 88305 0.75 Needle core bx with immuno 1+5=6 88305+>1*88342 0.75+>0.85 = >1.6 Frozen section (any indication) 3+3=6 88331 or 88332 1.19 or 0.59 BCC / SCC skin biopsy 1+3=4 88305 0.75 Melanoma skin biopsy 1+5=6 88305 0.75 Liver biopsy 1+5=6 88307 1.59 Nephrectomy for tumor 5+5=10 88307 1,59 Radical prostatectomy 10+10=20 88309 2.28 Cervical cytology 2 88141 0.42 Non-gyn cyto (1-3 slides) 2 88160 0.50 Non-gyn cyto (4-8 slides) 3 88162 0.76 Non-gyn cyto (>8 slides / complex case) 5 88173 1.39 Autopsy, low input 1.5 hours = 15 units Autopsy, intermed input 3 hours = 30 units Autopsy, high input 6 hours = 60 units Other Measurement Systems – Canadian Experience (2005) Comparison survey of 27 Canadian pathology services (with an 11.3% response rate) Survey data included the current and projected optimal pathologist FTEs, annual number of anatomic pathology specimens (surgical, cytology and autopsy, with sufficient detail to weight the former two), number of blocks and slides, and the patient population served by the practice The anatomic pathology consultative procedures (professional services) were categorized and weighted relative to the level IV surgical specimen as in the following table Individual Consultative Procedures Individual Consultative Procedures Relative Weighting CPT code - CMS professional component RVU - % of 88305 Level I - Gross only examination 14% 88300 - 0.08 - 11% Level II - Confirmation of normality by gross and microscopic examination of small specimens 32% 88302 - 0.13 - 17% Level III - Confirmation of common degenerative, inflammatory and common benign conditions 49% 88304 - 0.22 - 29% Level IV - Small specimens for diagnosis, including all endoscopic biopsy specimens and small organs removed for benign conditions 100% 88305 - 0.75 - 100% Level V - Complex biopsy specimens or small whole organs, including specimens from specialized biopsies and excisions 172% 88307 - 1.59 - 212% Level VI - Large complex organs, requiring extensive gross dissection and microscopic assessment 253% 88309 - 2.28 - 304% Screening cytology (sputum and urine cytology, pathologist review of marked Pap smears) 49% 88141 - 0.42 - 56% Diagnostic cytology (FNA, fluids) 100% 88112 - 1.18 - 157% 88173 - 1.39 - 185% Intraoperative consultations (with and without frozen sections) 150% 88329 - 0.67 - 89% 88331 - 1.19 - 159% 88332 - 0.59 - 79% Autopsy (full, uncomplicated) 800% Intradepartmental consultation 25% of level of specimen reviewed 88321 - 1.30 - 173% Consultation, review (e.g., cancer clinic reviews, for studies) 66% of level of specimen reviewed 88321 - 1.30 - 173% Consultation, complicated (for difficult cases, external) 150% of level of specimen reviewed 88325 - 2.22 - 296% Other procedures (e.g., FNA, bone marrow biopsy with or without aspiration) As per other specialties or 100% of level IV 10021 - 1.27 - 169% Among all the parameters surveyed, the correlation between the level IV equivalents as weighted above and the surveyed optimal FTE staffing was the best, with a mean of 3,600 level IV equivalents per optimal FTE pathologist Quantitative Considerations - Major Drawbacks of Alternative Systems 1) no explicit special study or procedure credit - would fail to recognize large portion of some subspecialties' work; 2) information not already collected - would require additional administrative procedures; 3) not directly related to billing - less effective as compliance monitor. => For these reasons, despite some attractive features of these alternative systems, MGH uses CMS RVUs, with adjustments as described. MGH Completely Subspecialized Diagnostic Pathology - "Complete Subspecialization" 7/1/95 - diagnostic pathology at the MGH => complete subspecialization. "Complete" subspecialization? Not a particular mix / combination of organ / disease oriented diagnostic services. A system in which each specimen comes directly to a pathologist with particular interest and expertise in the organ or disease the specimen represents => a system with no "general" diagnostic service. MGH Completely Subspecialized Diagnostic Pathology - Defined Subspecialties Developed list of diagnostic subspecialties usefully covering all our specimens, as follows: Autopsy Bone & Soft Tissue Breast Cardiovascular Cytopathology (FNA) Cytopathology (GYN) Cytopathology (NON-GYN) Dermatopathology Electron Microscopy ENT Eye Frozen Section GI GU GYN Hematopathology Neuropathology Obstetric/Perinatal Pulmonary Renal MGH Completely Subspecialized Diagnostic Pathology - Assigned Staff Subspecialties Each pathologist => chose five subspecialties and ranked them in order of preference. Each subspecialty => assigned at least two pathologists. Each pathologist => assigned at most three subspecialties. Work credit per week => assigned to each subspecialty => according to volume and complexity of cases. MGH Completely Subspecialized Diagnostic Pathology - Assigned Service Credits Net effect on number of staff to cover all services => increase by one FTE. No increase in actual number of staff => increase (by one) in number of average credit service weeks per FTE. Services less than average credit per week => number of actual service weeks per FTE potentially greater than number of average credit service weeks. MGH Completely Subspecialized Diagnostic Pathology - Assigned/Tracked Specimens Each specimen accessioned to => appropriate subspecialty service with memo (non-billing) fee code as flag to computer system. Number and characteristics of cases on each service => automatically tracked from subspecialty flagged accessioning and billing data. Different colored tissue cassettes => track blocks and slides from each subspecialty through histology. MGH Completely Subspecialized Diagnostic Pathology - Scheduled Residents Residents' work reassigned to correspond with new organization of specimen material => all services covered by