Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        About Pathology - Hospital Based Practice

LCHSD (Lexington County Health Services District) does business as Lexington Medical Center (LMC) as a special charitable services political district in South Carolina. Pathology Associates of Lexington, P. A.'s (PAL) pathologist efforts in behalf of the LCHSD, its organized medical staff, and patients in general comes under the heading of "Part A" (as to Medicare, Medicaid, and TriCare) or professional component of pathology & laboratory services..."professional component services". Such services are far more than just "administrative services", although they impact administrative things & must be administered. As members of the LCHSD/LMC organized medical staff, our professional providers are under an active system of peer review which is part of the over-all sytem of review such that we are officially under continuous review by, and accountable to, our patient community by way of this system. It is a performance improvment (PI) system which has the broad elements of accountability known as focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE).

One of our earlier documents relative to the commitment to effect quality & appropriateness of Department of Pathology and Laboratory Medicine services was published 20 January 1988. The service area is central S. C., primarily west of the Broad & Congaree Rivers & to borders of Orangeburg, Aiken, Edgefield, and Newberry counties. Our group serves by exclusive contract between PAL & LCHSD for provision of medical direction and diagnostic pathology services, hospital contractural services for part A paid to PAL by the hospital. The LMC main-hospital laboratory has quadrupled it’s test volume from 712 tests per day in FY ’85 to 2700 tests per day in FY ’03…while keeping total dept. costs/billable test trend line "flat" since FY ’84 (even unadjusted for inflation). This clinical lab testing is firstly focused in behalf of South Carolina’s 2nd busiest ER and a broad medical and surgical acute-care spectrum of diagnosis and treatment. The exclusive commitment of our group to LMC since 1971 has been predicated on the knowledge that "morphologic" testing and medical direction are the primary domain of the pathology group, and the technicalities of clinical laboratory testing are the primary domain of LMC. Additionally, we have gone from responsibilities for only the main hospital lab to a large spread of responsibilities having to do (from time to time) with all of the components of the Lexington County Health Services District (LCHSD)…CMC labs, MSO labs, Occupational Health Lab, physician office labs, and hospital Blood Gas lab.

Since LMC opened in late 1971, the same pathology group has provided Pathology & Laboratory Medicine Services at LMC. Deriving from Dr. Calvert's 10 years as a family practitioner, Dr. Shaw's experience of having been raised with a mother as an expert nurse, and Dr. Carter's direct-patient-care experiences with numerous incredibly outstanding mentors in the U. of Minn. residency program and his transfusion experiences while in Chicago, this is a group focused on the philosophy of point of service pathology: the view that patients are best served primarily by or through physicians in their own communities. This view also truly recognizes the value of experts and expert local & distant referrals & consultations but is well aware that even experts can't agree correctly (expert discordance and see Pathology Programs )!

In the 1980s, LMC avoided a merger with the 2 large downtown Columbia hospitals largely through an 11th hour meeting of key medical staff & many county council members. Dr, John Carter had been much distressed that this merger seemed imminent, a bad move which he'd personally witnessed in his decade of practice in Chicago as Northwestern U. gobbled up small hospitals. Lab employee, Deanna Rowland came by one day late in the process, "Dr. Carter, what do you think of this merger? If you are so against it, why don't you stop it? Did you know that my uncle is Bruce Rucker, county council chairman?" In short order, that meeting happened in the Granby room. A surgeon from downtown, Dr. Bill Moore, was at the meeting and mounted a most persuasive arguement against the merger as did most of the doctors present (which included Drs Shaw & Carter). Council members there were stunned that these professionals were so opposed and were so sure of a bright future without a merger. A few days later at the Grove Park Inn in Asheville, a vote carried to NOT merge.

Since the hospital opened in very late 1971, we have been an acute-care,  hospital-based pathology practice. Each doctor is licensed by the state of S. C. to practice medicine. Each pathologist is certified by the American Board of Pathology, and each pathologist and group-employed P. A. has undergone intense evaluation and the granting of organized Medical Staff (repetitive peer scrutiny) membership by the Board of Directors (influential appointed members from our community) & granted privileges for the practice of pathology within the LCHSD. The granted privileges are enumerated in a departmental "delineation of privileges" statement. And the medical staff department members operate according to defined rules and regulations (R & R) of the organized medical staff  ([a] original 15 Dec. 1976 version; [b] 1978 version; [c] 2005 version); [d] 2011 version. Such privileges to practice must be renewed every two years & include QA reviews, etc., and pathologist and non-pathologist peer reviews. Our lab has also been continually accredited by the College of American Pathologists (since 1978-2006) & then COLA since, a status implying intense "outsider" pathologist-peer review.  Pathologists working outside of hospitals (especially in commercial lab enterprises) are not subject to such constant peer & multidisciplinary review & accountability!

