WHITE PAPER
Contributions of Pathologists in Accountable
Care Organizations: A Case Study May 2012
David J. Gross, PhD
Director, Policy Roundtable, College of American Pathologists
College of American Pathologists
325 Waukegan Rd.
Northfield, IL 60093
Tel: 800-323-4040
cap.org
© 2012 College of American Pathologists. All rights reserved.
TABLE OF CONTENTS
Introduction ............................................................................................................................................................... 3
Background .............................................................................................................................................................. 4
Case Study: Specific Ways That Pathologists Are Adding Value in Three ACOs .............................................. 6
Findings—Common Threads ................................................................................................................................... 8
Challenges .............................................................................................................................................................. 13
Conclusions and Policy Implications ................................................................................................................... 15
References .............................................................................................................................................................. 20
Appendix A: Interview Participants ...................................................................................................................... 22
Appendix B: Discussion Guide For Semistructured Interviews .......................................................................... 24
Contributions of Pathologists in ACOs | CAP Page 3
INTRODUCTION
Accountable Care Organizations (ACOs) represent the most recent trend in trying to restrain the growth
in US health care spending. With an explicit goal of improving quality of care and health care
outcomes, as well as restraining spending, ACOs are coordinated care systems in which providers are
incentivized on the basis of outcomes rather than the number of services. The Affordable Care Act
allowed for the establishment of ACOs within Medicare, and ACOs (and other coordinated care
delivery systems) exist—and are expected to proliferate—in the private sector as well. The model
represents an attempt to address the problems of a fragmented, largely fee-for-service-based medical
care system that rewards provision of services rather than achievement of outcomes, contributing to
rapid growth in health care spending (now over 17% of GDP) and a system in which as much as 30% of
costs are generated because of overuse, underuse, and misuse of health care services.1
ACOs offer both challenges and opportunities for pathologists. The challenges accrue from substantial
changes that are associated with practicing in an ACO, in particular a movement away from
traditional fee-for-service payment and from an individual approach of practicing toward being part of
a care team. However, with their emphasis on health care quality and population health supported by
electronic connectivity, the ACO model also offers opportunities for pathologists to apply their skills to
help ACOs achieve their goals while finding new ways to show value in an environment where
reimbursement rates are expected to continue their downward trend.
Given these concerns and challenges, the College of American Pathologists (CAP) sought to gain an
understanding of how some pathology practices have been able to take leading roles in ACOs. To
accomplish this, CAP staff visited with pathologists, administrators, and other physicians at three such
health care organizations. These organizations represent diverse models of health care delivery. One,
Geisinger Health Systems, located in Danville, Pennsylvania, is an organization that has long been a
leading integrated delivery system. A second ACO, the Accountable Care Alliance in Omaha,
Nebraska, is a unique collaboration between a community health system (Methodist Health System)
and a university hospital (The Nebraska Medical Center) that has been operating as an accountable
care organization for about two years. The third, Catholic Medical Partners (CMP) in Buffalo, New York,
emerged from a partnership between four community Catholic Health of Western New York hospitals
and a network of associated physicians, CIPA Western New York IPA, Inc.
In this paper, we identify actions and approaches taken by pathology to help the ACO achieve its
goals of improving health care while reducing health care costs by offering more efficient, better
integrated, and more quality-driven health care delivery. Our research identifies ways in which
Contributions of Pathologists in ACOs | CAP Page 4
pathologists used their unique skill set to provide greater rationality to laboratory medicine in a way that
helps clinicians offer better patient care and helps the system to reduce costs. We also identify barriers
that these organizations have identified. Finally, we present a set of potential policy issues that can
enhance the ability of pathologists to achieve the goals of the ACO and of the overall health care
system.
BACKGROUND
What is an ACO? A simple definition of an ACO is that it is a network of health care providers that is held
accountable for the costs and quality of health care services that are provided to a defined group of
patients. While ACOs exist in different forms, the general framework is that it is an organization, physical
or virtual, that takes on the responsibility of reducing health care costs for this population while also
meeting predetermined quality standards for its patient population.2
Collaborative care models, such as ACOs, have emerged in the private sector in recent years, but
much recent attention has been focused on the development of Medicare ACOs. Beginning April 2012,
Medicare contracts with ACOs began operation under the auspices of Medicare’s Shared Savings
Program. This program follows Medicare’s Physician Group Practice Demonstration, the precursor to its
current ACO efforts, which involved 10 health care organizations that were eligible to share in cost
savings they could achieve and would receive bonuses based on their performance along 32 quality of
care measures. In addition, 32 health care organizations with a proven track record in an ACO-type of
model are part of a demonstration project called the Pioneer ACO model. In both of these structures,
the ACOs are eligible to share in savings for reducing costs and meeting quality standards, but in the
Pioneer program they have the opportunity for greater savings but also face financial risk if their costs
are not well managed.2
Key issues around ACO development. A key element to a successful ACO model, at least in theory, is
that health care providers become part of a team. The team—primary care physicians, hospitals,
specialists, and other providers—are jointly responsible for achieving efficiencies and seeking high
quality care for the patient.3 Nace and Gartland identify three interdependent aspects that are
necessary for an ACO: (1) care delivery reform, ie, replacing the current fragmented system of
providing care with a system which features clinical integration and coordination of care; (2) payment
system reform that rewards achievement of a set of quality standards and reductions in cost, rather
than one that rewards provision of services only; and (3) a health information technology system that
allows providers to access information about the patient across different care settings and allows for
implementation of the payment and care delivery reforms.1
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While appealing in theory, the practice of operating an ACO is quite complicated. Existing health
information systems often don’t communicate well between providers and practice settings; many
providers are only at the beginning of establishing electronic health records (EHRs) for patients; and
even within a single setting (eg, a hospital) different aspects of health technology may not be
interoperable. Setting up systems of coordinated care requires establishments of health networks and
changes in how providers work together. And, importantly, basing provider payment on savings and
measures of health outcomes and quality standards is challenging, particularly when it comes to
developing measures to reward providers such as pathologists, who provide a large amount of
cognitive and diagnostic services that aren’t easily measured by health outcomes. For example, in a
recent New England Journal of Medicine article, Bruce Landon notes that many of the measures
currently being considered for rewards in ACOs relate to primary care but that incentivization of other
specialties, particularly those that provide cognitive services, has not yet been adequately addressed.4
Potential pathologist roles in improving clinical outcomes. There is some literature from pathologists
regarding how laboratory medicine can contribute to efforts to improve clinical outcomes and increase
efficiency in the delivery of health care. Schuerch, et al, of Geisinger Health Systems, summarize the role
of the pathologist in improving ―laboratory clinical effectiveness‖ as:
• Sharing accountability for patient outcomes and performance of the health care system
• Providing reliable laboratory measures
• Establishing and using a standardized laboratory database for outcomes research and
health care improvement
• Participating in design of standardized practice algorithms for things such as laboratory test
ordering, test interpretation, and therapeutic recommendations
• Developing patient health information tools that are designed to improve patient care
• Extending laboratory reporting to include improvements in how the data are presented to
clinicians as well as clinical recommendations
• Using information system tools to improve reliability of quality of care in all health care
settings, including the hospital, the clinical, long-term care facilities, and the home
• Providing clinical consultations when appropriate.5
Sussman and Prystowsky, pathologists at the Montefiore Medical Center, recently reported on their
experiences in creating value in a risk-based environment. Their model of how pathologists add value in
such a system has five elements:
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• Working with clinical colleagues to optimize testing protocols
• Reducing unnecessary testing in both clinical and anatomic pathology
• Applying personalized therapy to help guide treatment
• Designing laboratory systems to allow quick data mining by pathologists and clinicians
• Administering cost-effective laboratories.
