Senator TALMADGE. My next question would be, I think, for Ms. Preuss. You have asked that S. 3205 be amended to include employee protection, which includes language to protect employees who have testified or are about to testify.

Why are you asking for this protection? Have there been any specific problems in the past?

Ms. PREUSS. Regrettably, there were problems in the early seventies regarding a former president of our organization who provided testimony relative to issues involved in this legislation, and who subsequently lost her employment. Our organization is concerned about this type of activity. I would like to add however that we have recently testified regarding the Clinical Laboratory Improvement Act and there have been no incidents of that nature as a result of those statements.

Senator TALMADGE. Do you have any evidence she was discharged because of her testimony?

MS. PREUSS. Senator, you can always be discharged because your shoes are not polished or you do not smile appropriately; however, the discharge came immediately following the testimony and the individual had been employed in the institution for 15 years.

Senator TALMADGE. Who fired her?

Ms. PREUSS. In that particular situation, I would assume that both the director of the laboratory and the hospital administration played a role.

Senator TALMADGE. Thank you.

Senator Curtis?

Senator CURTIS. Those of us who have a responsibility of recommending legislation to the Senate may disagree oftentimes on what is the best approach to the problem, but I can assure you that everyone is interested in stamping out fraud and any acts that are unethical and wrong.

I was impressed by your statement concerning the fear of loss of job security by not disclosing fraud.

What types of fraud are we talking about?

I would like to have some examples. Does it have to do with fraudulent records? What type of fraud is occurring that we should strive to give some protection to those who might reveal it?

I am not limiting the testimony before legislative committees. I am talking about the freedom to go to someone right in the local situation, the hospital administrator, hospital trustee, chief of staff, or whomever it is. What type of fraud is occurring and is not being detected because there is that very justifiable fear?

Ms. PREUSS. We are familiar with the fraud that has been described and discussed in the various governmental reports. The reason for that is

Senator CURTIS. What fraud is that?

MS. PREUSS. For example

Senator CURTIS. Performing services that are unnecessary, falsifying records? What is it?

MS. PREUSS. I would be happy to delineate areas of fraud if I could finish my rationale for qualifying my statement.

It is one thing to learn of these activities from others. It is another to have concrete data from a wide variety of sources to support your feelings and perceptions in this regard.

As president of ASMT last year, I know of members who were aware of fraudulent practices, and felt an obligation to report these. However, there was considerable fear for loss of employment. In one particular case, information was received but it was followed up by a letter which requested that I destroy the information because the individual was afraid they were going to lose their position. Their reason was that they had a family to support.

It has been incredibly difficult to encourage professionals to live up to their obligations in this regard.

As to fraud you asked me to identify-recent disclosures concerning kickback situations-was not news to us.

Senator CURTIS. By whom, to whom?

MS. PREUSS. Such as in Illinois where laboratories were paying funds back to the physician, who referred his lab work to the laboratory. There are situations where laboratory tests may go from a physician's office to more than one laboratory. That can involve double and triple charging.

There are situations where laboratories are paid for work done yet testing is done in another institution.

There is a great deal of variability in terms of what is charged for a laboratory test. It is possible to effect testing economics which could reduce the cost of the test to the patient. In some cases, the patient is the recipient of reduced charges. In other cases, the charges remain the same. A good question to ask is what happens to these savings.

Senator CURTIS. I realize that my time is up, but I have one more question. Believe me, all I want is information."

When a similar test is referred to more than one laboratory, is that ever for good medical reasons or double-checking, or something of that sort?

MS. PREUSS. Certainly, there are occasions where that should occur and it would be an abuse of the physician's obligations to his patient not to do so. We are talking about situations where it is a practice, a common practice, which is more than something which is advisable for a particular patient.

Senator CURTIS. How widespread is it?

Ms. PREUSS. I do not know.

Senator CURTIS. Based on your own experience, percentagewise is it happening in 50 percent of the cases, 3 percent?

MS. PREUSS. I cannot respond to that, Senator. We are unable to get that information.

Senator CURTIS. From your own personal observation?

MS. PREUSS. My own personal observation.

Senator CURTIS. How big a problem is it?

Does it involve 20 percent, 3 percent of the transactions, 100 percent?

MS. PREUSS. I have been fortunate to work in laboratory situations where this has not been a problem. If you are asking me to respond from personal experience, I cannot provide the information you request.

Senator CURTIS. How many years have you spent?

MS. PREUSS. How many years have I been a medical technologist?
Senator CURTIS. Yes.

MS. PREUSS. Over 15.

Senator CURTIS. That speaks well for all of your associates. It is a helpful bit of information to this committee.

No one knows better than members of Congress what it means to have adverse publicity, guilt by association, or blaming everybody for the abuses that occur in a small number.

Senator TALMADGE. Senator Dole?

Senator DOLE. I will address it to either witness. Does a medical technologist work as an employee of a pathologist or of the hospital? Ms. FIORELLA. Generally as an employee of the hospital, in most hospital-based laboratories.

Senator DOLE. In that capacity, are you required to make medical judgments? That is, do you for all practical purposes have final responsibility when a diagnosis is made, and are you accountable for that decision or analysis?

MS. FIORELLA. Accountable as far as having someone over you, yes. I am sorry, is that what

you mean?

Senator DOLE. I mean if-as you seem to indicate-you conduct all the tests, make all the diagnoses, and, in effect, supervise the lab as well, what is left for the pathologist to do except collect the fee?

MS. FIORELLA. There are a number of diagnostic and therapeutic decisions to be made.

Senator DOLE. Who makes them? Does the physician himself actually do it or does he in most cases just leave it up to a technologist? MS. FIORELLA. Some of those decisions would be beyond the educational expertise of the medical technologist. We are not saying that there should not be physicians involved in the laboratory.

