[Histonet] Patient slide send-out

Julia Dahl jdmd77 <@t> hotmail.com
Wed Aug 23 08:01:36 CDT 2006

Again, to be transparent with my biases - I am a subspeciality pathologist, 
with a large proportion of my case volume in consultations and I am actively 
involved in the ABQAURP (a quality assurance organization) and QA 
initiatives in pathology.

Recently within the lay media, there has been a significant influx of 
articles that "report" on rates of laboratory error.  Last January, Katie 
Couric hosted a guest that spoke for 12 minutes about the use of second 
opinions in Medicine to support her (the guest's) book sales for a book on 
this topic.  During the 12 minutes, she spent 6 seconds on the topic of 
pathology consultations.

The LA Times recently published a scathing article about anatomic pathology 
quality assurance, the Wall Street Journal, another article about 
misdiagnoses and quality issues in pathology AND the GAO released a report 
that there needs to be more laboratory oversight, as quality is basically 

There are pay for performance initiatives that will also drive MORE 
consults, not fewer, consults.

QA initiatives in pathology strongly recommend that 1 - 2% of all cases be 
referred to subspecialty pathologists for consultation UNLESS the home 
institution department has representation in each of the subspecialties 
(i.e. GYN, dermatopathology, placenta, neuropathology, GI/Liver, endocrine, 
cytopath, hemepath, etc.).  If your institution has a volume of 15,000 
cases/year - this translates to 150 - 300 send outs a year or 1 - 2 each 
DAY.  The same QA literature notes that only 30% of instititions actually 
meet this QA benchmark.

With this in mind - planning for the volume being sent out is imperative - 
to ensure the highest quality of care for each patient and to ensure the 
financial feasibility within the department.

Pathologists, histologists, hospital QA committees and others also  MUST 
take a more active role in defending the "billability" of consultations to 
insurance companies.

Did the media ever tell the patients what the second opinion would cost?  
No.  They reported that second opinions in pathology are necessary.... and 
patients ASSUME that their insurance will pay for it.

Well, two of the major insurance conglomerates that represent millions of 
patient's lives don't pay for consultations in pathology.  These 
conglomerates also select the laboratory for the patient and the clinicians 
with their exclusive laboratory agreements in which (unless performed in a 
hospital) the patient's biopsy material MUST be referred to their 
"preferred" laboratory.  Interesting.

I believe that the push for more send-outs - and this is just an 
observation, not supported by research - that more clinicians are becoming 
aware of subspecialty pathologists.  There are large conglomerate 
laboratories and other laboratories that are aggressively marketing 
subspecialty pathology services within a general pathology environment - or 
dedicated solely to ONE subspecialty to clinicians.  Clinicians will then 
pass along this marketing to their patient to advance their own quality in 
the patient's eyes --- "The biopsy is going to be sent to a lab that 
specializes in this type of disease and only looks at 'x' cases."  For many 
of these organizations - much, much more money within the laboratory is 
spent on marketing and management than on paying pathologists and techs.    
And this trend will continue, too.

There are a lot of published articles about why 2nd opinion in pathology is 
a very, very good thing. Rates of error when subspecialty pathologists 
re-review general pathologist's work can be fairly significant - in GI/Liver 
7.8% of all cases contain a medically significant error; 12.5% of Barrett's 
cases, 45-54% of IBD and up to 62% of medical diseases of the liver.  Does 
that translate to general pathologists being "bad" at GI?  Absolutely not.  
General pathologists must be facile in ALL of the organ systems, while 
subspecialists can focus on the nuances of just ONE.

So much for sending a brief overview.... but I hope this gives some insight,

Julia Dahl, M.D.
Mosaic Gastrointestinal Research Consortium
jdahlmd <@t> mosaicgi.com

>Just curious..why this increase in patients asking for a second opinion?
>Betsy Molinari HT (ASCP)
>Texas Heart Institute
>Cardiovascular Pathology
>6770 Bertner Ave.
>Houston,TX 77030
>832-355-6812 (fax)
>-----Original Message-----
>From: histonet-bounces <@t> lists.utsouthwestern.edu
>[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Zajic
>Sent: Tuesday, August 22, 2006 2:05 PM
>To: Richard Cartun; histonet <@t> lists.utsouthwestern.edu
>Subject: RE: [Histonet] Patient slide send-out
>Richard, you are not alone! We have also seen an increase in patient and
>physician requests for "send-outs". I am not sure of charging, but I
>have made a "send-out" policy for our department that all requests be
>put in writing (scripts for physicians)and faxed,inform the
>patient/office that it will at least be 48 hours before it can be sent
>out, they must provide a shipping service account (FEDEX, UPS) or
>physically pick up the slides. We have also been being charged for these
>consults by the other facility so we also inform them that if the
>insurance cannot be charged, they are responsible for the bill. It seems
>to work but we do run into some problems now and again. If they cannot
>provide an overnight shipping service, we will USPS mail them certified
>but that seems to take too long for their liking (here it's around a
>Not having enough staff to handle the sendouts is always a problem,
>hence the 48 hours..helps slightly.
>Kari :)
>Kari Marie Zajic HTL,MLT
>Histology Supervisor
>Palms West Hospital
>Pathology Department
>13001 State Road Eighty
>Loxahatchee, Florida 33470
>phone:      (561)798-6036
>telefax:     (561)753-4298
>voicemail: (561)753-4299
>pager:       (561)610-4949
>email: Kari.Zajic <@t> HCAHealthcare.com
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>-----Original Message-----
>From: histonet-bounces <@t> lists.utsouthwestern.edu
>[mailto:histonet-bounces <@t> lists.utsouthwestern.edu]On Behalf Of Richard
>Sent: Tuesday, August 22, 2006 2:49 PM
>To: histonet <@t> lists.utsouthwestern.edu
>Subject: [Histonet] Patient slide send-out
>Our Anatomic Pathology Office is overwhelmed with requests from patients
>asking for their pathology slides to be sent to another medical
>institution (for second opinion, additional surgery or therapy, etc.).
>Is it legal to charge patients for this service?  We don't have the
>personnel to handle these requests in a timely fashion and we can no
>longer afford to "eat" the shipping costs.  Thank you.
>Richard W. Cartun, Ph.D.
>Director, Immunopathology & Histology
>Assistant Director, Anatomic Pathology
>Hartford Hospital
>80 Seymour Street
>Hartford, CT  06102
>(860) 545-1596
>(860) 545-0174 Fax
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