By George Hollenberg, MD

 In an age when insurance mandates and HMO rules and regulations are as much a part of the practice of medicine as stethoscopes and prescription pads, it is no surprise that our choices as physicians have become more constricted. Escalating costs of drugs, equipment, and malpractice judgments have compounded the problem and forced more limits on medical practitioners.

The area in which these constrictions are most pronounced and where they can have the most impact is in laboratory services. The financially driven goals of cost containment and simplification have steered the practice of pathology away from individual, specialized laboratories, and given rise to the megalab, a clearinghouse for all specimens from routine to life-threatening.

 The largest of these megalabs operates more than 150 laboratories and about 2,000 patient centers across the US, and even more overseas, generating nearly $5 billion in revenue each year. Many of the country’s most popular health insurance plans either require or encourage patients and their doctors to choose these megalab services to receive the best cost advantage.

But for some doctors, the detriments of using such a massive corporate laboratory outweigh the financial benefits. According to Robert A Sable, MD, FACP, FACG, a New York City-based gastroenterologist, accessibility is far more valuable than low cost. “In instances where the insurance company gives us a choice, we prefer to choose a laboratory based on the reputation and skills of the pathologist, as well as his or her availability to discuss results, answer questions, and provide further insights if needed.” He notes that at many of the megalabs, the credentials—and even the identity—of the pathologist performing the analysis are unknown to the physician.

“All pathologists are not created equal,” Dr Sable says. “In cases where a serious diagnosis such as cancer has been made, the next decisions we make regarding surgery and treatment options are critical to the patient’s well-being.” He says that in some cases, he reviews the specimen and analysis with the pathologist to clarify the findings and confirm the best course of treatment, a process that is near impossible with a megalab. As incidences of medical errors continue to rise, such measured and thoughtful review and collaboration is essential to providing the best patient care and avoiding misdiagnosis or mistreatment.

Another disadvantage of megalab services is the unavailability of pathologists who have an expertise in a certain area of their field, such as gynecology, dermatology, or gastroenterology. Gerald H. Becker, MD, LTD, FACP, FACG, a consulting gastroenterologist based in Phoenix, says, “I much prefer to use a hospital-based laboratory or an independent lab, where I know there are pathologists on staff who specialize in GI pathology.”

One area in which doctors would like to see better compliance from independent laboratories, however, is in electronic transfer capability. “It’s quite valuable for physicians to be able to receive everything, from the report to the actual slide, via an electronic transfer,” Sable says. “We can then see what the pathologist sees, and we can provide faster service to our patients awaiting these results.”

Whether you use a megalab or an independent lab for your pathology services, the following suggestions can help you to achieve the best level of service and confidence in the lab’s findings:

Establish a relationship. If you can make contact with, get credentials from, and establish a rapport with one or two pathologists at the laboratory, you might ask that those doctors analyze all of your specimens, when feasible. You’ll know, then, who to contact when a question arises. A note of caution: Mega-labs can have a higher rate of turnover than independent labs, so check in often to ensure your contacts are still valid.

Ask for electronic transfer. When you have all of the data, including photos of the actual slide and corresponding analysis and reports, you can better ascertain where clarification might be needed.

Provide your patients with options. If insurance company dictates are the driving factor for using megalabs, research the costs and benefits of using an independent laboratory for your patients’ specimen analyses, and allow them to decide for themselves. “Reliability is important, both for doctors and for patients,” Dr Sable says. Providing a more reliable option, particularly in cases where the patient’s life is at risk, can give both of you more confidence in your post-pathology decisions.

George Hollenberg, MD, is founding director of Acupath Laboratories Inc, and a fellow of the College of American Pathologists, the American Society of Dermatopathology, and the AMA. He has published articles on skin, prostate, and gastrointestinal cancer, and is a consultant in dermatopathology for The North Shore University Hospital Center.