Since about 1985 (and definitely since 1988), we pathologists have been fully contractually responsible for every aspect of the Lexington Medical Center Laboratory, a multi-million dollar medical endeavor (a 9-digit figure of annual charge volume and about 120 FTE employees in 2003). We have 24/7/365 responsibility for general and specific details of every aspect of the operation, day-to-day and top-to-bottom. We do this in the context of overall institutional bylaws, medical staff bylaws, and administrative and medical staff rules & regulations and guidelines of the Lexington Medical Center. As Laboratory Directors, we determine who will or will not perform in the department (hiring and firing; appropriate caliber of personnel for each position; depth and breadth of staffing within each segment of 24/7/365); what will or will not be done in the department (scope and depth of services); when any of the vast number of activities will or will not be done (what tests are STAT, all shifts, daily, weekly, or reference-lab send-outs); where any of these numerous around-the-clock activities will or will not be done (geographic location of testing...bedside or lab, doctor’s office or main lab, within which department of the main lab, LML vs. distant reference labs); and how (what test method and by what instrument or kit vendor) each test is done. And it is up to us, as directors & designees, to always be able to defend the "why". How we medically direct the laboratory effort

In addition to an already-above-community-standard Part A-type PAL effort, our 7 pathologists (and 2 PAs and one AA) input a huge amount of effort in behalf of LMC patients in general. Each of the lab sections is directed by one of our pathologists, who is available 24/7 for minute-to-minute input. The intensity of commitment, service, and effort is maximal (all pathologists "on alert" and available by phone/beeper 24/7/365 & one always officially "on call"). Only a small amount, the daily work-load, is conceived and incubated and launched just during official, on-site hours. Dr. Carter is intensely involved, nearly full time, in directing the clinical laboratory. The other 6 doctors are much involved in section planning and direction, QA/QC, and medical staff efforts. 

Our group employs three non-physicians: Ted Mitchell, Pathologists Assistant, about 50% directly involved in LMC interests, Jennifer Klapper, Pathologist Assistant, and Susie Greenthaler, Administrative Assistant, about 80% involved in LMC interests (nearly all of their LMC-type efforts being in support of the pathologists efforts toward "Part A"). The pathology group is importantly (not trivially) involved in medical staff activities and in input into other areas of the greater LMC interests (e.g., Credentials Committee chair for over 30 years; IRB Committee chair for 15 years; and Infection Control Committee chair for 20 years). And, our group is devoted entirely to interests of the greater LMC (the LCHSD). 

There is definite value to LMC in our devotion to keep all pathologists on site, in the hospital (and not in outside facilities). As one of us has proposed: "the most important bidirectional interface is between me and you!" "On-site" equates to "early warning" & "full court press" as to departmental direction and management and "high intensity input". In recognition of this, the hospital provides office space & other valuable support.

The "reach" of Lexington Medical Center indicates to us medical directors how to make decisions in deploying our hospital's lab capabilities. Beginning in 1971, LMC was the first hospital in South Carolina to have its own full-time staff of ER doctors 24/7/365; and this allowed us to develop the lab as we have. Now, having the 1st, 2nd, or 3rd busiest ER in South Carolina, our lab continues to emphasize rapid, accurate, 24 hour per day centralized lab support for our ER, Operating Rooms, and Intensive Care Unit. Yet, we have, for example, partially decentralized & placed much glucose testing at the bedside and, in 2010, a "pocket lab" in the ER.

The initial pathologist contract with the then "Lexington County Hospital" was from 1971-1981...then declared void about August 1981. In years prior to 1980, pathologists in the USA tended to either be paid salaries by hospitals or contracted for services to the hospital by way of "percentage contracts"...payments of a percentage of the lab's gross or net billings or income. The outline below speaks to the PAL group whose next contract was signed in 1983 for 3 pathologists…the third (Dr. Carter) coming on board in latter half of 1984. PAL now has 10 employees (7 pathologists, 2 physician’s assistants, and 1 administrative assistant). The present 10 employees are all heavily involved in LMC interests, all 10 being paid for by PAL at the same contractual monetary support from LMC that commenced1983. And, the LMC Lab fiscal performance has been consistently, commendably, remarkably, and uniquely positive since 1987. Inflation has risen at least 60% since 1983, cutting the value of our unchanged Part A payment from LMC almost in half (as to purchasing power of 1983 dollars)!! With our desire for stability with a long-term contract, we must anticipate no less than 25% inflation between 2003 and 2013. We have maintained premier accreditation through the College of American Pathologists commission on inspection and accreditation from 1978-2006. We are now accredited by COLA. Our contract was voided in March 2002 and has not culminated in a new contract (as of 1 September 2010).

Now, what are the legalities behind the obligations for payment of pathologists for these general services? As to Medicare, the original verbiage leading up to the law in 1965 noted such payments as Part C payments...language that was deleted for the final 1965 law (at that time, the oldest members of our group were finishing college). Metropolitan centers in the northeast salaried most of their pathologists and started the habit of being reimbursed for same by Medicare under part A. In other areas of the USA, pathologists billed patients for such under Part B. In 1980, Medicare sought uniformity; and HCFA (now CMS) required that pathologist payments be through hospitals. Congress legislated such in TEFRA in 1982. In 1983, HCFA issued implementation rules. HCFA came up with time-related cost amounts and an RCE ("reasonable compensation equivalent"...the amount a pathologist's time was worth in a full time equivalent year doing only Part A). Time counted; talent, degree of involvement, and intensity of effort were not noted. Upon Medicare switching to DRGs (diagnosis related groups) for 1984, that new prospective payment system law did not address Part A payments to pathologists. Hospital attorneys tended to advise hospitals that the absence of the language meant that no payments were required. But anti-kickback laws have  noted such value of  pathologists' efforts and pressured hospitals toward being "fair". This position was endorsed by the federal OIG (Office of the Inspector General) in 1991 and strongly re-affirmed in a 27 January 2005 Supplemental Compliance Program Guidance for Hospitals in which "fair market value" of services is discussed.

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 (posted 22 December 2004; latest addition 19 October 2011)
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