Gastrointestinal pathology
Encyclopedia
Gastrointestinal pathology is the subspecialty of surgical pathology
which deals with the diagnosis
and characterization of neoplastic
and non-neoplastic disease
s of the digestive tract and accessory organs, such as the pancreas
and liver
.
, gallbladder
and pancreas
) is a recognized sub-specialty discipline of surgical pathology. Recognition of a sub-specialty is generally related to dedicated fellowship training offered within the subspecialty or, alternatively, to surgical pathologists with a special interest and extensive experience in gastrointestinal pathology. There are approximately 30 gastrointestinal pathology fellowships offered within the United States (predominantly academic, and more recently three "corporate" fellowships). This translates to fewer than 40 fellowship trained gastrointestinal pathologists being trained annually in the United States each year.
Fellowship in gastrointestinal pathology involves:
During the course of a one year gastrointestinal pathology fellowship, the GI-liver pathology fellow will review between 8,000 and 15,000 gastrointestinal and liver biopsy and surgical specimens with all clinical history, laboratory data and frequently, knowledge of response to treatment. This volume of cases is similar to approximately five years of case experience for general surgical pathologists in private practice.
Board certification in the United States requires approval by the certifying body, the American Board of Pathology. There has been considerable debate among academic and private practice gastrointestinal pathologists regarding the necessity, advantages and disadvantages of Board Certification in this subspecialty. The debate was last formally approached in 2001, during Dr. Joel K. Greenson's tenure as President of the Rodger C. Haggitt Gastrointestinal Pathology Society. The decision to seek Board Certification was declined by the membership of the Society.
, and included Henry Appelman (University of Michigan
), Harvey Goldman (Beth Israel Hospital
and Harvard Medical School
), Bill Hawk (The Cleveland Clinic
), Tom Kent (University of Iowa
), Si-Chun Ming (Temple University
), Tom Norris (University of Washington
), and Robert Riddell (University of Chicago
). This group, headed by Henry Appelman, organized a group for gastrointestinal pathologists.
Every gastrointestinal pathologist in the United States and Canada received an invitation to attend the first organizational meeting, held during the 1979 IAP meeting. At that meeting, the establishment of a society was approved, and four subcommittees were formed to deal with membership, finances, bylaws, and educational activities. During the next year, all organizational functions were completed, and at the 1980 IAP meeting, the organization was officially established, by-laws were approved, the first officers elected, the first dues collected, and the first educational program was offered.
The original name for the organization was the Gastrointestinal Pathology Club. Only later did it achieve "Society" status. In 2001, after the tragic and untimely death of Dr. Rodger Haggitt, the name of the society was officially changed to Rodger C. Haggitt Gastrointestinal Pathology Society.
The organization was developed as a mechanism:
The first three of these initial goals were accomplished early on. The Club was recognized as a companion society of the IAP and its first scientific session was presented about a year later. The fourth goal took longer, but it, too, has been fulfilled as exemplified by a published study on adenoma
s with invasive carcinoma
that was shepherded by Harry Cooper. It took e-mail technology to really allow the fifth goal, the referral network, to operate. The development of an e-mail group from the Society, which became an opportunity for members to consult a wide group of GI colleagues regarding problem cases, has been functional sine 1995. The sixth goal, the registry issue, has yet to get off the ground. Currently, the Society awards prizes for resident presentations at the USCAP annual meeting and organizes educational symposia
at national meetings, including the IAP, the American Society of Clinical Pathologists, Digestive Disease Week and the international congresses of the International Academy of Pathology
.
screening in the aging U.S. population. By 2010, gastroenterologists will perform at least 40 million endoscopic procedures annually, translating into $40 billion endoscopy and $12 billion related gastrointestinal pathology expenses annually in the U.S.
With less than 400 fellowship-trained gastrointestinal pathologists in practice in the United States, approximately 8% of the 20+ million gastrointestinal biopsies currently performed each year are reviewed by pathologists with fellowship training in digestive health and disease. The remaining 90 to 92% of biopsies are reviewed by highly skilled general surgical pathologists including some who have special interest in gastrointestinal pathology.