Senator DOLE. I am not suggesting that either. I am only wondering who is ultimately responsible and whether pathologists review laboratory findings or simply leave the decision up to a technologist who has not had all of the training that they have had.

Do you, in fact, make some of the judgments, and if you do are you in effect practicing medicine some of the time or not? Ms. PREUSS. Well

Senator DOLE. Like anything else, maybe these things tend to get routine after awhile. If you make a certain test 500 times or a thousand times, do you just wait for someone to initial the result when everything else is done? Is that how it operates, with the physician getting a big fee for the pathology service?

Ms. PREUSS. It will vary by institution as to what the roles are for medical technologist versus the pathologist. In some of your institutions, you do not even have a pathologist on a permanent basis or a contractual basis. They may be available on a consulting basis.

Obviously, the medical technologist in that situation carries a great deal more responsibility than he may find in an institution that is a specialized institution where you may actually find a pathologist actually involved with the performance of a test.

By and large, the majority of laboratory procedures go directly from the laboratory to the patient's chart. Unless you have a pathol

ogist who is accepting the responsibility of playing that vital role of reviewing and interpreting laboratory data to assist the physician. In most institutions I have worked for, the laboratory tests go directly from the technologist to the patient's chart.

I am speaking of four or five institutions. That does not mean that the pathologist doesn't, after the result gets on the patient's chart, work with the physician in those cases where it is necessary. The extent to which that occurs is difficult to evaluate. The majority of work in a laboratory is done by medical technologists. They accept a great deal of responsibility, both in terms of assuring that the work is of a quality nature, and providing information when requested. Senator DOLE. What is the pay differential? Do you have any idea of the comparative incomes of technologists and pathologists?

MS. PREUSS. The average salary, according to a recent survey of our membership of which 50 percent is involved in management shows that the average monthly salary for an administrative technologist laboratory manager is $1,244 per month. The monthly average for a chief technologist is $996. And, the monthly average for a supervisor is $950. I believe your committee has a full copy of that salary survey. The salaries are low.

Senator DOLE. You appear to be suggesting in your testimony that the differential is far too great between the technologists and pathologists. Do you have any criticism of what pathologists receive? After all, they have had considerably more training.

MS. PREUSS. ASMT's position is that personnel working in clinical laboratories should be reimbursed on the basis of their personal professional effort and the time spent in the conduct of laboratory procedures and laboratory affairs. We are not asking for an increase in medical technologists' salaries. We are not asking for a decrease in anyone else's reimbursement.

What we are saying is the entire issue of reimbursement, the way it is handled, needs to be assessed. We are committed to the premise that this assessment must be based on what actually occurs in laboratories.

Senator DOLE. What does it take to become a technologist-not a supervisor, but a laboratory technician?

MS. PREUSS. A baccalaureate degree. Approximately one-third of laboratory administrators responding to a recent survey have master's degrees.

Senator DOLE. Do you have to have a license as well?

Ms. PREUSS. To be a medical technologist, a certified medical technologist, you have to have a baccalaureate degree or the equivalent. Senator DOLE. Do either one of you have any personal experiences that should be brought to the attention of this committee with reference to Senator Curtis' line of testimony?

Where are you from, first of all?

MS. FIORELLA. University of Illinois Medical Center.

Senator DOLE. Do you have any personal examples from there of the double and triple charging situations we were discussing earlier? Ms. FIORELLA. Personal? No.

Senator DOLE. You have never observed any?

MS. FIORELLA. My situation in the last 8 or 9 years has been strictly academic, involved in teaching, so I have really been out of the clinical setting, so personally, I would have to say no.

Again, as Ms. Preuss has indicated, we do get information from some of our members, but that is not personal.

Senator DOLE. Thank you, Mr. Chairman.

Senator TALMADGE. I guess this question is for Mrs. Preuss.

What percentage of laboratory tests require medical judgment? MS. PREUSS. Again, I think that would vary with the institution, depending upon whether it was an institution which handled special medical cases, such as a cancer institute. That would require a different percentage of medical interpretation in terms of diagnosis and therapeutics than would a general hospital that dealt primarily with broken arms and legs. Across the board, institutionwise, it is difficult to establish a percentage. I think that what is done in the future today versus what should be done is a key point to consider.

Physicians need the assistance of pathologists in the diagnosis and treatment of disease. The laboratory industry has exploded technologically to such a degree it is very difficult for the medical community to keep up with it.

It seems that a great deal more activity should occur between the physician in a peer relationship with a pathologist in terms of making certain that diagnoses and therapy is in the best interest of the patient. What is actually the case now and what should be, and what will be done, are two different things.

Senator TALMADGE. What percentage of the time in laboratory tests is the opinion of a medical technologist final?

Ms. PREUSS. I am sorry?

Senator TALMADGE. What percentage of the time spent by the medical technologist is your decision final, of the test?

Assume you do 50 tests in a given day of all types. What percentage of those tests would your judgment be final, or would they have to be reviewed by pathologists?

MS. PREUSS. Again, speaking from personal experience, the majority.

Even in blood banks, oftentimes you have very little pathologist or physician involvement in crucial decisions as to whether a unit of blood is compatible or not. Certainly there are exceptions.

The survey I referred to earlier elicited comments suggesting that there was very little supervision as far as their responsibilities were concerned. That should not be interpreted to mean that there are not institutions where pathologists are very much involved.

For the most part, the majority of the laboratory tests go out of the laboratory from the technologist.

Senator TALMADGE. Any further questions?

Senator CURTIS. It goes to a physician?

Ms. PREUSS. That is correct.

Senator CURTIS. Thank you.

Senator TALMADGE. Thank you very much. We appreciate your contribution.

[The prepared statement of the American Society for Medical Technology follows:]