In the future, they say, success will hinge on ability to collaborate with clinicians, and provide education
to those clinicians, in order to manage the appropriate use of high-cost tests while also reducing the
unnecessary use of more common tests.6
Among the many concerns is how pathologists will get paid for these value-added services. Many
pathologists are used to getting paid under a fee-for-service model for outpatient services and under a
contract with hospitals for inpatient/Part A inpatient services, but the services that pathologists would
offer do not easily accrue under such a model. At Geisinger and Montefiore, pathologists are salaried
employees of the institutions, and incentives such as gain sharing and rewards for innovation are easier
to apply. As Sussman and Prystowsky note, however, this is not the same for all institutions.6
Such concerns are not isolated to pathologists. For example, the American College of Radiology (ACR)
recently published the recommendations of a work group it formed with the express purpose of
identifying ways that radiologists can successfully contribute in ACOs. Like pathologists, radiologists are
diagnosticians who apply their expertise to the diagnosis and management of a wide variety of
medical conditions. While not necessarily endorsing the evolution of ACOs, ACR’s recommendations
offer a framework for how radiologists can contribute within that environment as well as strategies for
being financially recognized for their contributions.7
CASE STUDY: SPECIFIC WAYS THAT PATHOLOGISTS ARE ADDING VALUE IN THREE ACOS
In order to get a sense of how some pathology practices are functioning in and dealing with the
challenges and opportunities associated with ACOs, we conducted site visits of three different health
care organizations in which pathologists have successfully integrated into ACO leadership positions.
These organizations, while not necessarily representative of all ACOs in which pathologists have been
active, represent three distinct organizational models as well as distinct histories in the development of
their structure. We conducted our interviews between February 15 and February 27, 2012.
The first ACO we visited, the Accountable Care Alliance in Omaha, Nebraska, is a unique collaboration
between a community health system (Methodist Health Systems) and a university medical center (The
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Nebraska Medical Center) that has been operating as an accountable care organization for about two
years. Methodist Health Systems (Methodist), founded in 1982, is a network of hospitals, clinics, and a
nursing and allied health college. It includes Methodist Hospital, a 440-bed facility in Omaha. The
Nebraska Medical Center, which was formed in 1997, is Nebraska’s largest health care facility. With
more than 1,000 physicians, it is the teaching hospital for the University of Nebraska Medical Center.
With facilities statewide, it includes a 624-bed acute care hospital in Omaha.8,9,10
Our second visit was to Geisinger Health Systems, headquartered in Danville, Pennsylvania. Founded in
1915, Geisinger is a physician-run, -integrated, and -coordinated health system that serves more than
2.6 million residents throughout 44 counties in central and northeastern Pennsylvania. Geisinger is an
―integrated delivery system‖ that has a long history of coordinating the delivery of health care across
the continuum of care, ie, preventive, primary, acute, and inpatient care.11,12
The third visit was to Catholic Medical Partners-IPA in Buffalo, New York. CMP emerged from four
Physician Hospital Organizations (PHOs) that were incorporated in the mid-1990s with the Catholic
Health System of Western New York hospitals and a network of associated physicians. CMP has long
held agreements with commercial health plans that hold it at financial risk. With over 900 members in its
network, CMP adopted a ―clinical integration‖ model around 2006 and places a focus on improving
clinical performance, being accountable for patient satisfaction, implementing new health care
information technology, and improving the quality of health care.13
For each of these organizations, the evolution to a coordinated care delivery model was more a
function of natural outgrowth of an existing business model than a reaction to health care reform or the
Medicare Shared Savings Program in particular. That is, they saw the model—whether it was called ACO
or began with another name—as a necessary way to rationalize health care costs while providing
enhanced value for payers and, importantly, for patients. Geisinger Health Systems offers the longest
experience of the three institutions in operating as a coordinated care system. While its original focus
was on primary care, for at least the last two decades it has focused on developing new, cost-effective,
and patient-centered approaches for treating chronic illness. Indeed, Geisinger can be considered one
of the models for ACOs, and it was one of the original 10 CMS Medicare Physician Group Practice sites.
CIPA Western New York IPA, Inc., the predecessor to Catholic Medical Partners (CMP) began in 1996 as
an Independent physician association (IPA) that jointly negotiated agreements with the health plan,
assuming financial risk and accelerating clinical integration. Over time, its leaders anticipated that
traditional fee-for-service reimbursement would eventually be replaced with something that looked
more like a bundled payment system that would be based on cost savings and provision of high-quality
care. As a result, over the last decade the organization has been evolving into a more coordinated
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care model. The TNMC/Methodist collaboration began in 2008 as a joint purchasing pool seeking to
gain leverage with their suppliers in order to get lower costs for both institutions. After successful
negotiations to save money on the purchase of blood products and apheresis services, both
organizations decided they could effectively work together and began to develop other ways of both
saving money and developing methods for improving patient care.
