Breathing New Life Into Autopsies

A 40-year old Tampa, Fla., attorney tells his secretary he has chest pain and asks for an aspirin. Moments later, he dies in the bathroom of his office. The man’s life insurance deems the death the result of natural causes, probably an aneurysm. A local medical examiner declines the case. But the attorney had a car accident a month before. Seeking higher insurance policy proceeds for accidental death, his son searches for a private pathologist to determine if his father’s death was accident-related. Through word of mouth, he finds Jose Suarez-Hojos, MD, owner of Tampa Pathology Laboratory, Dr. Suarez-Hojos, who performs private autopsies to augment the laboratory work he provides to clinics and hospitals, discovers the man did suffer an aneurysm. But due to the aneurysm’s location, he attributes death to the car accident. Once medicine’s gold standard, the autopsy was a preferred method to determine the cause of death, train new doctors, evaluate hospital care and carry out research. Before 1960, half the patients who died in hospitals underwent an autopsy at no charge to the patients’s estate.

Today, however, hospitals autopsy around 10% or less of corpses. Less than 5% of community hospitals autopsy or even maintain facilities to do autopsies, according to the Institute of Medicine of Chicago, an organization that tracks autopsies. They are more common in teaching hospitals but even there, the level is about 12%. Some hospitals use the burgeoning services as auxiliary pathology department. "With downsizing, some hospitals elect to outsource their autopsies," says Karl Smith, president of Chicago Area Autopsy Service. Smith is a former diener, or autopsy assistant, who opened his business in 1991. Last year, the business’ seven contract pathologist provided autopsies to 43 Chicago-area hospitals and logged 1, 300 procedures. This steep decline in a hospital autopsies, coupled with a rise of consumerism in health care, is giving way to new public interest in the fee-for-service autopsy. Last year, there were at least 3,000 requests for "contract autopsies." Private demand is small but beginning to build" says Margaret Hastings, PhD, executive vice president of the Institute of Medicine of Chicago, "People are aware that mistakes are made and that many things are unknown." Families exposed to television programs such as "Quincy" and "The X-Files" understand what autopsies can uncover. Some want their loved ones autopsied for evidence of hereditary diseases, such as Alzheimer’s and cancer. Others want a DNA test to check for parentage to resolve inheritance issues. Some are looking to prove medical malpractice. Many others simply feel their loved one’s attending physician did not give them enough time or information to unscramble exactly what happened at the end of life.

"In about 50% of cases, the families just want closure because the doctor did not explain things well," says Silvia Comparini, MD, a private pathologist in Los Angeles. Ralph DeSimone, MD, a Virginia contract pathologist, adds, "Families are looking for someone to give them time, energy and compassion." The situation has created a classic supply-and-demand market niche. To answer the call, more than half a dozen businesses have recently sprung up around the country. Some specialize in independent autopsies; others conduct them as an adjunct to their regular pathology work. "Private autopsy services are a growth industry in direct promotion to hospitals failing to do autopsies." charges Sidney Wolfe, MD, director of Public Citizen Health Research Group. In addition to performing autopsies, several services have relationships with federally funded organ procurement agencies to harvest organs or examine already harvested organs for infection and disease before implantation. They also harvest brains for researchers looking into Jakob-Creutzfeldt disease, Parkinsons, autism, schizophrenia, alcoholism, and Down syndrome. They harvest other organs for medical schools, scientific investigators and tissue banks. Even cadaver skin is banked to replace firefighters’ burned skin. 

Physicians see business opportunity.

The trend is putting extra cash in the pockets of pathologists who don’t mind the acrid smell, can handle standing hours on end and are accustomed to wearing moonwalker-like outfits. Those who take on the procedures, perform them on the side, most often in funeral parlors, while holding down full-time jobs in offices, hospitals and medical examiner’s offices. Robert Bayardo, MD, chief medical examiner for Travis County in Austin, Texas, says he earned about $11,000 last year providing independent autopsies. That’s a fraction of his $250,000 income, but he’s loathe to turn it down. Abdullah Fatteh, MD a Plantation, Fla., pathologist and former deputy medical examiner who practices family medicine , earned $40,000 performing autopsies. That’s beyond his regular $200,000-plus practice income. For some pathologists, such earnings represent their entire income. Dr. Comparini, once a deputy chief medical examiner in Washington, D.C., permanently injury her back and legs lifting corpses. Now she subsists on the $48,000 a year she earns working case by case as one of 13 on-call Services, Inc. in Los Angeles. The part-time job is less strenuous and allows her to take frequent breaks to sit down. Services report family referrals come by way of funeral directors, medical examiners, attorneys and hospitals that feel some autopsies unnecessary or that don’t want to do them.