same total number of residents but => services (as for staff) more heterogeneous so => PAs reassigned from general coverage to assistance on the heavy grossing services (Bone and Soft Tissue, Breast, ENT, GI Large, and GYN Large services). MGH Rationale for Subspecialization - General Major competitive advantage for large or academic medical centers - ability to offer subspecialized services, including diagnostic pathology services. Integrated health care delivery systems - infrastructure services to enhance value - minimize unit cost while optimizing clinical performance. Clinical laboratory testing - decreased unit cost with increased scale of operation. Increased efficiency in professional diagnostic services - if associated with maintained or improved quality - also increases value. MGH Rationale for Subspecialization - Pathology Patients go to referral facilities to consult subspecialized clinicians => expectation is specimens will be diagnosed by pathologists with similar expertise in their disease. With increasing clinical and pathology sophistication => difficult for individual to maintain literature familiarity and diagnostic competence in all areas of pathology. General diagnostic signout => pathologists encouraged to show difficult or unusual cases to staff with appropriate subspecialty expertise. MGH Rationale for Subspecialization - Diagnosis Significant diagnostic errors were rare but => increasing need to amend and reissue reports lacking data required by clinician. Occasional cases => even very good general pathologists failed to recognize need for subspecialty review. Change in Surgical Pathology Corrected Diagnosis Rate 1995 2002 % Change Surg Path Case 45,208 71, 586 +58% All Revised Rep 452 1.00% 544 0.76% -24% Corrected Final 50 0.11% 27 0.04% -66%* *p<0.001 Chi2 MGH Rationale for Subspecialization - Turn Around Time Frequency of intradepartmental consultations increasing => decreasing both staff and resident efficiency. For some specimen types => increasing turn around time due to frequent need for subspecialized second opinion. Turn Around Time - 1995 to 2005 Surgical Pathology Turn Around Time Days 1995 2003 2005 Absolute 2.9 2.7 2.9 Adjusted* 1.9 1.7 1.9 *Adjustment allows 1 resident preview day (0.98), not changed with subspecialization Differential between tech grossed and PA / resident grossed specimens from 0.46-0.87 days (GYL-GYS to GIL-GIS) MGH Rationale for Subspecialization - Communication and Collaboration Fifteen to twenty pathologists rotating on general diagnostic services => hard to build relationships that facilitate mutual understanding in difficult cases => better communication among smaller numbers of similarly subspecialized clinicians and pathologists. Subspecialized clinicians working with subspecialized pathologists => more likely to regard pathology subspecialists as members of the subspecialty patient care "team." MGH Rationale for Subspecialization - Academic Productivity and Support Closer relationship between pathology and clinical subspecialists fosters academic collaboration. Pathologists with academic careers are better served by concentrating on specimens in areas of interest. Quality of teaching and conferences improves with subspecialization. Change in Peer Reviewed Publication Record - 1995 to 2001 Year Staff Publications (Year) Publications per Staff 1995 43 155 (1996) 3.60 2001 44 159 (2002) 3.61 Includes publications cited in PubMed Does not include CPCs or book chapters Multiple authored publications counted once Change in Grant Support - 1995 to 2003 Service Rotations N 1995 N 2003 >10% Grant Support 1995 >10%Grant Support 2003 Subspecialty 12 67% General 31 13% 1 23 52% 2 20 30% 3 3 0% Total 43 46 28% 39% MGH Rationale for Subspecialization - Junior Residents Junior residents: => appreciate focused nature of signout => learn effectively when exposed repeatedly to a focused panel of specimens over the course of a rotation => enjoy not having to find and show cases to subspecialists after general signout Junior resident concern: => sustaining ongoing exposure to all areas of diagnostic pathology => MGH daily "Outs" conference: rotating subspecialties on MTW&F with good current cases of all kinds every Thursday. MGH Rationale for Subspecialization - Senior Residents Senior Residents: => appreciate the opportunities to focus on their interests in various subspecialties => appreciate the availability of surgical pathology fellowship type rotations in each area, either as resident electives or for post-residency fellowships MGH Rationale for Subspecialization - Staff Concerns Not seeing material from all diagnostic areas => those who stay in academic pathology have to subspecialize for career development An increase in number of weeks on service => true only for a few subspecialists all of whose services receive less than average credit and who do not "double up" signout => actual increases not sufficient to justify return to general signout; addressed instead by weighting duration (weeks of coverage) at 30% and intensity (RVUs per week) at 70% Increased senior staff responsibility for training and supervising the junior staff => balanced by increased efficiency of signout for senior staff in areas of expertise MGH Pathology E-Mail Survey 10/03 From your perspective, do you prefer the current MGH system of AP subspecialization to that of general signout? Responding Yes No Undecided Residents 19 100% 0% 0% Staff 34 97% 3% 0% MGH Model for Subspecialization - Requirements Practice size - match useful range of specimen types / diagnostic entities with subspecialized pathologists; Commitment to academic mode of practice - exchange broad general competence for narrower but deeper subspecialty expertise; Organizational support - administrative demands of subspecialized practice greater than baseline requirements of pathology practice.