CAP-ACP workload—2018 update (Level 4 Equivalent 2018)

The Level 4 Equivalent system is described in a document on the CAP-ACP website [3]. The implementation of L4E scoring included fragment counting and core counting for biopsies and block counting for large excisions to indirectly capture amount of work. This was done by parsing the ‘source of specimen’ section of the report (which captures how the submitting MD labelled the container bottles) and the ‘gross pathology’ section of the report.

The adjustment for “micro-only” was done, as the grossing in the environment is done by pathology assistants and pathology residents. This adjustment was done (on the “base L4E”) before adding the (L4E) points for the intraoperative consultations (frozen sections), ancillary testing (special stains, immunohistochemical stains, molecular testing), synoptic reports and consultations. The discount was based on the L4E 2018 definition; however, it was simplified. Cases with a “base L4E” greater than 10 L4E units (or 1 L6 unit) were reduced in value (or “discounted”) by 10%. Cases with less than 10 L4E units were discounted 5%.

Informal consultations (involving a few slides or review of a small case) were captured by searching the diagnosis and microscopic sections of the report for “Dr.” and “DR.” to capture unique individuals. If one doctor was found: 0.5 L4Es were added to the case. If two or more doctors were found: 1.0 L4Es were added to the case. If the case had a formal consult, i.e., the report had a “consultation” section, the value of the case was multiplied by 1.5x. As the institutions forming the regional laboratory are teaching hospitals with pathology residents, the L4E was adjusted; as per the L4E (2018) manual the adjustment is 1.3x.

Work2Quality (W2Q) and schedule of benefits fees

The implementation of W2Q was primarily based on the “pathology procedures” section of the report and the “source of specimen” section of the report. The W2Q score included adjustments for internal and external consults, special stains, immunohistochemical stains, molecular testing, synoptic reports, and frozen sections. An adjustment for teaching was not included.

The March 2020 Ontario Schedule of Benefits fees [15] were calculated using the parameters from the W2Q analysis. Currency amounts are all in Canadian dollars. Formal and informal consults were not captured for in the Schedule of Benefits fees (SOBF) calculation.

Classification by L86x codes

Cases may have multiple codes, e.g., a case may simultaneously have a L864 code and a L866 code. Codes are applied to the parts of a specimen, i.e., each container gets a code. The W2Q calculation and the SOBF calculation counted all L86x codes.

Cytology cases with a cell block are coded within the laboratory as L864 plus the relevant cytology code (e.g. L805). For the purpose of classifying cases, the highest L86x code was used if several were present. For example, a case with L866 and L864 would be classified as L866, and a case with L864 and L863 would be classified as L864. Cytology cases without a cell block were classified as ‘L86x = = 0’; this group was defined by no L86x code being assigned to the case.

Block count and number of lines

The analysis herein shows that the report length has increased and the number of blocks increased. The length per report was not explicitly assessed; however, as the number of reports decreased, it should be apparent that the report length (as assessed by ‘diagnosis’, ‘micro’ and ‘CCS’) increased >20% per case. The number of blocks increased because of (1) a shift away from cytology specimens, and (2) an increase of blocks per case, in selected types of cases.

The length of ‘diagnosis’, ‘microscopic’ and ‘CCS’ sections were evaluated, as they are the bulk of what the pathologist writes/dictates/enters, if they are not grossing. The report length is most certainly increasing universally (i.e. outside of the laboratory studied), as it is likely driven by (mandated) reporting requirements. The block counts also appear to be increasing universally, i.e. outside of the regional laboratory [16].

Synoptic reports

Pathologists have benefited from synoptic reporting; however, it has not been without considerable effort—that arguably may exceed the benefits to them. Seen in a larger context, it should be noted that: oncologists, surgeons and epidemiologists have benefited from the synoptic reporting; completeness and satisfaction with reports has increased [17]. In this context, when compared to free text, the synoptic report is, in the economics lexicon, an externality; pathologists deliver more value (reports are more complete, standardized, contain more information, easier to analyze) without more cost to the individuals consuming them. Thus, it can be argued that a re-balancing/further investment in pathology is needed, as pathologists are delivering more information and more value. Seen from a system management/research perspective, capturing data in individual fields is preferable in medicine, as it facilitates analysis work by reducing cost. If healthcare providers are required to absorb this cost, adoption will likely be slower.