General surgical pathologists who practice with a focus in gastrointestinal pathology may attend continuing medical education courses offered by fellowship-trained academic and private practice gastrointestinal pathologists, may attend intensive "mini-fellowships" that are offered by select institutions (i.e. AFIP) to further hone their diagnostic skills and develop close working relationships with gastroenterologists to ensure a broad knowledge base with regards to clinical correlation of the findings under the microscope
.
Whether a fellowship trained gastrointestinal pathologist, a general surgical pathologist with subspecialty interest in GI or an adept general surgical pathologist is reviewing a particular biopsy or surgical specimen, it is important to keep in mind that the training for the specialty of surgical pathology is rigorous. Following completion of both college and medical school, the surgical pathologist must have also completed an accredited residency in pathology and is board certified in Anatomic Pathology by the American Board of Pathology. Residency in pathology is one of the longest postgraduate training programs, encompassing 4–5 years. (In comparison, internal medicine
and pediatrics
are only 3 years.)
In most instances, gastrointestinal biopsies and surgical specimens represent common diseases that display common histomorphologic
patterns, and are accurately evaluated and classified by adept general pathologists. Similar to many aspects of medicine, not all gastrointestinal tissue specimens require sub-specialist review for the accurate diagnosis to be rendered. Internal medicine physicians treat many gastrointestinal conditions without referral to a gastroenterologist specialist. Similarly, many gastrointestinal tissue biopsies and surgical specimens are accurately diagnosed without referral to a gastrointestinal pathologist. Certain diseases are histologically subtle or the differential diagnosis
is complicated or complex. In such cases a close working relationship between the pathologist and gastroenterologist with correlation of clinical, endoscopic, and biopsy findings may be of great benefit to the submitting physician and to the patient.
Appropriate biopsy classification of GI biopsies is critical. Current literature and other non-published reviews estimate that at least 10% of the diagnoses of Barrett’s esophagus, a precancerous condition, are rendered in error. At least 15 – 20% of stomach biopsies have misclassified disease characteristics, 15% of colon
polyp
s are misdiagnosed, and up to 50% of all cases of chronic inflammatory bowel disease
are misdiagnosed or misclassified.
Though pathology diagnosis is a critical determinant of future cancer risk and screening interval, many of these diagnoses do not result in significant morbidity or mortality for patients; thus, errors may be "masked" by the limited effect to the patient in the present context.
The economic cost of inaccurate pathology diagnoses can be measured from the perspective of the healthcare system, the gastroenterologist practice and the patient. Within the healthcare system, gastroenterology pathology diagnostic inaccuracy of 10% is equivalent to 2 million misdiagnoses each year. The vast majority of these patients will incur additional medical expenses from repeat clinician office visits; repeat diagnostic procedures, unnecessary enrollment in surveillance programs, and treatment with incorrect or completely unnecessary medications. The cost savings of the correct gastrointestinal pathology diagnosis being rendered at first opportunity by expert board certified surgical pathologists is conservatively estimated within the range of $200M – $1B.
Born out of increasing awareness of subspecialty gastrointestinal pathology services, increased marketing efforts by gastrointestinal pathology companies and increased patient awareness of laboratory errors, there is an increasing trend toward referral of tissue specimens to surgical pathologists with special interest in gastrointestinal pathology.
To ensure that physician's referral for additional services are motivated solely by the best interest of the patient, Federal Law
(Stark
) and many State laws prohibit physicians from referring patients to organizations or facilities in which they hold a financial interest and therefore would profit from the referral.
Several pathology companies that offer "subspecialty" pathology services also offer to clinical physicians mechanisms by which the referral of their patient's tissue biopsies to a specific laboratory may result in additional revenue for the physician's practice. These mechanisms are generally designed to be practiced within the boundaries of certain loopholes in Stark laws and state regulations.
