Part 1: Workload Distribution Challenges and Solutions

In this series, Karim Sirgi, MD, FCAP, details the causes, impacts, and solutions to workload distribution challenges.

Part 1: What causes workload distribution challenges?

Unequal workload distribution ranks as one of the highest sources of stress and dysfunction amongst pathology groups affecting the morale of pathologists, laboratory and office staff, and often leads to burnout across all levels. It is therefore the responsibility of pathology group leadership to understand the causes of unequal workload distribution and take proactive steps to prevent it.  There are two main root causes to explain workload distribution challenges:

The Relative Value Unit (RVU) system

The RVU system was created in 1992 to bring more uniformity to Medicare's reimbursement system and to assist in controlling health care costs. The goal of RVU is to objectively quantify physician’s work, practice, and malpractice expenses. It is now the basic structure of payments for most commercial health insurers.

Physician work, identified by a Current Procedural Terminology (CPT) code, is linked to a payment scale by Medicare and private payers. CPT codes cover surgical pathology, cytopathology, clinical pathology processing and professional interpretation, and select clinical consultation activities. However, any pathology work that isn’t directly correlated with a CPT code is not accounted for in the RVU system. This includes standard pathology responsibilities such as:

• Medical directorship activities: Review of quality control, proficiency testing, writing laboratory standard operating procedures (SOPs), request for proposals (RFP), assessment of new laboratory equipment, and more.
• Clinical consultation activities: Review clinical histories, recommend appropriate testing, and investigate reference laboratories for special testing.
• Inspection of other laboratories.
• Driving to cover remote facilities.
• Medical autopsies.
• Group, departmental, and hospital meetings.
• Clinical conferences: Tumor boards, grand rounds, morbidity and mortality conferences.

Even within the RVU system, cases with the same CPT code are not equal. For example, CPT code 88305 refers to a benign GI biopsy, a skin biopsy of a melanoma, or a lymph node biopsy, each of which can vary significantly in the time and resources they require.

Absence of workload distribution standards in the United States

The variety of pathology practice settings in the US (independent, commercial, hospital-based, academic, private-equity owned) and the absence of a centralized health care delivery system makes it difficult, if not impossible, to establish a standard system for workload and productivity evaluation.

Individual pathology professional organizations therefore adopt a customized approach for workload and productivity evaluations. This leaves pathology leaders without a concrete system to address the inherent deficiencies of the RVU system.

Other sources of workload stresses

A variety of other internal and external stresses also factor into workload distribution:

Internal stresses:

• Leadership statements may not correspond to the processes in place to implement and monitor workload distribution.
• Pathologists’ expectations may be misaligned about work-life balance, compensation, and workload.
• Leadership may not be effectively communicating each individual's contribution to the group, leading to the silo-ing of various service lines (general pathology vs. hematopathology vs dermatopathology, vs clinical pathology, etc).
• Unanticipated retirements or employee departures create disruption.

External stresses:

• Accelerated consolidation of laboratory services across large hospital and academic systems.
• Race to the (pricing) bottom and broadening of hospital partnerships with large commercial laboratories.
• Dwindling reimbursements and its impact on discretionary funds for staffing and perks.
• Difficulty in recruiting qualified professionals (MDs, PAs, MTs, cytotechnologists, transcriptionists, etc).
• Hospitals and large clients adding service lines that are not currently supported by the pathology department without prior coordination.
• Hospitals and large clients requesting coverage for existing services, beyond the group’s current capacity.
• New regulations adding to the bureaucracy and red tape in the practice of medicine (eg, the new FDA LDT rules).

In part two of this series, Karim Sirgi, MD, FCAP, will discuss the impact of workload distribution challenges. 

Karim E. Sirgi, MD, MBA, FCAP, owns Sirgi Consulting LLC and offers expertise to medical groups in various aspects of practice management and leadership. Dr. Sirgi is board-certified in anatomic, clinical and cytopathology with additional surgical pathology fellowship training, he also holds an MBA and has 30 plus years of practice and leadership experience in private, academic, and hospital-based pathology and medical staff settings. Among his previously held positions, Dr. Sirgi served as president of the largest multi-specialty pathology group in the Rocky Mountain region and chair of the regional medical staff council for the largest hospital organization in the US. Dr. Sirgi is the immediate past-president of the American Pathology Foundation, the chair of the CAP Practice Management Committee, and the Chief Science Officer of Breath Tech.