I have posted two notes pertaining to the intrinsic value of autopsies and whether virtopsies should be substituted for the classic autopsy (see: A Clinician Laments the Decline of the Autopsy; More on the Value of the Classic Autopsy Based on a Reader's Comment). Here's a comment from Dr. Karl Robstad in response to the second of these notes:
As an aside, perhaps charging for autopsies might reduce the number of "unnecessary" autopsies. It's one thing to perform them in cases of sudden death, unclear cause of death or even in cases where the diagnosis is known but is rare or has high educational value; but, in my opinion, it is completely another to do restriction-less dissections of 90+ year-olds with a laundry lists of acronymous chronic diseases and obvious COD's [cause of death]. Simply, if you tell someone something is free, they are likely to want it, regardless of it's actual value. If case selection is more carefully curated, free or not free, I bet [virtopsies] would be embraced.
I believe that the idea of charging a fee for an autopsy has merit and is worth discussing. For now, I will avoid the contentious topic of who would pay the fee, assuming that the insurance companies and Medicare would pick it up. I had also previously understood that the cost of autopsies was theoretically "baked" into DRGs when they were launched many years ago. Therefore, Medicare officials might object to a new charge for autopsies, saying that the government is already theoretically paying for them. However and also putting this argument aside, I think that the most telling case against a charge for autopsies is that there have been fewer and fewer clinicians opting for the current free procedure. How do you justify charging for an autopsy when few clinicians elect to order one for free?
Karl's comment has given me another idea, however. How about persuading radiology departments to offer post-mortem total-body, high-intensity CT scans -- in essence, the first half of a virtopsy. The acceptance rate among family members would presumably be high because it would differ little from ante-mortem imaging procedures. We would then be able to obtain standardized, retrievable imaging, plus interpretation, of post-mortem pathology for those who accept the offer. A well established fee schedule for CT scans would be available as a benchmark. If such a procedure were offered by radiology, I am sure that the hospital pathology departments would quickly see the merit of the total virtopsy (imaging plus selected gross and microscopic tissue examination). We would then quickly have an operational model for close collaboration between pathology and radiology in the performance of all subsequent virtopies.
One aspect of autopsy performance that has not been mentioned in this series is the questionable autopsy competence of many hospital pathologists. Residents are not doing as many, the pathologists teaching residents are usually at the low end of the academic totem pole, and as a community hospital pathologist doing a handful of autopsies a year, I can attest "if you don't use it, you lose it".
Posted by: Jay Pemberton, M.D. | January 06, 2012 at 02:48 PM