These financial relationships include:
Surgical pathology
Surgical pathology is the most significant and time-consuming area of practice for most anatomical pathologists. Surgical pathology involves the gross and microscopic examination of surgical specimens, as well as biopsies submitted by non-surgeons such as general internists, medical subspecialists,...
which deals with the diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
and characterization of neoplastic
Neoplasia
Neoplasm is an abnormal mass of tissue as a result of neoplasia. Neoplasia is the abnormal proliferation of cells. The growth of neoplastic cells exceeds and is not coordinated with that of the normal tissues around it. The growth persists in the same excessive manner even after cessation of the...
and non-neoplastic disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
s of the digestive tract and accessory organs, such as the pancreas
Pancreas
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as a digestive organ, secreting pancreatic juice containing digestive enzymes that assist...
and liver
Liver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
.
Sub-specialty recognition and Board Certification
Gastrointestinal pathology (including liverLiver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
, gallbladder
Gallbladder
In vertebrates the gallbladder is a small organ that aids mainly in fat digestion and concentrates bile produced by the liver. In humans the loss of the gallbladder is usually easily tolerated....
and pancreas
Pancreas
The pancreas is a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as a digestive organ, secreting pancreatic juice containing digestive enzymes that assist...
) is a recognized sub-specialty discipline of surgical pathology. Recognition of a sub-specialty is generally related to dedicated fellowship training offered within the subspecialty or, alternatively, to surgical pathologists with a special interest and extensive experience in gastrointestinal pathology. There are approximately 30 gastrointestinal pathology fellowships offered within the United States (predominantly academic, and more recently three "corporate" fellowships). This translates to fewer than 40 fellowship trained gastrointestinal pathologists being trained annually in the United States each year.
Fellowship in gastrointestinal pathology involves:
- diagnostic evaluation of surgical (whole organ) and biopsyBiopsyA biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
pathologyPathologyPathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
of gastrointestinal tissue, [with the exception of at least one corporate fellowship] - consistent interaction with clinical colleagues (gastroenterologistsGastroenterologyGastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. The name is a combination of three Ancient Greek words gaster , enteron , and logos...
, colorectalColon (anatomy)The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a...
surgeons and gastrointestinal radiologistsRadiologyRadiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body. Radiologists use an array of imaging technologies to diagnose or treat diseases...
) to ensure understanding of the clinical aspects of gastrointestinal disease, treatment modalities and other diagnostic findings; - research in gastrointestinal physiology, disease mechanisms and histomorphology
- education of general pathologists and clinical colleagues.
During the course of a one year gastrointestinal pathology fellowship, the GI-liver pathology fellow will review between 8,000 and 15,000 gastrointestinal and liver biopsy and surgical specimens with all clinical history, laboratory data and frequently, knowledge of response to treatment. This volume of cases is similar to approximately five years of case experience for general surgical pathologists in private practice.
Board certification in the United States requires approval by the certifying body, the American Board of Pathology. There has been considerable debate among academic and private practice gastrointestinal pathologists regarding the necessity, advantages and disadvantages of Board Certification in this subspecialty. The debate was last formally approached in 2001, during Dr. Joel K. Greenson's tenure as President of the Rodger C. Haggitt Gastrointestinal Pathology Society. The decision to seek Board Certification was declined by the membership of the Society.
History of the Rodger C. Haggitt Gastrointestinal Pathology Society
At the 1976 annual meeting of the organization then called the International Academy of Pathology (IAP), now the United States and Canadian Academy of Pathology (USCAP), the long course was devoted to gastrointestinal pathology. Due to its success, the first evening subspecialty conference devoted to gastrointestinal pathology was presented the following year at the IAP annual meeting in March 1977. That first evening session was organized by Jack Yardley from Johns Hopkins UniversityJohns Hopkins University
The Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...
, and included Henry Appelman (University of Michigan
University of Michigan
The University of Michigan is a public research university located in Ann Arbor, Michigan in the United States. It is the state's oldest university and the flagship campus of the University of Michigan...
