© Springer International Publishing Switzerland 2016Lewis A. Hassell, Michael L. Talbert and Jane Pine Wood (eds.)Pathology Practice Management10.1007/978-3-319-22954-6_23
23. The High-Performing Practice into the Future
Department of Pathology, University of Oklahoma Health Sciences Center, 940 Stanton L. Young Blvd., BMSB 451, 73104 Oklahoma City, OK, USA
KeywordsPathology practiceFutureTechnologyProcess improvementLeadershipInnovationValuePractice structureRevenueManagementInformaticsDigitizationPractice of the futurePathologist of the futureArtificial intelligence
We recognize that the topics and case studies up to this point have been largely based on past experience, which in some settings might not be predictive of future success given the pace of changes happening in medicine today. However, we do believe that it is not just one principle that will define a practice as successful and that regardless of the changes in the global environment of medical practice and health-care delivery, the principle of being able to effect a synergy of the various aspects covered in previous chapters will be essential to both effective health care and rewarding work as a practitioner of pathology. That said, we recognize that it can be difficult to see how these pieces come together into a cohesive solution for all the various iterations of medical practice that do or will exist. With that in mind, we have asked a number of individuals from a wide variety of backgrounds and practice settings to give us their take on what the high-performing pathology practice will look like in the future. Herewith are some of their responses.
For years, the practice of pathology has enjoyed the enviable status of “well-kept secret” in medicine: Excellent case mix, superb lifestyle, and above average (to spectacular) income levels. However, with increased competition for health-care dollars, keeping what we do and how we do it secret from other colleagues and the public at large is not going to play to our advantage anymore, not that we had anything to hide in the first place: Our expert contribution to direct patients care accounts for 70 % of all subsequent medical decisions; this secret most definitely needs to get out!
To do so, a series of structural and organizational changes need to happen in order to (re)position pathology in the sweet spot of medical practice:
Integrate pathology into the broader and more visible world of diagnostic medicine:
(Re)design internal floor plans and workflows, within hospital institutions and outpatient settings, to provide patients with a one-stop shop for all diagnostic services, including radiology and pathology.
Urgently transition pathology diagnostic practice to the digital platform.
Smoothly integrate pathology, radiology, and endoscopy digital portals.
Build user-friendly bidirectional reporting and test ordering platforms for clinicians and their patients.
Associate all diagnoses to social media and web pages linked to relevant critical sites.
Bring pathologists to the forefront of direct communication with patients:
Make it known that we welcome direct communication with patients.
Assign pathology resources for extemporaneous and/or live (in person and electronic) communication with patients and other stakeholders in their care.
Coordinate with clinicians and create pathways that include pathologists in the communication of critical results to the patient.
Broaden the pathology department membership tent:
In tertiary-care facilities and other complex settings, we will need the expertise of “nontraditional professionals” in order to get invited to the table of accountable care organizations (ACOs) and other new health-care delivery models. Pathology departments and businesses will need to demonstrate added value (and subtracted waste) at all levels of the diagnostics value chain. Experts who understand population health analysis, and know how to tease relevant statistics from big data, will need to be included in our departments’ rosters, irrespective of their clinical or professional affiliation.
Become the standard bearer of enhanced connectivity at all levels of health-care delivery:
Lobby hard to have state and federal laws and regulations eliminate IT firewalls between institutions and mandate smooth interface between the various pathology, radiology, and electronic medical record (EMR) digital standards. We generate the information that leads to 70 % of subsequent care in medicine, and yet, we accept the fact that most of this information is “boxed” within the narrow confines of a single institutional IT system.
In the absence of such regulations, find ways to provide patients with a complete electronic record of their diagnostic tests (including digital images).
Although I am a strong proponent of merging the business interests of related diagnostic specialties (radiology and pathology, in particular), I also realize that such business and organizational merging will not always be possible. However, bringing these specialties and services together from a logistical and workflow point of view is feasible and should be the minimum goal desired. Radiology and pathology benefit more than any other specialty from fast-developing progress in technology, including the explosive field of molecular and personalized medicine. A walk through a modern laboratory and radiology department is akin to a walk into the future of medical science. I am confident that bringing these two giants together will exponentially enhance their individual visibility in the eyes of the patients and unequivocally assert their central relevance in the mind of all critical health-care stakeholders.