Autopsy clients, who span all socioeconomic levels, pay $900 to $3,000 - in advance - for answers. They pay many times that if pathologists have to travel out of state. What they receive is a pathologist who cuts open the corpse, examines vital organs and fluids, runs slides through a laboratory and spends about an hour explaining findings and answering questions. The Joint Commission on Accreditation of Healthcare Organizations and the Health Care Financing Administration formerly required a prescribed percentage of autopsies for accreditation and participation. Those requirements were dropped in 1970 and 1986, respectively. Because autopsies are costly and not required, hospitals rarely do them, Insurers prefer to conserve precise resources for the living. And medical examiners take cases only where foul play is strongly suspected. For Medicare patients, autopsy reimbursement is an unidentified amount paid through diagnosis-related groups for eligible patients. But hospital pathologists cannot bill directly for them using standard CPT codes because Medicare rules allow only for what is "medically necessary" for live patients, says Barry Eisenberg, PhD, director of AMA’s division of payment programs. Even teaching hospitals are sometimes reluctant to do autopsies,

Vincent J. M. DiMaio, MD, medical examiner for Bexar County in San Antonio, used to refer nontraumatic autopsy requests to the University of Texas Health Sciences Center in San Antonio, "I stopped referring cases two years ago. They don’t want to do them anymore because it often ends up with civil litigation and they don’t want to get involved." UT pathologists confirmed they do not accept outside cases. At academic meetings, the decline has stirred heated debates by pathologists, sometimes called the conscience of medicine," who believe an autopsy unequivocally establishes the cause of death. "Dwindling autopsy rates in hospitals is a huge problem today," says pathologist George Lundberg, MD editor of the Journal of American Medical Association and an outspoken critic of falling hospital autopsy rates, "Hospitals that don’t know the quality of care of their sickest patients - the ones who die - clearly don’t care." 

Marketing autopsies like any service

Several entrepreneurial independent pathologists who are receiving increasing autopsy requests are marketing that part of their businesses. "I hope it will grow. We are establishing a Web page and send mailings to funeral homes and medical examiners offices,: says Dr. DeSmione who owns Virginia Laboratory Services in Culpeper, Va. Pathology Support Services of Sacramento advertises on the radio. Special Forensic services of Tacoma, Wash., sells its services through a Web site, advertisers near the obituary section in newspapers and sends direct-mail brochures to morticians, hospital pathologists and home health workers.

Jane Weber, its president and former medical examiner’s operations manager, opened her autopsy service in 1996 with two on-call forensic pathologists willing to work for $1,000 of the $1,800 she charges. Last year, her company handled 36 autopsies. Weber’s operation is minuscule compared with Autopsy/Post Services, whose president and founder, Vidal Herrera, is called the "cadaver king" He may not have pioneered a new industry, but he brought it into the public eye when he opened in 1988. His company set the pace for marketing these services by parleying a high-visibility 800-AUTOPSY number and catchy slogan ("We give the dead a voice") into a six-figure annual business. Last year, it conducted 900 autopsies, some for noted attorneys like Johnnie Cochran. Herrera thrives on publicity and courts the press. He has been featured on CNN and "Dateline"’ profiles of him have been published in dozens of publications, including the Wall Street Journal, Newsweek and Inc. magazine. His business has been so successful, he is arranging to franchise autopsy services in the United States and abroad. An autopsy takes anywhere from one to eight hours. Herrera’s typical case is exemplified by a recent autopsy on a 69-year-old man taken to a hospital for dizziness. The man had a history of recent forgetfulness. When he died, it was ruled a natural death.

On autopsy, it was shown that the man had an old hemorrhage from blow and a fracture that was healing. The results were turned over to a medical examiner. Herrera reports his pathologist have also found broken backs, broken necks, suffocation and many euthanized patients. In fact, part of the decline in hospital autopsies is proportional to the increase in litigation that makes attending doctors reluctant to request them. "There is a fear the autopsy will uncover something missed," says William Hartman, MD, executive vice president of the American Board of Pathology. But an autopsy can work in a physician’s favor, too, says Ohio State pathology professor Peter Baker, MD. "It can back up a clinical diagnosis." Another often-cited reason for low hospital autopsy rates is that advances in imaging techniques more precisely pinpoint the cause of death antemortem, rendering the autopsy obsolete.

However, a study published in the April 23, 1983, new England Journal of Medicine specifically refutes that contention: "We conclude that advances in diagnostic technology have not reduced the value of the autopsy." Numerous additional studies published in JAMA and NEJM in recent years reveal that autopsies turn up an unexpected diagnosis that contributes to death approximately 20% to 40% of the time. Such errors skew vital statistics and priorities for funding disease research, which are typically drawn from death certificates. "Vital statistics are quite questionable when there is a low autopsy rate," Dr. Lundberg says. And Dr. Hastings adds: "There are tremendous implications for public health when a diagnosis doesn’t match autopsy results. There may be disease entities we’re not picking up." Some question the motives and controls of free-lance autopsy services. Only three states-Hawaii, Indiana and New Jersey-require that an autopsy be performed by a pathologist. All others just require a licensed physician, says John Pless, MD, president of the national Assn. of Medical Examiners.

Meanwhile, many are concerned about quality issues, Dr. Hastings says. Who is doing autopsies, and are they highly skilled? Some physicians going into private autopsies may not have the requisite skills and may be going into if for the money. "As hospital pathologists do less and few autopsies, their ability comes into question, too," Dr. Hastings adds. "In off-the-record nationwide interviews, a lot of physicians told us they didn’t have confidence in pathology departments to do autopsies." Still, independent autopsy businesses may grow further as a result of physicians and pathologists attempting to find work. Some may choose to start their own autopsy businesses. Nearly 12% of all 1995 pathology residents whose found jobs experienced difficulty in obtaining those jobs, according to a survey published in JAMA June 4, 1997. In 1995, the median pathologist salary was $185,000. In 1996, he last year surveyed by the AMA’s Sauce-Economic Monitoring System, it dropped to $170,000.

"Salaries have declined significantly in areas saturated by managed care," says Richard Horowitz, MD, UCLA and USC pathology professor. And Herrera adds, "I have a file of 4,000 pathologists out of work or looking for ways to supplement their income."