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Inside the Lab Laboratory management, Clinical care, Profession, Regulation and standards

Rethinking the Value Construct in Pathology

“A cynic is a man who knows the price of everything, and the value of nothing.”

― Oscar Wilde

I’ve learned a lot about value-based healthcare over the years – but not always in ways I expected. The term value is thrown around a lot, but what does it really mean? Value is defined as a cognitive construct, distinctive to an individual or group, with assigned importance (1). Views on value have changed throughout the years. Today, I think we may not fully understand what value truly encompasses inside the laboratory – and we perhaps have an outdated perception of the value pathologists provide in modern and ever-evolving healthcare ecosystems.

It is important to note that the lab has significant financial value; alongside surgical/outpatient services and imaging, the lab represents one of three major “revenue centers” for many health systems. The term “value” in the lab is often synonymous with costs, associated reimbursement, and, ultimately, revenues. In the current value construct, lower costs, less financial compensation for laboratory professionals, and higher overall reimbursement are often equated with more value. This could help explain why we have become the “invisible doctors.” Patients cannot always understand or appreciate the value pathologists provide to them, possibly because value is too strongly associated with cost and potential savings.

Recently, hospital-based clinical labs in the United States and worldwide have begun to adopt more methods of commercialization and other enterprise activities. Meanwhile, outsourcing of hospital-based clinical laboratory services is increasing (2). It is unknown how this will affect pathologists and laboratory services in general. Pathologists in certain geographic areas, along with those in academic settings, are consistently underpaid relative to their peers, suggesting that this may be a zero-sum game for some (3). 

In a recent paper regarding an academic department – “10-Year Outcomes After Deciding to Keep the Lab” – the authors discuss the benefits to patients and the financial performance of the parent health system. They show growing laboratory volumes and revenues, with annualized rates of 4.5 and 16 percent, respectively (4). However, comments were raised regarding whether patients were able to recognize the value provided by their lab.

In an editorial response, one commenter mentioned that “pathologists’ greatest threat today is our inability to clearly explain the value equation, to administrators, payors, legislators, and patients and their families” (5), further describing pathology as a “black box” in which we cannot articulate the quality care we provide to patients. Decisions and benefits regarding pathologists and laboratories often trickle down from the heights of corporate offices – but do the people in those offices truly understand and value our role? Or is too much emphasis given to cost, revenue, and reimbursement – with the quality of laboratory diagnostics seen as essentially the same thing?

My question to the readers is: how could we better define the value construct in pathology and laboratory medicine? And, even more fundamentally, what should we value? I am not sure that true value in pathology can be derived from costs, relative value units, revenue, or further commercialization or outsourcing of academic pathology laboratories and services. Perhaps it is time for a new formula?

We as pathologists could refocus the value equation on delivering excellence in patient care, empowering other laboratory professionals, creating an inspiring, incipient vision of the future, and better communicating the importance and findings of our work. Leadership that fully prioritizes and represents the needs and goals of our practitioners and our profession could also be part of a new equation. This will be critical in fostering our medical specialty and driving real value gains in precision medicine.

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  1. MJ Rohan, “A rose by any name? The values construct,” Pers Soc Psychol Rev, 4, 255 (2000).
  2. RE Mrak et al., “Outsourcing of academic clinical laboratories: experiences and lessons from the Association of Pathology Chairs laboratory outsourcing survey,” Acad Pathol, 2, 2374289518765435 (2018). PMID: 29637086.
  3. VP Crawford, “Learning the optimal strategy in a zero-sum game,” Econometrica, 42, 885 (1974).
  4. KJ Jensen et al., “Northwell Health Laboratories: the 10-year outcomes after deciding to keep the lab,” Arch Pathol Lab Med, 12, 1517 (2019). PMID: 31100013.
  5. TC Allen, “Threats remain,” Arch Pathol Lab Med, 12, 1440 (2019). PMID: 31765249.
About the Author
Sean M. Hacking

Pathologist at Toronto General Hospital in Toronto, Ontario, Canada

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