), Harvey Goldman (Beth Israel Hospital
Beth Israel Hospital
Beth Israel Hospital may refer to:*Beth Israel Deaconess Medical Center in Boston*Beth Israel Medical Center in Manhattan*Beth Israel Medical Center in Newark...
and Harvard Medical School
Harvard Medical School
Harvard Medical School is the graduate medical school of Harvard University. It is located in the Longwood Medical Area of the Mission Hill neighborhood of Boston, Massachusetts....
), Bill Hawk (The Cleveland Clinic
Cleveland Clinic
The Cleveland Clinic is a multispecialty academic medical center located in Cleveland, Ohio, United States. The Cleveland Clinic is currently regarded as one of the top 4 hospitals in the United States as rated by U.S. News & World Report...
), Tom Kent (University of Iowa
University of Iowa
The University of Iowa is a public state-supported research university located in Iowa City, Iowa, United States. It is the oldest public university in the state. The university is organized into eleven colleges granting undergraduate, graduate, and professional degrees...
), Si-Chun Ming (Temple University
Temple University
Temple University is a comprehensive public research university in Philadelphia, Pennsylvania, United States. Originally founded in 1884 by Dr. Russell Conwell, Temple University is among the nation's largest providers of professional education and prepares the largest body of professional...
), Tom Norris (University of Washington
University of Washington
University of Washington is a public research university, founded in 1861 in Seattle, Washington, United States. The UW is the largest university in the Northwest and the oldest public university on the West Coast. The university has three campuses, with its largest campus in the University...
), and Robert Riddell (University of Chicago
University of Chicago
The University of Chicago is a private research university in Chicago, Illinois, USA. It was founded by the American Baptist Education Society with a donation from oil magnate and philanthropist John D. Rockefeller and incorporated in 1890...
). This group, headed by Henry Appelman, organized a group for gastrointestinal pathologists.
Every gastrointestinal pathologist in the United States and Canada received an invitation to attend the first organizational meeting, held during the 1979 IAP meeting. At that meeting, the establishment of a society was approved, and four subcommittees were formed to deal with membership, finances, bylaws, and educational activities. During the next year, all organizational functions were completed, and at the 1980 IAP meeting, the organization was officially established, by-laws were approved, the first officers elected, the first dues collected, and the first educational program was offered.
The original name for the organization was the Gastrointestinal Pathology Club. Only later did it achieve "Society" status. In 2001, after the tragic and untimely death of Dr. Rodger Haggitt, the name of the society was officially changed to Rodger C. Haggitt Gastrointestinal Pathology Society.
The organization was developed as a mechanism:
- for propagating interest in gastrointestinal pathology
- for emphasizing the importance of gastrointestinal pathology as a sophisticated and complex area of pathology
- for sharing information among members
- for developing joint investigative efforts among members
- for establishing referral centers or referral mechanisms for specific types of case problems
- for devising a registry for unusual cases.
The first three of these initial goals were accomplished early on. The Club was recognized as a companion society of the IAP and its first scientific session was presented about a year later. The fourth goal took longer, but it, too, has been fulfilled as exemplified by a published study on adenoma
Adenoma
An adenoma is a benign tumor of glandular origin. Adenomas can grow from many organs including the colon, adrenal glands, pituitary gland, thyroid, prostate, etc. Although these growths are benign, over time they may progress to become malignant, at which point they are called adenocarcinomas...
s with invasive carcinoma
Carcinoma
Carcinoma is the medical term for the most common type of cancer occurring in humans. Put simply, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that generally arises from cells originating in the endodermal or ectodermal germ layer during...