In our interviews, we met with various officials from each institution (listed in Appendix A). We asked
questions about areas such as how the structure of the ACO, how pathologists are able to have an
impact in the organizations, evidence of impacts, and barriers to their successful involvement. These
questions were developed by staff at the College of American Pathologists and were reviewed by CAP
members who are members of the both the ACO network and steering group, some of whom provided
substantive suggestions that led to alterations in the survey instrument(shown in Appendix B).
FINDINGS—COMMON THREADS
Pathologists in these three institutions share a common perspective of the role of pathology in clinical
care. This perspective might be best expressed by Schuerch, et al’s assertion that:
―Pathologists must share accountability for the larger process, extend themselves outside their
traditional boundaries, and engage in activities that improve clinical outcomes. Pathologists
often have special knowledge to contribute in designing clinical pathways, and they have
informatics and communication tools at their disposal that may be used to improve clinical
performance.‖5
Not only have these pathologists adopted this broader perspective about their potential contributions,
but also they have successfully incorporated themselves into ACO leadership and demonstrated the
value that they could bring to the organization. Leaders in the ACOs we visited, such as ACO executive
directors, chief medical officers, and medical directors, asserted that pathology and laboratory
medicine play an integral role in successfully achieving the ACO goals of reducing costs and improving
quality and safety. They recognize the extensive influence of laboratory testing on clinical decision
making and the unique role that pathologists can play in assisting them to meet their objectives—
particularly in the application of evidence-based approaches to eliminate waste and inefficiencies in
laboratory medicine. The importance of pathologists comes in their ability, unique among medical
specialties, to collect and analyze data related to patient testing and diagnosis.
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We identified four examples of how pathologists and laboratory medicine have added value in their
institutions:
1. Development of protocols for laboratory ordering
One important way that pathologists in these institutions contribute to ACO goals is by setting up
test ordering protocols for high-cost or high-volume tests. Officials and pathologists at the
institutions we visited told us that clinicians don’t always know or understand which tests are
appropriate for different conditions. There is evidence that, in settings in which care is not
coordinated, ordering protocols for the same condition are not always standardized—protocols
can vary between sites or between physicians at the same site, and that the continuum of
evidence behind those protocols can vary from being well investigated to being developed on
an ad hoc basis.14 Other studies point to the substantial effort needed to ensure that protocols
are consistently updated to reflect medical advances and new information on clinical
effectiveness.15
While pathologist contributions to the development and maintenance of order sets are not
unique to an ACO environment, ACOs are unique in that (1) there is the opportunity to apply
similar standards across a wide range of health care settings, and (2) financial incentives can be
put in place to reward pathologists for this and other contributions to promoting efficiency and
effectiveness in clinical care delivery. As a vice president at Methodist Health System observed,
pathologists are ―uniquely situated‖ to lead the development and maintenance of
standardized, evidence-based order sets in ACOs. Such standards on test ordering can save
money by reducing unnecessary tests and can also improve patient treatment because the
patient is more likely to get the kind of tests that can most efficiently identify (or rule out) a
particular medical condition. This role is expected to be of greater importance with the
expected growth in high-cost genomic tests.
In the institutions we visited, pathologists develop standardized testing protocols in consultation
with other clinicians. In some cases, this consultation is done informally, while in others it is
conducted through more formal mechanisms, such as membership on a laboratory service
advisory committee, and/or other similar activities. Furthermore, the standards may be based on
clinical consensus or may be developed on the basis of evidence-based research.
There are several ways that standardized testing protocols have been implemented in the ACOs
we visited:
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Pathologists at TNMC/Methodist and at CMP have developed standards to reduce the use
of tests that are ordered too frequently or high costs tests that are rarely needed. When they
identify such tests, they contact the clinician to determine whether the test is necessary (as
compared to something that might be ―interesting‖ but not clinically necessary). At
TNMC/Methodist, such efforts have resulted in a reduction of proliferating or costly tests
(specific data on cost savings were not available), and efforts are ongoing to develop a
broader ―formulary‖ that would identify appropriate tests for different medical questions. At
CIPA, standards developed by pathologists are designed to provide a more rapid and more
accurate diagnosis for C. difficile colitis—a digestive condition that can have severe impacts
on patients and high costs of care—and to more appropriately test patients who are
suspected of having a thrombosis.
Another TNMC/Methodist effort led by pathologists is to reduce the use of red blood cells
and platelets for patients undergoing orthopedic and other surgery. Based on standards
established in the medical literature, adoption and enforcement of these standards at
Methodist Health System have contributed to roughly a 50% reduction in the cumulative
costs of blood supply over the last few years. It also has reduced adverse reactions to blood
transfusion and results in a reduced length of stay.
A pathologist chairs a multidiscilplinary laboratory utilization committee at Geisinger. Through
the Transfusion Committee, the laboratory has led the development of standard criteria for
transfusions and monitors the utilization of blood products against these criteria. The
laboratory has also provided leadership for a clinical blood conservation program.
Laboratory professionals vetted the standardized order sets of various specialties as they
were built into the EHR.
2. Population health management
Our interviews also identified ways that pathologists have applied their expertise to help ACOs
develop standards for identifying and managing chronic illness among the population enrolled
in the system.
Geisinger Health System’s experiences offer several examples of how population based analysis
can be applied. Geisinger has implemented standards under its ProvenCare programs, which
establish clinical guidelines and offer guarantees to patients and third-party payers that they
would not have to pay for readmissions due to care that should not have been needed. The
laboratory standards for this program are based on applying clinical data trends that identify
the most effective treatment, and that use the EHR to notify physicians (and patients) of when
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certain treatments are required. Among the results of Geisinger’s application of this approach
are:
Reducing the median days it takes for renal patients on EPO to reach a target hemoglobin
level, from 62.5 days to 35 days, and saving about $2,200 per patient per year.
Effectively following standardized guidelines for treatment of diabetic patients, resulting in a
one-third increase in the percentage of these patients who received flu vaccines, a 40%
increase in pneumococcal vaccination, a 50% increase in patients who met goal measures
of HgbA1c levels, and a 46% increase in meeting goals for blood pressure.
