AGA Response to Government Report on Pathology Self-Referrals

The U.S. Government Accountability Office (GAO) has released a report questioning self-referrals for pathology services. While the report includes data on gastroenterology, our field represents a relatively small portion of this perceived problem.

The GAO came to the AGA in advance of publishing the report and met with a number of our clinician members. AGA leadership discussed the number of factors that spurred the increased rate of self-referrals for pathology services. The most important factor is the clear mandate to increase adenoma detection rate (ADR) in our work to prevent colorectal cancer. For gastroenterology, the percentage of self-referred pathology increased from 6.6 percent in 2004 to 20.9 percent in 2010 during a time when our quality improvement efforts focused directly on increasing our ADR.

1. Pathology is an important tool in the fight against colorectal cancer. 

As rates of CRC screening increased and more patients underwent colonoscopy with removal of polyps, both the annual incidence and mortality from CRC dropped significantly during the pathology study period1. This is in part due to an increased focus on quality colonoscopy and a focus on ADR, both of which increase pathology biopsy rates.

2. In-house pathology improves patient care.

Integrating a pathologist into a GI practice provides patients with faster biopsy results, more accurate and predictable results from a pathologist expert in GI biopsies, and allows practices to capture and track their adenoma detection rate, which improves quality of care. It also allows the gastroenterologist to monitor the use of special stains.

3. The business of running a GI practice has changed in recent years.

In response to changes brought about by federal legislation, including the Affordable Care Act, many solo and small GI practices have merged, creating larger practices, which may offer integrated GI pathology services. The GAO data on self-referrals likely reflect this consolidation — clinicians who used outside pathology when in a small practice now, justifiably, use in-house pathology.


  • AGA is writing a guideline on “Rational Use of Endoscopic Biopsies.” Due to be published in 2014, this guideline will address questions about the need for special stains and the optimal number and location of biopsies and number of bottles for a number of GI diseases.
  • AGA is developing a bundled payment model. Due to increased pressures to reduce health-care costs and to establish other payment mechanisms, the AGA is developing tools and resources to help you be competitive in the newer and emerging markets. The colonoscopy bundle is one such tool, providing physicians with a framework around typical services billed during a routine screening or surveillance colonoscopy that will enable you to negotiate a fixed price directly with payors and self-funded employers for the care before, during and after a colonoscopy. With bundled payments, providers share risk and have financial incentives to be prudent. Note that AGA is not developing a price for a colonoscopy bundle; rather, the goal of the project is to provide you with a framework to use when discussing this payment option with local payors. Read more.


Members of Congress are always looking for ways to save money in this era of budget deficits. Unfortunately, the findings of the GAO report may appear on the surface to be a prime target for budget savings by entirely repealing the in-office ancillary exception for pathology services. Members of Congress need to know that integrated, efficient and high-quality care by gastroenterologists is not the cause of these increased costs. Stay tuned for additional information from AGA on how you can educate your lawmakers on this important issue.

Review the full GAO report.

1CDC accessed July 16, 2013:

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