that was shepherded by Harry Cooper. It took e-mail technology to really allow the fifth goal, the referral network, to operate. The development of an e-mail group from the Society, which became an opportunity for members to consult a wide group of GI colleagues regarding problem cases, has been functional sine 1995. The sixth goal, the registry issue, has yet to get off the ground. Currently, the Society awards prizes for resident presentations at the USCAP annual meeting and organizes educational symposia
Symposium
In ancient Greece, the symposium was a drinking party. Literary works that describe or take place at a symposium include two Socratic dialogues, Plato's Symposium and Xenophon's Symposium, as well as a number of Greek poems such as the elegies of Theognis of Megara...
at national meetings, including the IAP, the American Society of Clinical Pathologists, Digestive Disease Week and the international congresses of the International Academy of Pathology
International Academy of Pathology
The International Academy of Pathology was founded in the early 20th century, with the first documented meeting in 1907. Dr. William Osler, a scientist, played a key role in establishing the International Association of Medical Museums ....
.
Current Impact of Gastrointestinal Pathology as a Sub-Specialty
Digestive diseases affect 1 in 5 Americans annually – at least 60 million people in the United States each year. Digestive diseases account for approximately 50 million physician visits, nearly 25 million endoscopic diagnostic procedures and over 20 million gastrointestinal specimens directed to pathologists – representing $87 billion in direct medical costs attributable to gastrointestinal disease. The demand for gastroenterology care and diagnostic procedures continue to increase, driven by an increasing incidence of gastrointestinal disease and the need for colorectal cancerColorectal cancer
Colorectal cancer, commonly known as bowel cancer, is a cancer caused by uncontrolled cell growth , in the colon, rectum, or vermiform appendix. Colorectal cancer is clinically distinct from anal cancer, which affects the anus....
screening in the aging U.S. population. By 2010, gastroenterologists will perform at least 40 million endoscopic procedures annually, translating into $40 billion endoscopy and $12 billion related gastrointestinal pathology expenses annually in the U.S.
With less than 400 fellowship-trained gastrointestinal pathologists in practice in the United States, approximately 8% of the 20+ million gastrointestinal biopsies currently performed each year are reviewed by pathologists with fellowship training in digestive health and disease. The remaining 90 to 92% of biopsies are reviewed by highly skilled general surgical pathologists including some who have special interest in gastrointestinal pathology.
General surgical pathologists who practice with a focus in gastrointestinal pathology may attend continuing medical education courses offered by fellowship-trained academic and private practice gastrointestinal pathologists, may attend intensive "mini-fellowships" that are offered by select institutions (i.e. AFIP) to further hone their diagnostic skills and develop close working relationships with gastroenterologists to ensure a broad knowledge base with regards to clinical correlation of the findings under the microscope
Microscope
A microscope is an instrument used to see objects that are too small for the naked eye. The science of investigating small objects using such an instrument is called microscopy...
.
Whether a fellowship trained gastrointestinal pathologist, a general surgical pathologist with subspecialty interest in GI or an adept general surgical pathologist is reviewing a particular biopsy or surgical specimen, it is important to keep in mind that the training for the specialty of surgical pathology is rigorous. Following completion of both college and medical school, the surgical pathologist must have also completed an accredited residency in pathology and is board certified in Anatomic Pathology by the American Board of Pathology. Residency in pathology is one of the longest postgraduate training programs, encompassing 4–5 years. (In comparison, internal medicine
Internal medicine
Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. They are especially skilled in the management of patients who have undifferentiated or multi-system disease processes...
and pediatrics
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
are only 3 years.)
In most instances, gastrointestinal biopsies and surgical specimens represent common diseases that display common histomorphologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
patterns, and are accurately evaluated and classified by adept general pathologists. Similar to many aspects of medicine, not all gastrointestinal tissue specimens require sub-specialist review for the accurate diagnosis to be rendered. Internal medicine physicians treat many gastrointestinal conditions without referral to a gastroenterologist specialist. Similarly, many gastrointestinal tissue biopsies and surgical specimens are accurately diagnosed without referral to a gastrointestinal pathologist. Certain diseases are histologically subtle or the differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
is complicated or complex. In such cases a close working relationship between the pathologist and gastroenterologist with correlation of clinical, endoscopic, and biopsy findings may be of great benefit to the submitting physician and to the patient.
