Current Procedural Terminology Coding in an Academic Breast Pathology Service.

Abstract

To the Editor: We read with interest the article by Johnson et al1 positing that breast pathologists reviewed more slides than other subspecialty services and that therefore the valuation for breast pathology services needs to be increased. Although there is a sound basis for increasing the valuation of work on the breast service, and in pathology as a whole, the discussion the authors present is incomplete as it does not acknowledge the primary premise for subspecialization. The benefit of subspecialization is based on the concept of “gains in trade.” When 2 individuals perform different work, the greatest total work output is achieved by dividing work based on expertise. Using the equity of work as the primary principle for dividing work in large departments with subspecialty competencies imposes extremely high opportunity costs on both individuals and reduces the total productivity of the group. As an example (Table 1), assume that a breast pathologist can sign out 6 breast (B) cases in a day, but only 4 gastrointestinal (GI) cases; whereas the GI pathologist can sign out 10 GI cases in a day, but only 2 B cases. As Table 1 shows, dividing work based on subspecialty results in total productivity of 6 B+10 GI cases per day, while the equitable distribution of work results in a productivity of 4 B and 7 GI for the BGI group. This model, however, requires that each unit recognize the advantage to the whole and “share” in a mutually beneficial manner in the profits of this trade. This model provides no benefits in a system where each can do both jobs equally well. Equity in work is the better model in that circumstance (hence, the favored model for smaller, community practice setups). There are other downsides to the generalist model that are not pertinent to this discussion and are not presented here. Therefore, a primary characteristic of the subspecialization model is “different strokes for different folks.” Irrespective of the system of valuation of work, work will not divide equitably in this model. The only impact will be who is advantaged over the other. Therefore, a system that applies valuation based on a RVU model will favor the case-heavy specialties; while applying SVU (slide valuation unit) models will favor slideheavy specialties. Applying a valuation at an individual level to “equity” in work in a subspecialty-based model will simply result in one of the subspecialties feeling undervalued. Those disadvantaged by the SVU system, such as GI, may well argue that processing breast cases require more resources, that the higher valuation for hormone receptor studies relative to other immunohistochemical stains is unfair, and that high complexity GI frozen sections have workflow interruption costs that the SVU models do not consider. The most unsettling response could be from the Centers for Medicare and Medicaid Services (CMS), which has the herculean task of distributing finite dollars in a stressed health care environment. The result may be a reduced valuation of biopsies rather than an increase in the valuation of breast cases, leading to a total loss for the department. The bottom line is that the valuation of work in a subspecialty model cannot occur between specialties. Although plausibly it could be compared across institutions, one would have to ensure that institutional resources and supports are matched for a comparison to be valid. The point of our raising these issues is not to undercut the primary argument that the authors are making. We fully agree with our colleagues, that workloads for pathologists have become unbearable, so much so that we now stand on the verge of infighting. We also wish to focus attention on the social costs that are often considered secondary to transactional and economic costs of administrative decisions. The division into subspecialties brings with it a division of the departmental “social group” into subspecialty-based social groups, with attendant loss of cohesion at the departmental level. This cost is wholly borne at a departmental level and therefore rarely considered by institutional leaders or policymakers. Therefore, even as department leaders move to subspecialization for overall economic benefit, they need to be extremely cautious about valuing individual contributions on an equity model. These are not applicable to subspecialty systems and are sure recipes for loss of collegiality, burnout, loss of meaning in work and eventually loss of quality and safety for patients.