Compass on ‘consumerizing health care’ and more

I heard a definition of the AI abbreviation that I like: assisted intelligence. Fundamentally every laboratorian wants to get it right, and if there are tools to help do that in a better way, whether it’s better optics on a microscope, digital imaging, or assisted intelligence, I think the majority of pathologists will be open to it once they get past the fear of being replaced by a computer.

Pete Dysert, does the shortage of pathologists lead you to think more about digital pathology and AI?
Dr. Dysert (Baylor Scott & White): It does. If you can leverage your investment in that platform across your practice, then potentially you could augment the skill sets of the community-based pathologists. You still have to cover frozens and the outside areas and connect them to our experts. We hope it will be an offset to improve the efficiency and productivity of our existing staff. We’ve struggled with getting everything put in place to allow our histology labs to be able to optimize our pathologists’ productivity, because I think we will face a potential shortage, at least in the short term. And then you have the issue of access to the specialty physicians, subspecialty experts.

I met someone at the War College who is representing a group whose objective is to acquire pathology groups and outfit them with a national digital pathology network and bid for all kinds of work, a little like a NightHawk Radiology. Steve Carroll, what do you think about those ideas?
Steven Carroll, MD, PhD, chair, Department of Pathology and Laboratory Medicine, Medical University of South Carolina: It’s something we’ll be seeing more frequently. The day of the small private pathology practices is coming to an end. A lot of it is driven by surgeons, oncologists, and so forth wanting a subspecialist to look at their cases. Small groups can’t support subspecialists, so you will have to go to a larger group. Therein lies the rub because if you are, say, a neuropathologist, those cases are few and far between, so you have to have a larger catchment area to justify your existence and generate enough revenue for things to move forward. As a result we’re going to see more consolidation of pathologists into larger groups, and the natural evolution will be national and international capture of cases so you can take maximal advantage of that structure.

John Waugh, what do you make of the discussion about greater disparities of care? I’m hearing more about how the local community practice is letting patients down because they don’t have the subspecialty expertise of all the people involved in cancer care.
John Waugh, MS, MT(ASCP), system VP, pathology and laboratory medicine, Henry Ford Health System, Detroit: That dovetails with the digital pathology conversation, and we use a model that has subspecialty pathologists and they cross-cover two or three different subspecialties. It helps with covering meetings, vacation times, tumor boards, those kinds of responsibilities.

Community practice at our community hospitals has more of a generalist need, but often there are areas that seasoned pathologists can come into on that. They can read different cases with great confidence. We have daily conferences in which difficult or interesting cases are compared on digital screens across sites. We can have a multi-group sign-out on a given case. Nobody is out there on their own.

What is your volume of send-outs for consults or second opinions?
John Waugh (Henry Ford): Our send-outs are almost nonexistent. We keep a lot of cases in-house. There are consensus sign-outs that give people a good opportunity to be teachers of each other, to share opinions, to reach consensus if there are challenging cases. The only types of cases we send out are those that need a referee. There are a handful of those over the course of a year.

Julie Hess, tell me about the staff or pathologist shortages at AdventHealth. Are you still involved in trying to improve subspecialty coverage?
Julie Hess, VP, laboratory services, Advent-Health, Orlando, Fla.: Our pathology groups have independent contracts. They are recruiting different specialties based on some of the service-line growth in our hospital system, so as the needs arise they focus on that and work closely with our clinicians. We cover a large network, so we can have more specialized cases funnel into one or two people. We have an advantage because our pathology is centralized to our Orlando campus, so those specialists can sit at that location and it’s efficient.

As we recruit some of our newer pathologists or people new to the field, with our growth at the number of facilities and the need to have medical directors over different campuses, we’re challenged with finding people who want to cover the clinical pathology side and be a medical director, because they were expecting to be more specialized or stick strictly to the anatomic side. It’s something we’re having to balance.

Milt Datta, talk about Allina’s perspective on these topics.
Milton Datta, MD, chair of pathology, Abbott Northwestern Hospital, Allina Health, Minneapolis: We look at our regional hospital lab directors for CP, and we’ve been lucky to find a couple of people who are willing to drive to rural or suburban places. When we do cover operative cases there, it’s usually senior pathologists who are willing to go there and work. We’re expanding our telepathology to those sites for remote reads, advising, everything from the gross examination to the frozen sections.