Appropriate biopsy classification of GI biopsies is critical. Current literature and other non-published reviews estimate that at least 10% of the diagnoses of Barrett’s esophagus, a precancerous condition, are rendered in error. At least 15 – 20% of stomach biopsies have misclassified disease characteristics, 15% of colon
Colon (anatomy)
The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a...
polyp
Polyp
A polyp in zoology is one of two forms found in the phylum Cnidaria, the other being the medusa. Polyps are approximately cylindrical in shape and elongated at the axis of the body...
s are misdiagnosed, and up to 50% of all cases of chronic inflammatory bowel disease
Inflammatory bowel disease
In medicine, inflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn's disease and ulcerative colitis.-Classification:...
are misdiagnosed or misclassified.
Though pathology diagnosis is a critical determinant of future cancer risk and screening interval, many of these diagnoses do not result in significant morbidity or mortality for patients; thus, errors may be "masked" by the limited effect to the patient in the present context.
The economic cost of inaccurate pathology diagnoses can be measured from the perspective of the healthcare system, the gastroenterologist practice and the patient. Within the healthcare system, gastroenterology pathology diagnostic inaccuracy of 10% is equivalent to 2 million misdiagnoses each year. The vast majority of these patients will incur additional medical expenses from repeat clinician office visits; repeat diagnostic procedures, unnecessary enrollment in surveillance programs, and treatment with incorrect or completely unnecessary medications. The cost savings of the correct gastrointestinal pathology diagnosis being rendered at first opportunity by expert board certified surgical pathologists is conservatively estimated within the range of $200M – $1B.
Born out of increasing awareness of subspecialty gastrointestinal pathology services, increased marketing efforts by gastrointestinal pathology companies and increased patient awareness of laboratory errors, there is an increasing trend toward referral of tissue specimens to surgical pathologists with special interest in gastrointestinal pathology.
Subspecialty gastrointestinal pathology and financial relationships
Over the last decade, physician reimbursements have been declining steadily, both for clinical physicians (i.e. gastroenterologists) and for pathologists. To replace revenue lost from declining reimbursements, many physicians replace revenue by providing more services (seeing more patients) or explore capturing revenue from additional services (contract research or "ancillary services").To ensure that physician's referral for additional services are motivated solely by the best interest of the patient, Federal Law
Federal law
Federal law is the body of law created by the federal government of a country. A federal government is formed when a group of political units, such as states or provinces join together in a federation, surrendering their individual sovereignty and many powers to the central government while...
(Stark
Stark Law
Stark law, actually three separate provisions, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.- Physician self-referral :...
) and many State laws prohibit physicians from referring patients to organizations or facilities in which they hold a financial interest and therefore would profit from the referral.
Several pathology companies that offer "subspecialty" pathology services also offer to clinical physicians mechanisms by which the referral of their patient's tissue biopsies to a specific laboratory may result in additional revenue for the physician's practice. These mechanisms are generally designed to be practiced within the boundaries of certain loopholes in Stark laws and state regulations.
These financial relationships include:
- Discounted client billing.
Client billing refers to a purchased services agreement between the physician caring for the patient and taking the biopsy and the pathology laboratory preparing the histologic slides and reviewing the biopsy material. The clinician and pathology company enter into a contract in which the clinician group buys pathology services from the pathologist at a rate substantially less than what the pathologist would be paid by insurance companiesInsuranceIn law and economics, insurance is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for payment. An insurer is a company selling the...
for the same service. The pathologist accepts payment from the clinician for the services as full compensation for pathology services. The clinician then bills and collection from the patient's insurance company for the full amount of the pathology service. In most instances, the clinician realizes a profit ($10 – 100) for each biopsy referred to the laboratory. - Condominium (pod) laboratories.
- Technical component/professional component splitting.
- Clinician owned histology laboratories.
- Reverse TC/PC splitting.