3. Improving physician access to actionable data from the laboratory
As noted earlier, access to electronic patient data is a foundation of an ACO’s ability to
effectively coordinate care. As EHRs and HIEs become more common, a key role for
pathologists is to design the format for lab results in the EHR and HIE, making the format as
―actionable‖ as possible. As ―owners‖ of the laboratory data, pathologists in these organizations
either have taken, or are looking to take on, a leadership role in making data more accessible
and more actionable by physicians. Pathologists at CMP are working on how they can use data
to improve care management. For example, they are looking at how to use the EHR to identify
diabetic patients who had not been getting the HgA1cb tests that are needed to determine
whether their disease is under control. The medical director of Univera Health Plan, a health plan
that covers many of the ACO members with which CMP has a contract, has been favorably
disposed toward such efforts, and it expressed a desire for pathologists and the laboratory
community to give extra help to primary care physicians and other ordering physicians on when
follow-ups are needed (eg, following diabetics who aren’t getting their tests).
Pathologists at Geisinger Health Plan stated that the report to the treating physician is the most
important product that a pathologist can produce. Indeed, pathologists at Geisinger explicitly
stated the view that their job does not end when the data is provided to the clinician; rather,
they see all aspects of lab enterprise analytics as their responsibility, including how the data are
used and how they are communicated to the patient. In an environment where the LIS and the
EHR are well-integrated, as at Geisinger, laboratory staff are working toward a goal of designing
laboratory reports that makes it easier for the clinician to act faster and more efficiently: more
clearly communicating test results, providing simpler test interpretation in order to reduce the
burden on the clinician, increasing the probability of the information getting to the patient, and
clearly identifying actionable contents of the report. This type of activity is welcomed by other
providers in the organization, some of whom expressed a desire to have improvements such as
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electronic prompts to the physician identifying when patients need particular tests or when they
need particular follow-up.
4. Greater collaboration with other clinicians
Both pathologists and nonpathologists agreed that pathologist leadership and collaboration
with other physicians and with ACO leaders are major contributors to their success. As they
note, many clinicians do not understand the analytic role that pathologist play or the expertise
of pathologists in understanding the most effective applications of laboratory medicine. As a
result, it is easy for pathologists and for laboratory medicine to be overlooked during the
development of ACOs.
The opportunities for pathologists to collaborate are varied. Already mentioned is their role in
establishing guidelines for laboratory medicine and for improving treatment of chronic disease.
Pathologists can provide post-test consultation for complex tests such as
coagulation/hemostasis work-ups; cancer diagnosis with ancillary genomic/proteomic results;
pharmacogenomic testing; and follow-up disease-risk genomic testing.
Pathologists in the three institutions we visited achieved their leadership roles by proactively
asserting their ability to help the ACO meet its goals. In each organization, there is an
established culture of pathologists working in a coordinated and integrated manner with other
clinicians. For example, the pathology department at Methodist Health System had nearly one-
half century of leadership by pathology department chairs that focused on applying data and
evidence toward medical practice throughout the hospital. Geisinger’s pathology leadership
for the last two decades has been at the forefront of coordinated care, and has been in an
institution where coordination is part of the culture. At Geisinger, the lab has an integrated
presence in every owned clinic site, providing phlebotomy, performing on-site testing, and
ensuring seamless services and information flow into the EHR. A close partnership with
pharmacy is the foundation of a system of coagulation clinics serving about 16,000 patient
encounters per month. The lead pathologist at CMP has also been a leader for over a decade
in pushing his institution to incorporate clinical effectiveness guidelines from pathology and
laboratory medicine into efforts to improve outcomes and reduce costs.
Interviewees also noted that pathologists would have a much harder time implementing
recommendations without strong support from ACO leadership. Lacking such support, it would
be difficult both to get resources for pathology to develop guidelines, but more importantly
there may be reduced incentives for other clinicians to follow pathologist advice.
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CHALLENGES
Despite their successes, pathologists in these organizations, as well as the organizational leadership,
continue to face challenges relating to achieving the greatest possible value from improving laboratory
medicine. One of the most important problems they face is how to pay for pathologist contributions. As
noted earlier, others—such as the American College of Radiology and Landon—have cited the difficult
issues associated with paying for such services under a bundled payment model. One difficulty is that a
traditional fee-for-service model may not be appropriate because adoption of guidelines and
measures promoted by pathologists may actually decrease the volume of laboratory tests (and
therefore the income derived from fee-for-service payments). In addition, many of the ways in which
pathologists add value to the ACO are not related to the provision of particular services to specific
patients, but to the development of systems (such as EHR coordination with laboratory) and guidelines
that globally reduce costs and potentially improve patient care.
Payment. The institutions we visited have had differing degrees of success with determining how to pay
pathologists and how to allocate to them gains from greater efficiency in health care delivery.
Geisinger, with its two decades of experience working in a coordinated care environment, has
developed a system under which all providers are salaried and are eligible for substantial incentive
payments for areas such as cost savings and development of care innovations. Pathologists at
Nebraska Health Center and Methodist Health System are salaried, and the pathology department gets
a bonus that is based both on cost reductions and on achieving quality targets. While pathologists will
be among the medical specialties eligible for sharing in cost reductions from greater efficiencies under
shared savings agreements in the physician hospital organization in which the pathologists at Methodist
participate, the share going to pathologists and all other PHO physicians had not been determined at
the time of our visit.
Payment issues are particularly important for organizations such as CMP, where pathologists are not
employees of the hospitals or ACOs and therefore are not directly compensated for the quality
improvement services that they provide. Instead they contract with the hospitals for inpatient/Part A
services and receive fee-for-service payments from payers for outpatient services. Under their IPA
arrangement, pathologists were eligible for incentive payments based on performance measures.
Under CMP, the formal ACO, how pathologists should be paid for efficiency gains is a work in progress
and not yet fully resolved conceptually or specifically.
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Improving the capabilities of Health Information Technology (HIT) systems. A second important issue is
the extent to which ACOs’ HIT systems are bi-directional, ie, allowing laboratory pathologists easy
access to patient data across the patient’s EHR and allowing other clinicians easy access to readable
and actionable data from the laboratory. Such data are used in several ways, including implementing
population health management programs (such as those used at Geisinger), communicating and
assessing the effectiveness of standardized laboratory order sets, and presenting laboratory results in a
way that makes it easier and more efficient for the clinician to provide appropriate care to the patient.