Karim E. Sirgi, MD
CEO, LambdaX3 International
One must make certain assumptions when attempting to predict the future. Plus, one should not attempt to predict too far in the future, because with each passing year, the predictive accuracy steadily diminishes. Or, as Winston Churchill put it: “I always avoid prophesying beforehand, because it is a much better policy to prophesy after the event has already taken place.” With those caveats in mind, I provide one possible picture of pathology practice through the rest of this decade (through 2020) and, in particular, the nature of the successful “Pathologist of the Future” (POTF) . It is predicated on the following assumptions: (1) there will be a steady decline in fee-for-service compensation arrangements, with increased payment bundling and risk/reward sharing, (2) hospital and physician group consolidations, including hospital ownership of physician practices, will increase, (3) technology, particularly in the “-omics” domain, will continue to develop and its clinical utility will expand, and (4) the number of practicing pathologists will grow at a rate that lags the increasing demand for pathology services, resulting in a net deficit in pathologist supply.
The POTF in a high-performing practice will avoid marginalization from clinical health care by being fully engaged with clinician colleagues and their patients. The goal of that engagement is high-valued (high quality, lower cost) patient outcomes. The POTF will be a master diagnostician and clinical knowledge-generating consultant, driving diagnostic accuracy in anatomic and clinical pathology services. He/she will develop, validate, and provide access to appropriate new technology for optimal patient care. The POTF will be a steward of patient data sets that drive patient outcomes management, quality of care improvement, and population health management through early predisposition prediction and disease prevention or mitigation interventions. He/she will be an effective and appropriate steward of limited health-care resources, serving as a critical source of appropriate utilization management information for clinicians and patients. This includes improving test selection, improving test accuracy, improving the knowledge derived from these tests, improving the timely and informative communication of results, and improving the follow-up and management of clinical information. This means becoming integral and indispensable members of patient-care coordination teams in the evolving new delivery systems. He/she will cultivate effective interpersonal communication skills and be “good citizens” of their health-care institutions. The POTF will understand their environment—particularly the culture of the clinical care settings—in their health-care institution, their community, and the greater health-care delivery systems at large.
This future “sweet spot” has a number of implications. Organizationally, pathology practices/departments will demand effective leadership , including a meaningful place at the institutional leadership table/organizational chart (e.g., C-suite, medical board/staff leadership). Pathologists must be willing to participate in key institutional committees, including as chairs. They must be effective at interpersonal communication and team play. The financial infrastructure of the practice must understand risk/reward-sharing arrangements, and must have a voice in payer contract negotiations and billing systems. New group members should be recruited from forward-thinking residency training programs that engage trainees in the competencies necessary for success in the future. Recruiting for attitude and effective behavior is as important as recruiting based upon academic achievement. This will be particularly important, because these future high-value practice settings will be collegial and collaborative, with high performance, high expectation and accountability, and open and transparent working environments. The values’ threshold will be set high, and incentives will be aligned accordingly. Recalling Winston Churchill, remember that “A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty.”
Ronald Weiss, MD, MBA
Department of Pathology, University of Utah,
Salt Lake City, UT
Wayne Gretzky said that to be successful in hockey you have to “skate to where the puck is going to be, not where it has been.” It is tempting to try and lay out a vision of where pathology is “going to be” in a few years and offer that as the secret to the “high-performing” practice. But Gretzky’s success was determined in large part by “playing by the rules” in a context in which the rules were relatively static, as determined by the National Hockey League (NHL) and physics (of puck and player speed and trajectory, that is, rules governing gravity, friction, and conservation of energy). Pathologists (and all physicians as well as other stakeholders in health care) are now playing in an arena in which the rules are changing and to a large degree being rewritten as we go along.
