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A question of professional ethics.

During the last few years, clinical laboratories have been attacked from all sides with allegations of quality deficiencies, fraud and abuse, kickbacks, and excessive charges and reimbursement. The news media have had a field day with these issues, and one 1987 Wall Street Journal series on lab quality problems even received a Pulitzer Prize for investigative reporting.

The Journal articles, along with a special TV series in the Washington, D.C., area, laid the groundwork for the 1988 Clinical Laboratory Improvement Amendments. Among other things, that act seeks to insure quality in physician office laboratories and cytology. It is a good example of how lawmakers move quickly when the media arouse the public with dramatic presentations.

Since 1982, there have been numerous legislative and regulatory initiatives related to laboratory operations. Congress, the Health Care Financing Administration, and the 'Health and Human Services Department's inspector general have been focusing attention on charge abuses and reimbursement. Each year, independent and hospital laboratories have been hit with reduced reimbursement from Govemment and private payers.

Some insurers have developed guidelines that recommend when doctors should use selected tests. In 1987, when the Blue Cross and Blue Shield Association published testing guidelines in cooperation with the American College of Physicians, the list was said to be purely educational. But it was widely expected that individual Blue Cross/Blue Shield plans would eventually use the guidelines as criteria to deny claims for tests deemed medically unnecessary. This issue has yet to reach a final outcome. Meanwhile an updated version of the list, adding more tests, is planned for release soon.

A great deal is at stake in attempts to tighten up on test utilization and charges. According to several sources, there were 200 million urinalyses in 1987 at a cost of $3 billion, 200 million cholesterols costing $3 billion, and 100 million panels (12 to 40 tests) costing $4.2 billion. Many physicians believe that well over half of the diagnostic tests performed do not really contribute to a patient's diagnosis or therapy. Many laboratorians would probably agree.

The fraud and abuse issue, along with unnecessary testing and excess payments, has again become a significant Congressional concem. Hearings held on March 2 followed a two-part Wall Street Journal report (Feb. 27 and March 1) titled "Patients for Sale" and a critical report by Dan Rather on CBS News. The economics of physician ownership referrals and rate reimbursement will be debated and legislation drafted. What will be proposed only time will tell.

As more and more critical and derogatory comments and articles were aimed at clinical laboratories , lab representatives responded aggressively. These responses were defensive and pointed to the many good laboratories and honest, ethical laboratorians. Laboratory critics were charged with scare tactics and using isolated incidents to paint a negative picture.

These defenders of the laboratory field were right in some respects. But they failed to acknowledge that abuses, though numerically small, can escalate if not corrected. By focusing only on the good, they did not see the responsibility they had for trying to correct the bad. This is the ethical dilemma that I feel still exists today.

Don't you wonder what laboratory employees were doing when their employers allowed sink testing; when their physician clients were getting kickbacks; when tests were billed but not performed; when they saw erroneous results reported? What would you do if you found out your employer was involved in illegal or unethical activities? How would you react if you were asked to report out a result that you knew was wrong? Would you protest if your laboratory was running proficiency test samples for physician clients and letting them report the PT results as their own? What steps would you take if you knew the doctors you worked for ordered unnecessary tests merely to augment their income?

For every one of the dramatic horror stories we have read about there must have been at least one pathologist, laboratory manager, supervisor, doctoral laboratory scientist, or technologist aware of what was going on. Though not directly involved, wouldn't they be equally responsible if they just stood back and let it happen?

Where do our professional ethics come into this picture? What should a laboratorian do when faced with an ethical question?

Those who don't agree with my comments often accuse me of being out of touch with the reality of what goes on in laboratories today. So I am not going to even try to answer the above questions. I will say, however, that I firmly believe the majority of labs and laboratorians are honest and ethical. But I also recognize that those that are not can cast a bad light on the rest.

I would like to hear what you think individuals should do in the situations mentioned. Do you believe it is our responsibility, as laboratory professionals, to speak out? Or should we let chance and the news media influence the legislation Congress adopts? Winston 'Churchill said "The price of greatness is responsibility." Where do you think your respon
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Title Annotation:clinical laboratory testing
Author:Barros, Annamarie
Publication:Medical Laboratory Observer
Article Type:column
Date:Jun 1, 1989
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