Turf battles in medicine: Urologists may need to use a little muscle

March 1, 2010

State legislative challenges for urology come in many forms, including turf battles with other physicians, but by working cohesively and aggressively, urology can defeat these bills.

Whenever I watch a mobster movie, like "The Godfather," I quickly realize that one of the overarching themes is the struggle for power. While the political divergence in state capitals is not as bloody or as dramatic as this award-winning film, opinions on state health policy often come down to a similar theme-the conflict between those who have and those who want. It is part of history, nature, and, certainly, the political process.

Under the current billing system, a urologist takes a biopsy, for example, to check for prostate cancer and sends the sample to a pathology lab for analysis. The urologist can choose from multiple labs competing for their services. The lab sends back test results and is fully compensated by the treating urologist for all services rendered. The urologist then seeks reimbursement from the third-party payer-either a private insurer or government payer-for the total charge for services, including the pathology lab service. The payer receives one bill for all services from the one treating physician-pretty simple.

Over the past number of years, the College of American Pathologists (CAP) has moved to make an important tweak to this current structure. CAP believes payment for anatomic and clinical pathology services should only be made to the person or entity that performed or directly supervised the service. Pathologists are attempting to disrupt the existing reimbursement structure, so that they can be paid directly by the third-party payer, instead of the treating physician. What pathologists are really attempting to do is enact a legislative solution to an internal turf battle between themselves and specialists (urology, dermatology, gastroenterology, and gynecology, among others). It seems benign, but in actuality makes a big difference for urologists and their patients.

Think of it this way: You go to a deli and buy a pastrami sandwich with pickles, lettuce, mustard, and tomatoes. The owner hands you the sandwich and you hand her your $5.00. Then the short-order cook, who made the sandwich, steps from behind the counter, demanding you pay him $1.00 of the $5.00 directly, because he directly made the sandwich. Do you pay the cook his $1.00 or do you pay the owner for the complete price of the sandwich? You pay the owner, of course.

Like the cook, pathologists want to be paid their $1.00 directly from the third-party payer that specialists, like urologists, already possess. Is it wrong to want this power? No. Is it necessary? Absolutely not.

With strategic guidance and messaging from the American Association of Clinical Urologists (AACU), urologists continually fight to keep these legislative changes at bay. In Tennessee, Washington, and numerous other states, urology highlights the following points:

*All pathology services provided through a urology office already utilize a pathologist, so it does not matter who bills because everyone is fairly compensated.

*Billing restrictions of this type are not good for patients or the health care system.

*The changes just add more costs and layers to an already complicated reimbursement system.

*Physician services and in-office ancillary services, exempted under federal law and state counterparts, provide the proper limits for referrals for professional pathology services while balancing the need for efficient delivery of care in patient-convenient settings.

*These changes do not improve patient care or reduce the cost of health care.

State legislative challenges for urology come in many forms, including turf battles with other physicians, but by working cohesively and aggressively, urology can defeat these bills. Urology needs to be vigilant of actions that seem to be benign, but turn out to be a power grab by other physicians. Does urology need to be as aggressive about protecting its turf as Don Corleone in "The Godfather"? No, but urology does need to work to ensure that state health policies reflect what is in the best interest of patients. If that involves using a little "muscle" or "going to the mattresses," then so be it.

To learn more about the proposed direct billing legislation in Tennessee and Washington, or how this legislation might affect the practices in your state, please visit AACU's Action Center today at www.aacuweb.org

We also encourage you to post your comments about this topic in the "Post a Comment" box below.