Limitations

The reports do not capture all workload elements consistently. For example, the number of blocks is not always recorded in the pathology procedures section of the report; a sub-analysis showed that 1,716 (of 406,719) surgical cases are defective in this regard. Based on the block count sub-analysis and the audited cases (n = 1,100 cases), it is estimated that workload parameters in the reports have an error or are incomplete in 1–2% of cases.

A small number of cases had apparent coding errors that led to extreme workload/SOBF values (e.g. one case had 442 HR codes—but was truncated to two digits); these prompted case maximum values. The number of L4E units was limited to maximum of 50 per case. The number of W2Q units was limited to 50 per case. The SOB fees were limited to $1,500 per case. On re-calculation the maximums resulted in a very small but noticeable correction. The L4E, W2Q and SOBF maximums were seen in 152, 84 and 395 cases.

Employment records from human resources were not available (to the authors) to assess the workforce. Thus, pathologist work was assessed based on the final signature only. If a pathologist only signed addenda or did not sign-out cases during a given ISO 8601 week it would not be counted. The ISO 8601-week definition de facto assumes that the pathologists take their continuing medical educational (CME) leave/vacations in whole weeks (off work Friday/return to work Monday). If a pathologist customarily takes their vacations or CME Wednesday to Tuesday, the analysis done herein under-counts the weeks off/over-counts the weeks worked. With the FTE definition used, this is a potential issue for (1) part-time pathologists, i.e. pathologists that signed less than 42 ISO weeks in a year, and (2) pathologists that are at the full-time/part-time interface (41 weeks versus 42 weeks). For pathologists clear of the 41-week cut-point there is no difference from a week more of less, e.g. it makes no difference whether a pathologist is signing for 44 weeks or 45 weeks.

The molecular tests were not separately tabulated/counted; however, they were captured in the workload assessment. A simple count of all the molecular tests is likely non-trivial to interpret, as there are a number of different tests (e.g. sequencing (multiple genes versus single genes), FISH, SISH).

The analysis does not consider the time value of money or the Ontario Schedule of Benefits changes. A more complex analysis would adjust for the Ontario Schedule of Benefits changes and costs of living increases that took place over the time period analyzed. As physicians services compensation increases have been modest in comparison to the cost of living changes [18–20], a more rigorous analysis taking this into account would likely increase the negative compensation per work unit trend. As presented, the analysis (in 2020 dollars) is likely a conservative calculation that forgoes some accuracy for lower complexity.

Evolution of practice and fee codes

The fee codes heavily value biopsy specimens. We believe this is largely due to history; the codes were created when “big” specimens (L866 cases) were typically “smaller” (<10 blocks), the number of diagnostic lines less (frequently <5 lines), biomarkers (e.g. HER2 testing) did not exist, and Cancer Care Summaries (synoptic reports) did not exist.

The data herein shows that the ground is shifting; the compensation per unit work is changing dramatically. At the current point in time, the subset of pathologists that do primarily small specimens (L864) are considerably advantaged. Whether small specimens should be more highly valued and if so by how much, should be further considered; however, this is beyond the scope of this work.

Level 4 equivalent (L4E 2018) system

The L4E system is complex and was a challenge to implement with the current reporting practices. The increase in work, as measured by L4E units, was driven by synoptic reporting, increased block counts, and a shift to larger specimens. Several aspects of the L4E system were not implemented, e.g. the increased workload points for high-grade dysplasia in polyps (as was likewise excluded by Halwani et al. [21]), clinician consult, case conferences with clinicians (as this information is not consistently well captured in reports).

The immunostain use drove some increases in the time frame 2011 to 2015, as the number of immunohistochemical stains increased in the time frame. The decrease in IHC use in the later part of the period was driven by several factors. The large factor was likely the elimination of negative immunostain controls, in the context of polymer-based antigen retrieval (as recommended by the Institute for Quality Management in Healthcare [22]). A subset of cases were previously analyzed in detail in a separate study; this likely led to some decreases, due to changes in practice [23]. Also, staff turnover is suspected to have played a role.

Work2Quality (W2Q)

The W2Q system, like the L4E system, shows increased work; however, the change is less pronounced. Ancillary tests are more heavily weighted in the system. The significant decline in IHC tests and a dramatic shift away from L86x0 cases and a relative shift away from L864 cases (due to gynecologic cytopathology and small gynecologic specimens moving to another laboratory) counteract (1) the increased reporting requirements and (2) increased molecular testing.