In their current operations, pathologists typically utilize laboratory information systems (LIS) and
anatomic pathology information systems (APIS) that enable them to receive test orders, track test status,
and report test results and provide interpretive reports. These test results and interpretive reports are then
typically transmitted by interface to the EHR. However, in many organizations without a single electronic
medical record (EMR), physicians often are not able to access complete ambulatory and hospital due
because of complex interface barriers. At least one expert with whom we spoke believes that these
problems eventually will be corrected but require both more time and more resources. The lack of a
single EMR also makes it much more difficult for the treating physician to access actionable data from
the laboratory record (eg, automatic prompts that a patient is due for a test; electronic versions of
testing protocols associated with a particular patient condition or symptom; or information about
whether the patient has already had a particular test—particularly a costly genetic test for which results
would not change in a patient’s lifetime). It often falls to the clinical laboratory to solve EHR interface
problems, so as to establish robust mechanisms to link laboratory testing and results to the patient’s
clinical record. Such high functionality is required to ensure timely delivery of test results to providers, to
avoid duplicative testing, and to ensure coordinated management of patient testing and therapeutic
management by the patient’s treating physician(s). Pathologists are key to ensuring the quality of
laboratory tests by collecting, surveying, analyzing, and using patient population clinical results to guide
therapy, best practices, and safety for individual patients and patient populations.
Among the organizations that we visited, Geisinger Health System has the most integrated HIT networks,
but even officials there say that such networks take years to develop and requires continuous
improvement efforts. At the other institutions, however, integration is still far from complete. TNMC and
Methodist Health System have interoperability in their LISs, enabling pathologists in one institution to see
what tests have been run (and results found) in the other institution, but the institutions use different EHR
systems. As a result, they need to work on ways to integrate these systems so that the two hospitals can
access patient data from one another. In addition, Methodist Health System’s LIS is still not fully
integrated with its EHR. CMP is able to access clinical information through HEALTHeLINK, a regional
health information organization (RHIO) operating in Western New York state that offers access to patient
records at different institutions. While this system provides a physician with access to the broad menu of
Contributions of Pathologists in ACOs | CAP Page 15
care that a patient may be receiving, officials with whom we spoke told us that data is not easy to
extract.
Difficulty of culture change. Finally, officials and pathologists at all three institutions agree that moving to
an ACO model takes a substantial amount of time, effort, and behavior change. Specific to pathology,
it requires changes in how clinicians and administrators see the role of pathologists, and in how
pathologists view themselves. In organizations that are moving to a collaborative care model,
pathologists who are not used to such active collaboration may need to be retrained in how they
practice, how they communicate with other providers, and what kinds of role they can play in
increasing their value. As CMP’s David O. Scamurra, MD, FCAP noted, it will take retraining of
pathologists to show them new ways of adding value. And because other clinicians typically are not
aware of the contributions and capabilities of pathologists, it requires retraining and methods for
providing continuing education to reinforce how pathologists can enhance patient care and reduce
institutional costs. As Dr. Scamurra said, pathologists need to continuously identify and stress the
importance of pathology, or they will be left out of the discussion.
CONCLUSIONS AND POLICY IMPLICATIONS
The growth of collaborative care models such as ACOs presents challenges to pathologists, particularly
those who have relied on traditional methods of payment and of practicing laboratory medicine.
Pathologists—particularly those in independent private practice—may face pressures to show their
―value added‖ or could face an environment where the ACO views their services as a commodity to
be purchased from the lowest bidder rather than as a service that can help the ACO achieve its quality
and cost-reduction goals. But, for those pathologists who are seeking an expanded role in applying their
skills as diagnosticians and integrators of health data, they also pose a dramatic opportunity. In
addition, in an era of continually falling reimbursement rates for pathologists operating in a fee-for-
service environment, roles in collaborative care may offer a growth opportunity for pathology and
laboratory medicine. As one of the pathologists we interviewed said, one cannot stand still in this
environment because payment systems are bound to change. And, because of the unique capabilities
that pathologists bring in data management and testing, they offer important opportunities to help
ACOs achieve their goals of providing better care while rationalizing the costs of that care.
These three case studies of very disparate ACOs show distinct ways in which pathologists within those
organizations have been able to add value and become leaders in their institutions. They have been
able to implement collaborative approaches that reduce costs without reducing—indeed, often while
enhancing—patient safety and health care outcomes. Admittedly, implementing these approaches is
Contributions of Pathologists in ACOs | CAP Page 16
not easy. And success requires vision and leadership from pathologists, from administrators, and from
lead clinicians in the institution. Success may also hinge on reorienting both pathologists and other
clinicians to work better together and on successful use of interoperable electronic connectively both
to provide the data and to make best use of the analysis and feedback which pathologists provide.
The ACO model relies on innovation by private actors, notably physicians and hospitals. Even the
Medicare ACO model is designed to allow models to emerge under a broad set of regulations that
merely set the financial and quality ground rules. Nevertheless, our site visits suggest some potential
areas where public policy changes can establish an environment that would enhance opportunities for
ACOs to be more effective:
1. ACOs should establish an advisory board that evaluates and monitors clinical laboratory testing
protocols and guidelines. Given the fundamental role played by the clinical laboratory in
allowing the ACO to achieve its health outcomes while reducing costs, it is vital that the
laboratory provide diagnostic protocols, including optimized order sets, that are evidence
based and designed to make sure that the patient gets the right test at the right time. Several
institutions, such as the Mayo Clinic and the institutions we visited, already have advisory boards
that identify areas for standards that are evaluated by providers and are based on strong
medical evidence. Currently, about half the states have considered ACO legislation that would
allow these entities to function under state law. The Massachusetts Society of Pathologists (MSP)
is advancing legislative language, to be included in anticipated legislation, which would require
each ACO to establish a clinical laboratory testing advisory board, charged with
recommending guidelines or protocols for clinical laboratory testing in the ACO. According to
an undated MSP legislative memorandum in support, the MSP proposal would require the
board’s membership to include at least one physician who is both a member of the ACO and
the medical director of a CLIA-certified clinical laboratory. It is important to note that such
legislation not establish the guidelines themselves. Rather, it would require the ACO to establish
such an advisory board, including a CLIA-certified laboratory director physician who is a
member of the ACO, as part of the approval process for any ACO.
