Irish Labs Appeal to Keep Pap Smear Expertise

Decision to outsource nation’s Pap tests overseas makes it tough to train new doctors in cytology

CEO SUMMARY: In Ireland, pathologists are asking the government to return enough Pap tests back to the country to support and sustain medical training programs in gynecologic cytology. It was 2008 when the Irish government outsourced all Pap testing to a U.S. lab company. That forced Ireland’s major cytology laboratories to shut down their cervical cancer testing, leaving them without access to the specimens needed to support medical training programs in cervical cancer screening and diagnosis.

IN IRELAND, LABORATORY PROFESSIONALS are taking active steps to protect expertise in gynecological cytology testing one year after the Irish government decided to outsource all the nation’s Pap testing to a laboratory in the United States.

This is an unprecedented situation for developed countries. It has gone under-reported and mostly unnoticed by the clinical lab testing industry in the United States. However, THE DARK REPORT believes this is the first example of the national government in a developed country outsourcing the total caseload of a major health service to providers in another country.

For that reason, this action opens the door to what has often been discussed by pathologists: what happens when a national health service decides to outsource large volumes of clinical laboratory specimens? Will the Irish Pap test outsourcing deal become a precedent that encourages other nations to send laboratory specimens to foreign countries for such reasons as faster turnaround time, to save money, or to improve quality?

In the case of Ireland, government health officials said in 2008 that outsourcing all the nation’s Pap testing was necessary to resolve excessive delays in the turnaround times for the country’s Pap testing. Cost savings from the outsourcing contract were initially not disclosed to the public.

In the latest development, the Royal College of Physicians in Ireland (RCPI) has been negotiating with Ireland’s Department of Health and the National Cancer Screening Service (NCSS) to request that some volume of Pap testing be returned to Ireland. These cases would be used in programs to train new doctors and other categories of health professionals that need these skills.

Pap Testing In Irish Labs

“We are cautiously optimistic that a solution can be reached that would see some gynecologic cytology being processed fully in Irish laboratories, which would address the training needs and also ensure that Ireland has a strategic resource and is not completely dependent on other countries to perform a critical laboratory function,” stated Dr. Conor O’Keane. He is Dean of the Faculty of Pathology at RCPI. He was quoted earlier this year in Irish Medical News.

Just a few weeks ago, Irish newspapers reported that government health officials were requesting that Quest Diagnostics Incorporated, which holds the Pap testing outsourcing contract, cooperate in subcontracting Pap smear cases back to Irish laboratories. Press accounts say Quest Diagnostics has been requested to subcontract back to Irish labs between 25,000 and 50,000 of the 300,000 Pap tests it gets annually from Ireland. Irish officials hope such a proposal can be developed by the end of September. These cytology specimens would be used for training pathologists and others in Ireland’s medical school programs.

No Alternatives Were Offered

Within Ireland, the decision to outsource all the nation’s Pap testing to Quest Diagnostics has not been without controversy. Pathologists and patient groups have pointed out that alternative approaches to solving the problems associated with gynecological testing in Ireland were not given equal consideration with the option of total outsourcing.

In 2007, the health service moved what was then called the Irish Cervical Screening Program (ICSP) into the National Cancer Screening Service (NCSS). The goal was to provide a single national cervical cancer screening program to cover the 1.1 million women in Ireland who are between 25 and 60 years of age.

This national cervical cancer screening program was launched on September 1, 2008. It is called “CervicalCheck.” On July 1, 2008, just 60 days prior to that introduction, the Pap test outsourcing contract with Quest Diagnostics took effect.

A primary criticism of the then-existing Pap testing capability in Ireland was that it commonly took six months for results of a Pap test be reported. In some cases, physicians and patients might wait as long as 12 months to get the results from the Pap test. For these reasons, one primary goal of NCSS was to cut the turnaround time on Pap test reporting to 10 days. It published a public tender (request for bid) in December 2007.

Three Criteria To Bid

Three primary requirements in the tender were: 1) the cytology lab bidder needed to have performed a minimum of 25,000 tests during the previous year; 2) the bidding laboratory had to be accredited; and, 3) the laboratory had to be able to process a test within 10 days.

