How do you hide a dollar from a radiologist? - Pin it to the patient.

How do you hide a dollar from a surgeon? - Put it in a textbook.

How do you hide a dollar from a pathologist? - Put it in a living patient.

How do you hide a dollar from an internist? - Put it under a surgical dressing.

How do you hide a dollar from a plastic surgeon? - Ah, that's a trick question: there is no way to hide a dollar from a plastic surgeon!

How do you hide a dollar from a urologist? - Apparently you can't.

Now, here is another good one:

A couple of weeks ago, healthcare insurance giant, Aetna will require physician practices with in-office pathology labs to be both CLIA certified and accredited by either the College of American Pathologists (CAP) or the Joint Commission (JCAHO) in order to receive payments from the company for anatomic pathology services. Aetna has 18.5 million health plan members making it the third-largest health insurance company in the United States after UnitedHealth and Wellpoint.

So, let me see if I get this right.  

While the College of American Pathologists is "vigorously lobbying" Congress to stop the practice of in-office pathology laboratory services, including, but not limited to, lobbying efforts and supporting the recently published Mitchell study looking at overutilization of these businesses, in the meantime, until their voice is heard and their "vigorous efforts" bring a close to these operations, they will inspect them, accredit them and allow them to use the "CAP Accredited" stamp of approval to get paid.

Huh?

I guess, as the saying goes, if you can't beat them, join them.

I don't actually blame the College for doing this.  It is part of their business to accredit laboratories.  And the Laboratory Accreditation Program (LAP) offered by CAP, is nationally and I believe increasing internationally renown for offering objective, balanced, thorough and professional inspections through a series of checklist items to establish best clinical practices for laboratories.  Over the decades, the process has stood the test of time with minimal shenanigans by either laboratories or inspectors with a few notable exceptions that aren't worth rehashing.  Until a few years ago, inspections were scheduled and labs that submitted to be inspected were notified of the inspection date(s).  Now they are more of a "surprise" were there is a date range during which you can be inspected. This allows for a lab to be ready when the window opens inasmuch as being ready on the date of a scheduled inspection.

The core of the LAP is that it largely remains a peer-reviewed process.  Like individuals from like laboratories inspect one another.  As a pathologist from a large hospital system, my lab would be inspected by a group from a similar size that offers comparable tests and complexity of tests.  Likewise, I would inspect similar labs and pathologists and laboratorians from smaller operations, say with minimal complexity staffed by a handful of pathologists would do the same.  

Typically, in the peer-inspection process, a team, usually led by a pathologist will take others along with him/her from their laboratories, or other laboratories to make sure that all sections of the lab that are applying for accreditation have the necessary personnel and folks who know those areas of the lab to inspect the lab appropriately.

Having done a few inspections, and been through many more, I always find them thoughtful, professional, engaging and whether you are inspector or inspectee, one always learns something they can either leave or take with them to their own shop.  Peer-to-peer criticism and compliment.

Herein lies the problem.

Who is going to inspect the in-office laboratories?  Pathologists and teams from other in-office laboratories I would imagine.  

Ironically, pathologists that get self-referral work would self-refer to one another as part of the CAP LAP program for accreditation.

Huh?

What is a pathologist goes into one of these shops and discovers that these labs are not doing triple stains on all their prostate biopsies? Or doing fewer than 12 cups of tissue per patient? Or not doing DNA ploidy analysis on the numerous cores to insure it came from that patient?

What standard of care would these laboratories be subject to?  Has been awhile since I did the surgical pathology checklist as part of an inspection but I do not recall specific questions about number of containers, stains or cancer detection rates in these laboratories.

Also not sure what came first here, Aetna saying it would require CAP inspection for claims to be paid or if the CAP responded to a need by the insurance company in some way, shape or form.

At this point it doesn't really matter.  What does matter is that the College should inspect these labs accordingly for appropriate accreditation in defense of the College, its Laboratory Accreditation Program and what it stands for.  

Modifications should be made to the existing checklists to ensure that these laboratories practices are in accordance with CAP standards of practice and those of other types of laboratories that, specifically, do not self-refer, but rather earn business because of CAP accreditation, rather than labs that do it just to get paid.