Comparing W2Q and L4E 2018

W2Q and L4E yield a similar work increase; however, this appears to be a chance finding that is due to several simultaneous changes. To illustrate this, we calculated differences between hypothetical practices that purely do L864 cases and L866 cases, using the medians calculated in the data set. If one compares a pure L864 practice (an environment that only does L864 cases) with a pure L866 practice (an environment that only does L866 cases) on the basis of a yearly target of 7,560 L4E units per pathologist, the SOB fees would be $397,089.50 (7,560 L4E x $97.30 / 1.85 L4E = $397,089.50) and $171,316.40 (7,560 L4E x $347.25 / 15.43 L4E = $171,316.40) respectively; the difference is $224,762.10 for the same work in L4E units.

If one uses a yearly W2Q target of 7,500 W2Q units per pathologist, the SOB fees would be $364,875.00 (7500 W2Q x $97.30 / 2.00 W2Q = $364,875.00) and $314,158.60 (7500 W2Q x $347.25 / 8.29 W2Q = $314,158.60) for pure L864 and L866 practices respectively; the difference (favouring L864 practices) is $50,716.38 for the same W2Q units. If one recalculates the work 7,500 W2Q units into L4E units, the work would be 6946.875 (7500 W2Q x 1.85 L4E / 2.00 W2Q = 6946.875) and 13,863.47 (7500 W2Q x 15.43 L4E / 8.29 W2Q = 13,863.47) for the pure L864 practice and pure L866 practice respectively; the difference is a factor of 2.0x.

The systems (L4E and W2Q) give dramatically different results for different environments. W2Q favours small specimens (that are done in non-hospital labs in Ontario) and disadvantages environments with large specimens (hospital pathologists and academic pathologists).

Ontario Schedule of Benefits (SOB) fees

The SOB fees increase closely tracked the W2Q numbers. This is not coincidental. The W2Q and SOB fees are so closely related; they cannot be considered independent measures. It should be noted that there are no actual billings to compare with the herein calculated SOB fees. Compensation in the laboratory is almost entirely based on the province’s “uniform level of compensation” for pathologists (which is paid in a complex arrangement by the hospital and Ministry of Health). The fee schedule is used for/in (1) referred in “RR cases”/cases sent to the lab for review/further analysis (not analyzed herein), and (2) non-hospital laboratories; these predominantly process smaller specimens (e.g. L864s).

Measuring workload/capturing complexity

The traditional workload measures (case count, billings) are misleading, as there has been a shift in the case mix and the complexity of cases have increased. Report length captures the amount of information within the report and has been found to be representative of work over a twenty year period [24]. The block count is an indirect measurement of the work [1]. It is impossible to manipulate in small (biopsy) specimens; however, it can be in large resections. A high volume of ancillary testing does not necessarily represent added value [23]. It is noted that the Royal College of Pathologist (UK) workload system has a built-in disincentive for more blocks [4].

The number of report lines / (non-space) characters appears to be a robust measure but may be manipulated or “gamed”. Thus, the number of required reporting elements may be worth exploring as a workload measure. Currently, synoptic reports (Cancer Care Summaries) in W2Q and L4E are all weighted equally (1 W2Q unit, 3 L4E units).

If a mandated synoptic report has 25 separate report elements (or questions) and another has 5 questions, the former is likely more work than the latter. The weighting could be adjusted by the required ancillary testing (e.g., MSI testing in endometrial cancer)/ancillary testing recommended by consensus statements (elastin staining to assess for lymphatic invasion/vascular invasion in colorectal cancer resections).

Work complexity is important to consider in the larger context of workforce planning. The local workforce (as measured by number of FTEs) has not changed substantially in the past nine years; however, the Canadian pathologist workforce has increased significantly. In the time period 2007 to 2017, the Canadian pathology workforce increased by approximately 20% [25]. Though country to country workforce comparisons may be compounded by several factors and of limited value [16], in the same time period (2007 to 2017), the US pathology workforce decreased by approximately 18% [25].

Technical changes and progress

Pathology may be in a unique position at this time vis-à-vis other specialties. If the pathology case complexity (conservatively estimated) has increased 25% and a pathology case can be considered analogous to a patient encounter, does it take other specialists 25% longer for a patient encounter versus 9 years ago?

The analysis herein presents several metrics that are broadly congruent and demonstrate increasing work for hospital pathologists. As a group, the authors believe the increased reporting requirements have improved care and represent progress; however, this has also been an erosion of the practice environment in hospital pathology. If the workforce had kept pace with the workload, approximately 6–7 full-time equivalent (anatomic) pathologists would have been added to the team in the 9-year period analyzed.