2. CMS guidelines for ACOs should, at a minimum, strongly encourage that patient EHRs allow for
bi-directional exchange of data between the laboratory and other patient information. The EHR
is, in effect, the central nervous system of an ACO. EHRs should enable all relevant providers—
including pathologists—to have the ability at any points in the decision-making process to
access the information on the patient’s health status, the health care plan, and results. Such
information helps to avoid medical errors, unnecessary duplication of services, and underuse of
appropriate services.16 This access is particularly important because patients may be getting
Contributions of Pathologists in ACOs | CAP Page 17
care at different sites within the ACO. For example, they could be getting care at two different
hospitals and from several different physicians. All of the experts we interviewed expressed the
importance to ACO success of pathologist access to data in the EHR in order to correctly assess
patient needs and to implement programs that promote appropriate care.
3. CMS should study the extent to which patients and smaller health care practices in rural areas
are able to take advantage of any cost and quality improvements that may be associated with
ACOs. The ACOs that we visited are all well established and had experience operating in an
organizational capacity (eg, hospitals, major regional health centers, large physician practice
organization). But patients receiving care from such organizations should not be the only ones to
benefit from coordinated care models. In some markets, particularly in rural areas, starting an
ACO poses not only major logistical problems but also financial problems (particularly for the
required investments in common EHR systems). They also face greater risk because there is
uncertainty about whether ACOs in rural areas can achieve savings.17 Similarly, the smaller
pathology practices typical of such rural areas may lack the financial capital needed for
startup. This could be particularly important where such practices are the only ones available in
the community.7 CMS has recognized the issue of barriers in establishing ACOs in smaller
communities, particularly in their financial ability to build an EHR system, and established the
advance payment program to give such ACOs access to future shared savings in order help
fund startup costs without any net government contribution. However, these payments only
address start-up costs and do not reflect the potentially greater risks that ACOs face in these
communities. In addition, there is concern that the eligibility requirements do not reach all
necessary communities, and while the funding accrues to the ACO, it is not clear that the ACO
would distribute the funds in a way that would provide needed investment funds to specialists
such as pathologists, who would need to make investments in data integration. Inadequate
distribution of funds would diminish the effectiveness of the ACO in achieving the types of gains
that can be achieved in larger markets.
While adoption of these policy measures would enhance pathologists’ ability to contribute in an ACO, it
would be naïve to think that all—or even most—pathology practices are able to immediately provide
coordinated care systems with the kinds of laboratory-based contributions that have been highlighted
in this analysis. These are particularly true for small- and medium-sized practices, which still employ the
majority of practicing pathologists in this country. If coordinated care systems such as ACOs become a
more dominant part of the health care delivery system, practices seeking to participate as leaders in
those systems must address the following issues:
Contributions of Pathologists in ACOs | CAP Page 18
Many of the potential roles for laboratory medicine in ACOs require expertise in laboratory
medicine, but smaller practices often have focused their current staff expertise in anatomic
pathology. In order to be a leader in the ACO, a pathology practice needs to have sufficiently
broad expertise to allow them to be leaders in all areas of pathology, including the laboratory
medicine areas of clinical chemistry, hematology, medical microbiology and transfusion
medicine, equally with anatomic pathology.
Similarly, ACO administrators may be looking to pathologist for standards and protocols in
emerging areas of diagnosis, including molecular testing. Again, some practices may not have
sufficient staff expertise in all the areas where such protocols might be needed.
Relatively few pathologists have the training and skills in health care informatics that are
required to acquire and analyze the data needed for population health management. Even
though not every pathologist would need these skills, many small- and medium-sized pathology
practices do not have sufficient staff expertise in this area.
If pathology practices beef up their staffing to enhance their value to existing or future
coordinated care delivery systems, the question remains of how to pay for this enhanced
staffing. Pathology practices may be unable (or, at a minimum, reluctant) to invest in these
resources when there is no established basis for payment by an ACO for the savings and
improvements in quality that these staff would bring to the ACO.
That being said, ACOs are still in their formative stages in most parts of the country, and this analysis
suggests ways that pathologists can best avail themselves of the opportunity to be part of this new
world:
Be proactive. As noted earlier, individual pathologists can be proactive in reaching out to ACO
organizers in their communities, explaining the potential for pathology and laboratory medicine
to contribute to ACO goals, and offering to take a leadership position by participating in the
ACO and joining ACO committees. Working with local ACO leaders and administrators, and
getting an early ―seat at the table‖ is vital for pathologist, particularly in an environment where
roles, procedures, and payment mechanisms are still being invented.
Document value. Once a laboratory is in an ACO, it is important to document ways that its
actions have contributed to enhanced outcomes, more appropriate care, and cost reductions
for the ACO. Examples such as we heard, where a pathologist was able to talk to a clinician
about the reasons for not ordering a requested $1,500 test—which the clinician noted wasn’t
vital but would just be ―interesting‖—need to be identified and highlighted. Conversely, there
should be an opportunity to identify the specific value of ensuring that appropriate testing is
done at the appropriate time, with appropriate interpretation and follow-through.
Contributions of Pathologists in ACOs | CAP Page 19
ACOs and coordinated care models also offer opportunities to the profession of pathology as a whole.
In particular, pathologists—working with other clinicians—have the opportunity to apply their substantial
laboratory-based information and expertise to develop evidence-based guidelines for optimal use of
laboratory tests to monitor the health status of patients with chronic disease, detect illness in patients at
risk for health problems, and facilitate initiation of treatment interventions. Admittedly, this may be a
new and perhaps controversial area for pathologists to explore. But the need for such standards came
up repeatedly among ACO administrators with whom we met, at least one of whom cited similar
standards that have been developed for radiology. The CAP should consider whether it would be
appropriate and useful to follow the example set by the American College of Radiology to develop
criteria for testing.18 Such an action could potentially raise the visibility of pathology and lead to
improved—and potentially less costly—outcomes for patients.