Of the six Irish laboratories which submitted bids, none were selected. In response to that news, Terry Casey, with the Medical Laboratory Scientists Association (MLSA), was quoted in the Irish Times as saying: “to send a message that none [of the Irish labs that bid] could meet the criteria to deliver this important program for the Irish public is damning.”

Under criticism from many quarters about this decision, Mary Harney, Minister for Health, defended it by observing that the price submitted by Quest Diagnostics was one-third less than any bid put forth by an Irish laboratory—while also noting that Quest’s services were “quality assured” and it would meet the 10-day turnaround requirement.

Irish Cytology Labs Closed

Now, a year into the contract, Irish laboratories which performed cervical cancer screening tests and offered specialized training in cytology have closed. The nation’s medical schools have no capability to train new pathologists for the six weeks of gynecologic cytology required for them to pass their exit examinations. It is this situation which spurred pathologists to speak out. They requested that some number of cervical cancer screening tests be returned for testing in selected Irish labs to reestablish gynecologic cytology training programs.

Ireland, as the first developed nation to outsource a major and important healthcare service such as screening tests for cervical cancer, is breaking new ground. Concerns about the inability to properly train new Irish doctors in gynecologic cytology certainly have merit.

On the other hand, the government health service has defended its outsourcing decision by pointing out that physicians and patients in Ireland now get Pap test results within a couple of weeks, and that is a major improvement from the prior waits for test results, which were commonly six months and sometimes longer.

What Comes Next?

Of course, perceptive readers of THE DARK REPORT no doubt noticed that, by the admittance of Health Minister Mary Harney, the Irish Health Service is saving 33% on all its Pap testing! That’s a big win in anyone’s book. And all these improvements and savings seem to have been achieved without any major problems since the outsourcing contract began last year.

What has not yet been weighed and found wanting about the “total outsourcing” strategy are the longer-term consequences to Irish patients. Will the elimination of most in-country gynecologic cytology capability prove to be an issue? It will take several more years for that question to be answered. The bad news is that, if there proves to be a problem, it will be female patients who bear the negative consequences—not the health system bureaucrats who decided to close down all the nation’s operational cytology laboratories in favor of total outsourcing.

Doing Business on Low Price

There’s another interesting dimension to this groundbreaking outsourcing arrangement. Might this current Pap testing contract encourage accredited and well-run laboratories from countries with significantly lower labor costs to enter bids at the expiration of this contract? Will this arrangement between Ireland and Quest Diagnostics become the door-opener that allows laboratories in countries like India, Malaysia and similar developing countries to contest for the next Irish lab test outsourcing contract?

This is why events now unfolding in Ireland may have global ramifications for pathology and laboratory medicine. Ireland’s Pap test outsourcing contract may turn out to be a major step toward the further commoditization of laboratory testing.

Irish Health & Quest Had Relationship Since 2006

WHEN THE IRISH NATIONAL CANCER SCREENING SERVICE (NCSS) awarded Quest Diagnostics Incorporated with a multi-year contract to perform almost all the nation’s cervical cancer screening tests, it was not the first business deal between the two organizations.

As early as 2006, officials in the Irish health service were sending Pap specimens to Quest Diagnostics in order to clear backlogs of testing. These specimens originated at such laboratories as Cork University Hospital, The Royal College of Surgeons in Ireland (RCSI) in Dublin, and St. Luke’s Hospital in Dublin. During the next two years, as many as 50,000 Irish specimens were tested by Quest Diagnostics in its laboratory facilities in the United States.

Several lab sites in the Quest Diagnostics system handled this Irish testing, including Quest labs in Irving, Texas, and Atlanta, Georgia. Public information indicates that most of the 300,000 Pap tests under the current national contract are being handled by Quest laboratories in Chicago and Teterboro.

During these two years, the contracting relationship must have gone smoothly enough for the Health Service Executive (HSE), Ireland’s national health administrator, to have confidence that Quest Diagnostics was up to the challenge of handling 300,000 Pap specimens each year from Ireland under the current contract.

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