How Do We Prove Our Worth?

Pathologists stand at the intersection of every medical specialty and, as such, are the perfect ambassadors for the implementation of change. According to Michael Porter (Bishop William Lawrence University Professor at Harvard Business School’s Institute for Strategy and Competitiveness), the core purpose of healthcare is value for patients. The value formula is based on the health outcomes that matter to patients and the costs of delivering those outcomes. If we are to adhere to this formula, healthcare delivery must shift from volume to value.

Quality also features in the value formula; in the lab, value is represented by a cumulative sum of accuracy, precision and timeliness of result. Opportunities abound in the clinical laboratory to substantially reduce costs and to improve outcomes – and ultimately increase value for patients. It’s important to recognize that we pathologists must contribute to value-based healthcare to prove our worth in the healthcare team.

Here, I offer nine areas where we can boost our value.

1. Reduce process variation. By implementing Lean and Six Sigma principles (1), every pathologist should make sure their lab has an effective quality management program.
2. Eliminate low value services.Identify tests of low value, those that may be harmful or costly and do not provide higher quality of care. Several examples are available from the Choosing Wisely Initiative of the American Board of Internal Medicine. In my own lab, a process was implemented to review all test orders that previously were sent to a reference lab, regardless of expense. This involves a pathologist researching the test, identifying potential alternatives, review of the medical record and/or discussion with the ordering provider, and setting up the test when approved. This has saved tens of thousands of dollars.
3. Minimize the use of skilled staff for less skilled activities. An excellent example here is the use of automation for a previously manual lab test, such as chemistry testing in the core lab or slide staining in histology. Human error is minimized, accuracy and precision is improved – and all at a lower cost.
4. Move routine services out. An example of special relevance for pathology is the use of centralized labs or the consolidation of reference labs. Services don’t always have to be outsourced, but rather redistributed. Pathologist specialization can be used to improve quality and value by directing cases to the best-trained people (2). Alternative practice models can be particularly effective in offering high-value care (3).
5. Improve utilization. Value can be delivered through test utilization initiatives (4) and lab formularies (5). Pathology is positioned at the intersection of all medical specialties, with the lab generating massive amounts of data. As a consequence, pathologists have the unique opportunity to leverage a hospital’s IT system to deliver value and measure results. Indeed, cloud-based computing has been demonstrated to improve utilization and outcomes (6). The clinical laboratory, instead of serving as an ancillary service, then becomes a partner in the healthcare team, contributing to the delivery of high value for patients.
6. Rationalize redundant administrative units. Pathologists should create process maps throughout the lab. Through an understanding of the entire care cycle of a patient, test ordering can be made more efficient. One can identify “invisible cost centers” associated with defects in a value stream, meaning that waste can be eliminated. Doing so will often involve units outside of one’s department; for example, our lab streamlined a complex preauthorization process for costly genetic testing by working with the lab, oncology, neurology, gastroenterology and a genetic counselor. Working with other labs and payers may sometimes be necessary.
7. Reduce cycle times. Something simple for pathologists to consider is the discontinuation of routine repeat testing of critical values (7). Valuable time can be saved, which eliminates any delay in reporting critical values to clinicians. 
8. Add services that lower total cost. Here, one must be able to measure actual costs of patient care. Consider bringing in-house tests that were previously sent out to a reference lab; for example, vitamin D, celiac, tick panels. Recently, our histology department implemented testing for HER2 in breast cancer cases, and it will reduce the need for reference lab testing by 60 percent.
9. Increase cost awareness. Pathologists can play an important role in clinician education on test costs (8) – an area where there is a clear need for improvement. One of the mistakes of healthcare today is that it is too broad in focus. Instead, focus should be on the individual provider. Pathologists can help by monitoring utilization rates among clinicians and providing a “report card” on patterns. Porter states that many cost reduction opportunities will actually improve outcomes.

In many cases, it’s clear that pathologists must partner with clinical colleagues to measure outcomes that matter for patients. Of course, I do acknowledge that change can be difficult. One example is the new HPV and Pap smear guidelines; despite recommendations on utilization and positive data on outcomes, many practitioners have been slow to implement change (9). Nevertheless, pathologists can and must facilitate change and help educate our clinical colleagues.

As the transition from volume to value continues, pathologists need to be proactive and effective team members; it will be crucial to the success of new care models (for example, Accountable Care Organizations, Patient Centered Medical Homes). We pathologists must recognize our value, and our clinical colleagues must also become more aware of the high value of having pathologists as a part of the care team. But it’s our responsibility to make it happen.