________________
David J. Gross, PhD is director of the Policy Roundtable, College of American Pathologists (CAP). The
author acknowledges the contributions of his CAP colleague Sharon West, who participated in the
ACO site visits and whose expertise on ACOs helped to frame the issues addressed in this paper as
well as to provide the basis for substantial comments throughout the paper’s development. The
author also received valuable comments from John Scott and John Olsen, MD, both of CAP;
members of CAP’s Policy Roundtable Committee, including Richard C. Friedberg, MD, FCAP; James
M. Crawford, MD, PhD, FCAP; W. Stephen Black-Schaffer, MD, FCAP; Thomas M. Wheeler, MD, FCAP;
and Michael B. Cohen, MD, FCAP; as well as from Donald S. Karcher, MD, FCAP, who chairs the
CAP’s ACO Network. The author accepts responsibility for any errors or omissions. Any opinions
expressed herein are solely those of the author and do not necessarily represent the policies or
positions of the College of American Pathologists.
Contributions of Pathologists in ACOs | CAP Page 20
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1. Nace D, Gartland J. Providing accountability: accountable care concepts for providers.
http://www.strategiestoperform.com/volume5_issue2/. McKesson/Relay Health white paper.
Published 2011. Accessed March 14, 2012.
2. Berenson, RA, Burton, RA. Health policy brief: next steps for ACOs. Health Affairs. January 31,
2012. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=61. Accessed April 17,
2012.
3. Meisel Z, Pines J. Post-HMO health care: are ACOs the answer? Time. May 31, 2011.
http://www.time.com/time/health/article/0,8599,2074816,00.html. Accessed April 18, 2012.
4. Landon B. Keeping score under a global payment system. N Engl J Med. 2012;366(5):393–395.
doi: 10.1016/j.cll/2007/12/005.
5. Schuerch C, Selna M, Jones J. Laboratory clinical effectiveness: pathologists improving clinical
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6. Sussman I, Prystowsky MB. Pathology service line: a model for accountable care organizations at
an academic medical center. Hum Pathol. 2012;43(5):629–631.
7. Bibb A Jr, Levin DC, Brant-Zawadzki M, Lexa FJ, Duszak R Jr. ACR white paper: strategies for
radiologists in the era of health care reform and accountable care organizations: a report from
the ACR Future Trends Committee. J Am Coll Radiol. 2011:8(5):309–317.
8. About the partners. Accountable Care Alliance website.
http://www.accountablecarealliance.com/partners/. Accessed April 18, 2012.
9. About us. Methodist Health System website.
http://www.bestcare.org/mhsbase/mhs.cfm/SRC=DB/SRCN=/GnavID=46. Accessed April 18,
2012.
10. About us. The Nebraska Medical Center website. www.nebraskamed.com/About-us. April 18,
2012.
11. Geisinger Health System. About Geisinger. http://www.geisinger.org/about/index.html. Updated
March 14, 2012. Accessed April 18, 2012.
12. Department of Public Relations & Marketing, Geisinger Health System. 2010 System Report.
http://www.geisinger.org/about/ar_2010_2.pdf. Accessed April 18, 2012.
13. A new era of accountability is here: 2011 annual report. Buffalo, NY: Catholic Medical Partners;
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14. Meleskie J, Eby D. Adaptation and implementation of standardized order sets in a network of
multi-hospital corporations in rural Ontario. Healthc Q. 2009;12(1)78–83.
15. Busby LT, Sheth S, Garey J, et al. Creating a process to standardize regimen order sets within an
electronic health record. J Oncol Pract. 2011;7(4):e8–e14.
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16. eHealth Initiative. Laying a foundation for care coordination: the role of health IT.
www.ehealthinitiative.org/resources/. Published March 8, 2012. Accessed April 19, 2012.
17. American Medical Association. Accountable care organization (ACO) principles. Policy
adopted by the American Medical Association House of Delegates, 223rd Meeting of the
American Medical Association, San Diego, CA, November 6-9, 2010. http://www.ama-
assn.org/ama1/pub/upload/mm/399/aco-principles.pdf. Accessed April 23, 2012.
18. ACR appropriateness criteria®. American College of Radiology website.
http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx..
Accessed April 19, 2012.
Contributions of Pathologists in ACOs | CAP Page 22
APPENDIX A: INTERVIEW PARTICIPANTS
CAP staff interviewed the following individuals as part of its research for this white paper:
The Nebraska Medical Center
Steven H. Hinrichs, MD, Professor and Chair, Department of Pathology and Microbiology;
Director of Microbiology and Virology
James L. Wisecarver, MD, PhD, FCAP, Professor and Vice Chair, Department of Pathology and
Microbiology; Medical Director, Clinical Laboratory; Medical Director, Molecular Diagnostics
Jodi Garrett, MT(ASCP)SM, Director, Clinical Pathology
Methodist Health System
Ken Klaasmeyer, Vice President, Managed Care
Anton Piskac, MD, Vice President, Performance Improvement
Thomas L. Williams, MD, FCAP, Medical Director, Methodist Pathology Center
Gene N. Herbek, MD, FCAP, Medical Director, Methodist Women’s Hospital & Transfusion
Services
Josie Abboud, Vice President, Ancillary and Clinical Services
Laura Block, Laboratory Service Executive
William Shiffermiller, MD, Vice President, Medical Affairs
Geisinger Health System
Conrad Schuerch, MD, FCAP, Chair, Laboratory Medicine
Therese A Snyder, Vice President, Operations, Laboratory Medicine
David P. Gingrich, Operations Director, Customer Support
Jay B Jones, PhD, Director, Chemistry; Director, Geisinger Regional Laboratories
Harold H. Harrison, MD, PhD, FCAP, Director, Clinical Pathology
Al Shulski, Director, Laboratory Information Systems
Beth Amarose, Supervisor, Ancillary Services
Jeffrey W. Prichard, DO, FCAP, Director, Surgical Pathology
Fan Lin, MD, PhD, FCAP, Director, Anatomic Pathology
Albert Bothe Jr., MD, Executive Vice President and Chief Medical Officer
Jonathan Darer, MD, MPH, Chief Innovations Officer
Thomas R. Graf, MD, FAAFP, Associate Chief Medical Officer, Population Health Chairman,
Community Practice Service Line
Contributions of Pathologists in ACOs | CAP Page 23
Catholic Medical Partners
Dennis R. Horrigan, President and CEO
Mike Osborne, Vice President, Finance (Non-Acute Ministries), Catholic Health
Lisa Cilano, System Vice President, Finance/CFO, Acute Care, Catholic Health
Richard Vienne, DO, Vice President and Chief Medical Officer, Univera Health Care
David O. Scamurra, MD, FCAP, Eastern Great Lakes Pathology PC
Contributions of Pathologists in ACOs | CAP Page 24
APPENDIX B: DISCUSSION GUIDE FOR SEMISTRUCTURED INTERVIEWS
1. Being a leader in the Organization
Current model/market:
o How long has the clinical integration/collaborative care model been in existence at your
facility/practice?
o Please describe this model currently (# of physicians, hospitals, other facilities), including
any relevant changes since inception as well as any changes in your involvement over
time. Please also include any relevant information on your local market (managed care
penetration, competitive environment, etc).
o How is your ACO/integrated model governed? (physician representation on board,
committee structure, etc)
o Do you or other pathologists have a leadership role (official or unofficial) in the ACO’s
governance structure and/or management of the ACO? If so, please describe the
current role and how it came to be? Did the organization reach out to you or did you
initiate contact/involvement initially? Were you and/or other pathologists serving in a
leadership capacity prior to the formation of the integrated system?