One cannot even say that rational “market forces” can be relied upon, as we are now engaged in a grand experiment to replace one set of nonmarket-driven incentives, with another that (as was the first set) is deemed by some authorities as more likely to produce optimal health for individuals and society. A high-performing pathology practice in the past might rationally have built its success upon a strategy of highly efficient, quality production based upon the reimbursement of an 88305, coupled with the ability to market to physician clients who had the independence to choose a pathology lab based on quality and service. Of course, there were other forces acting too, such as local politics and referral patterns , and even (let it be said) legal and nonlegal kickbacks and inducements. But all of this, for better or worse, made up a more predictable context in which decisions could be made about how to organize one’s practice of pathology. At some point (likely only in the distant future), there will perhaps be another relatively stable and predictable context that determines the rules of play within which a pathology practice could rationally lay out such criteria and strategies for success. However, for the foreseeable future, pathologists will be in an environment of high unpredictability that makes the approaches of the past (which were successful for many pathologists) hard to replicate.
So I will take a different track and answer the question not of what the “high-performing” pathology practice will look like, but instead: What are the characteristics of the “high-performing” pathologist likely to be? That is in essence answering the question: What are the personal qualities or guiding principles that can help an individual pathologist thrive in a time of great uncertainty and unpredictable and often negative change for our profession and society?
Be adaptable—Darwin demonstrated not survival of the fittest but of the most adaptable. Our morphology skills, most valued in the past, may become commoditized, and the skills that might be most valuable in the future, such as leadership , knowledge of informatics , health-care economics, molecular medicine, or direct engagement with patients (!), may not be the ones we learned in school or residency.
Focus on quality and integrity in your work—These make life worthwhile, which is the gift given to all who do meaningful work—by doing it better, we can also do more good.
Be “patient centered”—This is the cliché du jour in health care, but there is a useful application for pathologists: Make sure (as much as possible within the context of what you are required to do) that what you do actually matters to the patient that it adds value and passes the “common sense” test—that it is not done mindlessly in the false pursuit of “quality” or “value.” We can all fall victim to this. For example, while templates, synoptics, and checklists are useful tools to assure better care, they can be overused in a slavish fashion and result in nothing more than a longer, less efficiently produced pathology report that contains meaningless information and pseudo-quantitative measurements of characteristics beyond the mathematical significance of the measurement itself or any enduring usefulness to the patient. It is easy to create complexity where simplicity will do.
Follow the money—Not in the crass sense of self-interest but with the enlightened realization of two facts: (1) As a society, we can no longer afford the health care we buy (or more properly borrow from our children’s future), (2) No pathology practice can survive standing alone or as part of a business entity that spends more than it makes.
Be willing to innovate and try something new—When the outside world is changing, defending the status quo (the principle activity of most medical professional organizations) may not be the best strategy: Wayne Gretzky also said, “You miss 100 % of the shots you don’t take.”
Luke Perkocha, MD, MBA
San Francisco, CA
I looked around my office for my trusty crystal ball, but could not find it. Either it was stolen, confiscated as a hazardous material, or considered outdated along with my adding machine. Without that assistance, I will try to summarize my thoughts, while remembering that health care as an industry continues to be driven by providers at the local and regional setting. There is much discussion about the impact of the Affordable Care Act on the execution of health care as though standardization at the national level is inevitable and just around the corner. In my experience, ACO models, hospital systems, physician practices, and managed care contracting remain local. Even large multistate organizations are forced to adapt to the local level in order to provide care in that setting.
We find ourselves in a challenging and ever-changing environment. Health care has always been the realm of change. However, it is the rate of change that causes concern for so many. There are a few common threads that tomorrow’s pathology group will embrace as essential for success
Only large groups will survive. According to the College of American Pathologists (CAP), it has long been held that the average pathology group size was 5–7 members. Technology and economics will change this long-held statistic. I predict that metropolitan areas will probably be served by a single pathology partnership that might encompass 70–80 pathologists under a single tax identification number (TIN). There will be a greater need for fellowship-trained or organ-specific experienced pathologists in community settings where there is (currently) insufficient volume to support such talent in a small group. This diagnostic need will bring pathology groups together in the interest of mutual survival. Technology will improve to the point that digital pathology will become a reality, allowing cases to be matched with those most capable of rendering diagnoses, while allowing pathologists to reside miles apart from one another. Some might speculate that such technology will cause pathology to be outsourced overseas. I do not believe this will be the case as medicine will still require communication between pathologists and specialists in order to maximize diagnostic accuracy and efficient health care. Medical staffs will never accept the loss of pathology relationships from their health-care teams.