Since LMC opened in late 1971, the same pathology group has provided Pathology & Laboratory Medicine Services at LMC. This is a group focused on the philosophy of point of service pathology, the view that patients are best served primarily by or through physicians in their own communities. This view recognizes the value of experts and expert local & distant referrals & consultations but is well aware that even experts can't agree correctly (expert discordance and see Pathology Programs )! Since the hospital opened in 1971, we have been an acute-care,  hospital-based pathology practice. Each doctor is licensed by the state of S. C. to practice medicine. Each pathologist is certified by the American Board of Pathology, and each pathologist and group-employed P. A. has undergone intense evaluation and the granting of organized Medical Staff (repetitive peer scrutiny) membership by the Board of Directors (influential appointed members from our community) & granted privileges for the practice of pathology within the LCHSD. The granted privileges are enumerated in a departmental "delineation of privileges" statement. And the medical staff department members operate according to defined rules and regulations (R & R) of the organized medical staff  ([a] original 15 Dec. 1976 version; [b] 1978 version; [c] current version). Such privileges to practice must be renewed every two years & include QA reviews, etc., and pathologist and non-pathologist peer reviews. Our lab has also been continually accredited by the College of American Pathologists (since 1978-2006) & then COLA since, a status implying intense "outsider" pathologist-peer review.  Pathologists working outside of hospitals (especially in commercial lab enterprises) are not subject to such constant peer & multidisciplinary review & accountability.

Since about 1985 (and definitely since 1988), we pathologists have been fully contractually responsible for every aspect of the Lexington Medical Center Laboratory, a multi-million dollar medical endeavor (a 9-digit figure of annual charge volume and about 120 FTE employees). We have 24/7/365 responsibility for general and specific details of every aspect of the operation, day-to-day and top-to-bottom. We do this in the context of overall institutional bylaws, medical staff bylaws, and administrative and medical staff rules & regulations and guidelines of the Lexington Medical Center. As Laboratory Directors, we determine who will or will not perform in the department (hiring and firing; appropriate caliber of personnel for each position; depth and breadth of staffing within each segment of 24/7/365); what will or will not be done in the department (scope and depth of services); when any of the vast number of activities will or will not be done (what tests are STAT, all shifts, daily, weekly, or reference-lab send-outs); where any of these numerous around-the-clock activities will or will not be done (geographic location of testing...bedside or lab, doctor’s office or main lab, within which department of the main lab, LML vs. distant reference labs); and how (what test method and by what instrument or kit vendor) each test is done. And it is up to us, as directors & designees, to always be able to defend the "why". How we medically direct the laboratory effort

Our group employs three non-physicians: Ted Mitchell, Pathologists Assistant, about 50% directly involved in LMC interests, Jennifer Klapper, Pathologist Assistant, and Susie Greenthaler, Administrative Assistant, about 80% involved in LMC interests (nearly all of their LMC-type efforts being in support of the pathologists efforts toward "Part A"). The pathology group is importantly (not trivially) involved in medical staff activities and in input into other areas of the greater LMC interests (e.g., Credentials Committee chair for over 25 years; IRB Committee chair for 11 years; and Infection Control Committee chair for 16 years). And, our group is devoted entirely to interests of the greater LMC (the LCHSD). 

There is definite value to LMC in our devotion to keep all pathologists on site, in the hospital (and not in outside facilities). "On-site" equates to "early warning" & "full court press" as to departmental direction and management and "high intensity input". In recognition of this, the hospital provides office space & other valuable support.

The "reach" of Lexington Medical Center indicates to us medical directors how to make decisions in deploying our hospital's lab capabilities. Beginning in 1971, LMC was the first hospital in South Carolina to have its own full-time staff of ER doctors 24/7/365; and this allowed us to develop the lab as we have. Now, having the 1st, 2nd, or 3^rd busiest ER in South Carolina, our lab continues to emphasize rapid, accurate, 24 hour per day centralized lab support for our ER, Operating Rooms, and Intensive Care Unit. Yet, we have, for example, partially decentralized & placed much glucose testing at the bedside.

The initial pathologist contract with the then "Lexington County Hospital" was from 1971-1981...then declared void about August 1981. In years prior to 1980, pathologists in the USA tended to either be paid salaries by hospitals or contracted for services to the hospital by way of "percentage contracts"...payments of a percentage of the lab's gross or net billings or income. The outline below speaks to the PAL group whose next contract was signed in 1983 for 3 pathologists…the third (Dr. Carter) coming on board in latter half of 1984. PAL now has 10 employees (7 pathologists, 2 physician’s assistants, and 1 administrative assistant). The present 10 employees are all heavily involved in LMC interests, all 10 being paid for by PAL at the same contractual support from LMC since 1983. And, the LMC Lab fiscal performance has been consistently, commendably, remarkably, and uniquely positive since 1987. Inflation has risen at least 60% since 1983, cutting the value of our unchanged Part A payment from LMC almost in half (as to purchasing power of 1983 dollars)!! With our desire for stability with a long-term contract, we must anticipate no less than 25% inflation between now and 2013. We have maintained premier accreditation through the College of American Pathologists commission on inspection and accreditation from 1978-2006. We are now accredited by COLA. Our contract was voided in March 2002 and has not culminated in a new contract (as of 1 January 2007).

Now, what are the legalities behind the obligations for payment of pathologists for these general services? As to Medicare, the original verbiage leading up to the law in 1965 noted such payments as Part C payments...language that was deleted for the final 1965 law (at that time, the oldest members of our group were finishing college). Metropolitan centers in the northeast salaried most of their pathologists and started the habit of being reimbursed for same by Medicare under part A; in other areas of the USA, pathologists billed patients for such under Part B. In 1980, Medicare sought uniformity; and HCFA (now CMS) required that pathologist payments be through hospitals. Congress legislated such in TEFRA in 1982. In 1983, HCFA issued implementation rules. HCFA came up with time-related cost amounts and an RCE ("reasonable compensation equivalent"...the amount a pathologist's time was worth in a full time equivalent year doing only Part A). Time counted; talent, degree of involvement, and intensity of effort were not noted. Upon Medicare switching to DRGs (diagnosis related groups) for 1984, that new prospective payment system law did not address Part A payments to pathologists. Hospital attorneys tended to advise hospitals that the absence of the language meant that no payments were required. But anti-kickback laws have  noted such value of  pathologists' efforts and pressured hospitals toward being fair. This position was endorsed by the federal OIG (Office of the Inspector General) in 1991 and strongly re-affirmed in a 27 January 2005 Supplemental Compliance Program Guidance for Hospitals in which "fair market value" of services is discussed.

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