We’re planning our five-year strategy for the health care system, and the lab is trying to step up the analytics. Mike Laposata, MD, PhD [professor and chair of the Department of Pathology at the University of Texas Medical Branch at Galveston], gave a talk describing the Laboratory 2.0 movement. We invited senior executives to listen to the opportunities in data analytics for population health metrics. One of the arguments we’re putting forth is if we do a good job shifting from reactive treatments of critical lab values to proactive result trends identification, we will take some of the pressure off our frontline medical teams and reduce burnout, and that’s one of the ways we’re selling it as a benefit.

How is the recruitment and supply of pathologists in Minneapolis?
Dr. Datta (Allina): We have recruited extremely well. We’ve recruited several people mid-career from academic centers who started looking at their volume of responsibilities. We’re a private practice group yet we offer subspecialty work and other opportunities for publications and so on that are a little less pressured, and I can’t help but think it’s that.

Wendy Kleckler, what’s your reaction to the discussion of point-of-care testing in grocery stores and pharmacies?
Wendy Kleckler, VP of Business Development, ACL Laboratories, West Allis, Wis.: We do a fair amount. We’re selective on where point-of-care instrument assays are located. Our medical groups are employed by Advocate Aurora Health, so we have a little control over that. We have point-of-care testing in some of those clinics. The lab oversees what we purchase and what tests are done, but there’s an Advocate Aurora team that determines who runs the point-of-care in those systems. The lab’s not completely responsible. We have clinics within Walgreens but no lab testing. Those clinics are staffed with nurse practitioners and some medical assistants. They do collections and our couriers pick up samples and bring them to the laboratory.

One focus for us is how we reach the consumer. Our young people don’t want to go to the doctor. They would rather walk into a pharmacy and pick up a kit from the shelf. How can we look at direct-to-consumer from a population standpoint? It would allow us to go outside our region in Illinois and Wisconsin and might give us a bigger bandwidth. I’m on a strategic planning team to identify how we can do that. Can we build it? Do we buy it? What does it look like for the future so if a kit was sent home for a lab test, it would come back to ACL and we could perform the testing and get results out via our LiveWell app?

Are you in the initial stages of that effort?
Wendy Kleckler (ACL Laboratories): Yes. One of the key markets is our Medicare Advantage population—how we can get, for example, colorectal fecal immunochemical tests [FIT] to market so they don’t come into the office prior. We’re starting with a pilot population of FIT tests in that patient population.

There’s a notion that we need to glue the consumer to our health care system because that’s where the big bucks come from. The belief used to be that we got inpatients through the emergency room or through the affiliated doctors. Wally, what are you doing in Cleveland to keep patients coming to the clinic and from not going to places like Houston or San Francisco?
Dr. Henricks (Cleveland Clinic): We have significant marketing outside of northeast Ohio. We have a spot on the Super Bowl each year and ads on huge walls at the airport. We have different ways to get the name in front of people in unexpected areas.

There is a lot of community outreach, more than there’s ever been in my time here. We’re also partnering with larger employers for specialty care, especially in cardiac medicine, providing opportunities for large self-insured employers to have Cleveland Clinic as a primary or secondary consultation that’s covered by their plan. Our electronic consultation program and virtual visits support these efforts.

Sterling, what are the practice models of pathology within Intermountain?
Dr. Bennett (Intermountain): We have one group that has about half of our pathologists, but we have multiple affiliated groups. We have one small group employed by Intermountain. It’s both a generalist model and a mixed generalist-subspecialist model.

Is there a system push to have one kind of model within the system?
Dr. Bennett (Intermountain): We don’t have a clear, consistent read from the organization about one model. But we think as we enter the digital pathology age, it would be beneficial to have a single model.

Dwayne, I came away from the War College in part thinking there are a lot of forces urging us toward one model for pathologists serving in a network. Did you come away with that same impression, and if so, what do you think will happen at Northwell?
Dr. Breining (Northwell): All roads are leading to a subspecialized central service. In Michigan they put forward a model of the pathology hospitalist who can cover frozen sections and AP/CP demands, but then you have a mothership of subspecialists that can be readily consulted. [See CAP TODAY, April 2022: “Pathology hospitalists in place at UMich.”] Digital pathology will facilitate that as it gets established.

It will be helpful because maintaining an equal high standard of care and equal access to subspecialists when you need it will become more important as different cancer services get regionalized and need to be provided at a high level, like some places have done with cardiac programs. It’s already starting to happen for cancer, and that’s the way we’ll integrate.