― What precipitated your decision to join the ACO? How did you conduct an
evaluation that led you to this decision? Do you engage counsel or a consultant
to assist with this evaluation? (Note: not applicable for employee model)
o Does your organization have collaborative care agreements with private payers? Does it
plan to participate in the Medicare Shared Savings Program (MSSP) effective 4/1/2012 or
7/1/2012 or other CMS program? If the MSSP, track 1 or track 2?
o Is your group the only one providing laboratory/pathology services to the ACO?
Receptivity to your Involvement
o What was the receptivity to your role and collaborative care efforts within your
organization?
o What resistance, if any, did you meet from administrators and/or other providers?
o What resistance, if any, did you face from pathologists (or others in the laboratory)?
o How did you address this resistance?
o How long did it take to overcome this resistance, and what do you think did the trick for
you?
2. Adding value
How does the role of pathology in your integrated model differ from the role/practice of
pathology in a nonintegrated environment?
as this the way it always was, or did you need to make changes in the way pathologists work?
Contributions of Pathologists in ACOs | CAP Page 25
Can you give us some examples of how pathologists have made an impact in the following
areas (and are there studies or supporting evidence/data)?
o Utilization: Reducing use of unnecessary tests and procedures, and increasing the use
where appropriate.
o Quality Measurement: Using laboratory data to help the organization meet its quality
measure reporting obligations (eg, helping other physicians/your organization
demonstrate they achieved laboratory measures such as hemoglobin A1c and other
testing/monitoring for diabetes). It has been our observation that many of the quality
measures for health care outcomes derive partially or entirely from clinical laboratory
diagnostic testing;
o Test Selection: Providing guidance and direction to practitioners to ensure the correct
tests are being ordered for diagnosis, prognosis and monitoring therapy/assisting
providers with appropriate test selection
o Personalized Medicine: Interpreting laboratory-derived, genotypic information on which
personalized health care relies heavily and engaging in collaborative consultations on
diagnosis and therapy with other physicians. Advancing new methods of molecular
analysis that provide for better management of an individual patient’s disease and
predisposition toward disease including tests to more precisely diagnose subsets of
diseases and more importantly, the selection of therapies best suited to patients with
specific genetic characteristics.
o Data Integration/Population Management: Serving as integrators of laboratory data and
information for the ACO/integrated entity. Identifying high-risk patients, employing
pattern recognition, risk factor identification and other clinical judgments and utilization
observations, including peer comparisons to assist with chronic disease management
such as diabetes, detection of other diseases such as cancer, and overall population
management.
3. Have technological advances (molecular and genetic testing, digital pathology, etc) enabled you
to play a more collaborative (rather than reactive) role in patient care and underscored the
importance of pathologists serving in this capacity? To what extent is this perspective regarding
collaboration with pathologists shared by other providers?
4. How are pathologists’ performance and contributions on the collaborative care front measured?
Are there pathology performance measures included in your organization’s model?
Is ongoing reporting on your performance provided? If so, is it at the individual or group level?
Contributions of Pathologists in ACOs | CAP Page 26
5. Barriers
What barrier, if any, do you face (from other clinicians, administration, technology, or
organizational structures) that prevents you from providing even more value to the ACO?
Does your health system/integrated model have an EHR? If so, do you have adequate access to
the EHR? Is your system’s EHR integrated with the laboratory’s information system (LIS)? What
problems, if any, do you encounter regarding your systems electronic connectivity (laboratory
reporting, etc)? Do you have the following?
o Bi-directional interface with LIS?
o Anatomic pathology reports fully incorporated electronically in the EHR?
o Laboratory/pathology data in a format suitable for population/community analysis?
Does the system have computerized physician order entry (CPOE),
6. Evidence of results (or lack thereof)
Are there any data on how you’ve added value (eg, patient safety, costs, medical errors,
number of procedures, outcomes, etc)? Has there been any way to estimate or even
demonstrate/quantify how this affects downstream or related nonpathology costs?
Are there data to show that reductions in tests or treatments (eg, transfusions) have not led to
adverse or undesirable outcomes?
What kind of impact are you having on health care quality?
What is the role of evidence-based research, and what advantages do pathologists bring in
developing such information?
7. Effects on the practice of pathology
How do you think your practice of medicine is different, as a result of being in the ACO, from the
traditional way that pathology has been practiced outside of an ACO environment? How have
you had to change your thinking about how you practice? Have you seen a similar change in
thinking amongst other physicians?
Are there new kinds of services that you provide?
Are there services you no longer provide?
To what degree have other pathologists with whom you work open to/resistant to these
changes?
Has your interaction with patients and collaboration with other practitioners increased?
8. Payment
How are savings achieved globally by the ACO?
What changes have there been in how you get paid for delivery system contributions?
Contributions of Pathologists in ACOs | CAP Page 27
o Are there other financial incentives (shared savings distribution or other mechanism) to
provide collaborative care and/or achieve measures for those in your delivery system?
o Are pathologists eligible for such payments? If not, are other specialties eligible? Are
different specialties financially incentivized for their ACO efforts in different fashions or
under different models?
What changes might be on the horizon?
What changes would you like to see?
9. Lessons learned
If you were starting over again, what would you do differently?
What would you recommend to other pathologists who want to become leaders and/or raise
their visibility in ACOs?
What would you recommend to other pathologists who are facing resistance or indifference to
their efforts to be more active in ACOs?