Lucrative biopsies spur spur fight by pathologists
|By Jim Doyle [email protected] 314-340-8372 Jim Doyle, St. Louis Post-Dispatch|
|McClatchy-Tribune Information Services|
It's also potentially lifesaving. Biopsies such as Pap smears and the analysis of polyps, tumors and skin anomalies are crucial in detecting certain cancers.
But how much a biopsy costs and who pays for it can be complex.
For example, a skin biopsy may cost
These biopsy markups are a hidden profit center in the health care industry, especially in states such as
Unknown to most consumers, there's a running feud over who controls the billing for biopsies -- one stretching back for several years and involving a tug-of-war between physicians, hospitals and laboratories. As consumers pay an increasing share of their medical costs, markups are drawing new attention.
On one side: the
In opposition are referring physicians -- independent clinicians such as dermatologists, gynecologists, gastroenterologists and family medicine practitioners who obtain biopsies from patients and send specimens to outside labs.
At stake is a piece of an extremely lucrative and growing business, one that's helped fuel the growth of nationwide laboratory chains while also providing new profit opportunities for physicians.
"I think both sides really see this as a black-and-white issue, but those in the middle see infinite shades of gray," Holloway said. "In the halls of the Capitol, it's doesn't seem to have enough heft to warrant a lot of attention. It's white-hot to the people involved in it, but it's not sexy enough for everyone else."</p>
Long ago, independent physicians would examine a tissue sample through a microscope to explore signs of disease. With specialization, sophisticated technical analyses and the growth of independent labs, pathologists emerged as expert interpreters of biopsies.
But today, pathology services are often controlled by a referring physician who orders the biopsy, ships a specimen to an external lab, marks up the lab costs, and sends a final bill to the consumer and/or insurer for both the doctor's visit and lab services.
Two national companies --
In the last decade, Quest and
But the two lab companies also have been sued repeatedly by competitors and whistleblowers. Critics, who tout regional labs' high quality and customer service, have chalked up the emergence of Quest and
"The big reference labs have been siphoning off the business by saying to doctors, 'Send it all to us, We'll save you overhead, time and money,'" said
But, he added, it's misleading to generalize about the quality of national versus regional labs.
"It's like any other service industry. Some do a good job, some do a crappy job," he said.
Referring physicians, who have absorbed cuts in reimbursements from
Doctors justify such markups, he said, by citing the time they expend to process a biopsy: sample it, box it, store it, send it, receive it, bill for it.
Many doctors' offices do not disclose to patients that a biopsy has been sent to an outside lab, let alone the dollar amount paid to a lab, industry experts say.
Because insurance carriers often pick up the tab for doctors' bills, many patients never question their lab costs -- unless a patient takes issue with an invoice sent directly by a lab. So it is difficult to quantify the economic impact on patients.
"Patients should recognize that biopsies performed on them will be submitted to marked up charges and in our opinion these are exploitative charges," said Dr.
Referring physicians -- particularly in specialties such as dermatology, obstetrics and gynecology, gastroenterology, urology and family practice -- have grown used to profiting from the work of discount labs.
These doctors, who claim to win savings for consumers, say their markups are fair, given the time and expense of handling specimens and negotiating with outside labs.
"More legislative and regulatory oversight is needed on these price issues, because we can't do that as consumers," Caplan said. "We are living in a world where we're told this is how much it costs. That's not a good system. It's not a free market. ... There's too much dependency on the (health) provider to generate demand and say what it costs.
"I would like to see at the state level more transparency and more requests to justify how prices are set," he said. "We don't have any idea where these prices come from. You should know what you're paying for."
Lombardo described marked up charges for lab services as "surreptitious fees that are being charged to patients and their payers." He said the markups, which he characterized as pervasive, "exploit
"These bills can be marked up as much as 150 percent, 200 percent, 300 percent," he said. "We don't think it's fair that a patient awaiting a cancer diagnosis is exploited by these practices."
"I know exactly what it's going to cost the patient," Puckett said. "And we're able to take care of a lot of people who don't have any insurance at all, offering those patients a discount on lab services they wouldn't get otherwise. It helps increase access to care for those who are uninsured or have a high deductible."
He attributed direct-billing legislation -- which requires the lab or provider of pathology services to bill the patient without an intermediary -- to pathologists who "want to be the only ones who can bill the insurer direct. ... They're trying to legislate removal of the competition, removing us as the middleman who's cutting into their profits."
Puckett said pathologists tell horror stories of grossly marked-up prices but offer little if any proof. "We mark up our lab fees just the same way we mark up our radiology. The cost is reasonable."
For years, health insurers tolerated markups for lab services by paying these patient bills and passing along the higher costs to consumers in the form of higher deductibles, co-pays and premiums. But some insurers such as
Since 1984, the federal
In 2001, the
Pathologists have sought unsuccessfully in recent years to push legislation through the
Nineteen states including
"Marking up a fee is not appropriate, but it's not illegal (in
Opponents of direct billing, he said, have "sought to confuse the issue and characterize this as differences of opinion among specialties. Our position is that the health care industry and patients will benefit from direct billing."
Last year, the
The proposed rule was opposed by the
"This is clearly not an ethical issue," Dr.
Current billing practices for lab services, they wrote, "greatly benefit our patients."
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