Commentary: Prepare for Reimbursement Turbulence

Increases in the volume of dermatologic procedures over the past 15 years are the result of dermatology's reinvention of itself as a surgical specialty, as well as a result of what is a very real skin cancer epidemic.

But that, coupled with the disproportionate percentage of the total reimbursed relative value unit (RVU) pool going to dermatologists, has raised red flags for those charged with cutting costs, and has left the specialty particularly vulnerable to cuts in reimbursement.

Between 1995 and 2008, skin biopsies increased by 76%, destructions by 64%, excisions by 17%, actinic keratoses (AKs) of 15 or greater by 17%, and use of pathology code 88305 by 81%. Even more striking - and potentially at the expense of cuts of up to 25%-30% in reimbursement for these procedures - Mohs surgery is up about 400%, according to the most recent data.

The powers that be aren't looking too favorably upon these increases, especially considering that from 1992 to 2002, the total reimbursed RVU pool percentage for dermatologists increased from 2.5% to 2.9%, while dermatologists accounted for only 1% of all physicians.

This increase is appropriate, given the overhead required for the surgical components of dermatology practice and the increased demand, but it has led to a view of dermatologists as greedy and overpaid.

I don't think we're the greedy dermatologists that many make us out to be; we're office-based, frontline specialists responding to an unrecognized epidemic. But those charged with cutting costs don't see it that way, because they either don't understand or refuse to acknowledge that there is a very real skin cancer epidemic in this country.

A review of multiple Medicare and Ambulatory Medical Care Service databases showed that the number of procedures for skin cancer increased 77% from nearly 1.2 million in 1992 to nearly 2.1 million in 2006. The most recent estimate is that the total number of nonmelanoma skin cancers in the U.S. population is about 4 million.

There are a number of misconceptions about dermatology that are contributing to the specialty's being under siege, and some of them are from dermatologists themselves.

Among the fundamental misconceptions by MedPAC, Congress, and the Centers for Medicare and Medicaid Services are the following:

• What dermatologists do is not important and is mostly cosmetic.

• The increase in RVUs comes from waste and abuse, and from unimportant minor-procedure codes that pay too much.

• There is no skin cancer epidemic.

• New money is not needed in the payment pool for health care.

Dermatologists themselves are also guilty of misconceptions about the specialty. For example, there is a misconception among dermatologists that training more dermatologists and physician extenders will benefit dermatology, when in actuality they will increase utilization and trigger more scrutiny and punishment in the form of cuts to reimbursement.

Similarly, promoting dermatology services to the public won't help until the utilization constraints on the payer side have been solved.

In the next 5 years, it is likely that physicians - and particularly specialists - will take the brunt of any cost-savings attempts by Congress. Dermatology, in particular, will be targeted for cuts because of increased utilization.

I also predict that in the next 5 years the skin cancer epidemic will continue as baby boomers age; that Mohs surgery will not regain its multiple surgery reduction exemption; that appropriateness criteria for Mohs, AK destruction, and perhaps even shaves, skin biopsies, and pathology will emerge; that existing ambulatory surgery centers will become more valuable because new centers will become difficult to license; that Mohs surgeons will band together in groups; and that cosmetic procedures will continue to increase as baby boomers age.

In the face of so many misconceptions and some dire predictions about the future of the specialty, it is imperative that dermatologists work together to educate Congress, MedPAC, and the CMS about the skin cancer epidemic, and prove that dermatologists are the solution, not the problem.
We have to show them that as their constituents live longer, they get more diseases per unit of time, and that we aren't making this up to make more money.

We also have to convince them that epidemics require new money to allow them to be addressed adequately.

This will require a coordinated agenda at the highest levels. Quality must be defined and measured on our terms, and utilization must be controlled or we will risk losing our specialty. We must define our peer groups within dermatology, and a list must be developed of acceptable and unacceptable nominees to the Independent Payment Advisory Board - the panel appointed by Congress to determine payment structure, which is perhaps the biggest threat to the specialty.

What else can you do? Join the American Medical Association (AMA), not because of their politics but because our representation is dependent on your membership. Also, donate to the SkinPAC. This is critical to get politicians elected who understand us. And elect strong, decisive people - not necessarily the nicest people - to your leadership and board of directors because there are some challenges and tough decisions ahead.

Dr. Coldiron is president of the American College of Mohs Surgery and a clinical assistant professor of dermatology at the University of Cincinnati. He has a private practice in Cincinnati.

Increases in the volume of dermatologic procedures over the past 15 years are the result of dermatology's reinvention of itself as a surgical specialty, as well as a result of what is a very real skin cancer epidemic.

But that, coupled with the disproportionate percentage of the total reimbursed relative value unit (RVU) pool going to dermatologists, has raised red flags for those charged with cutting costs, and has left the specialty particularly vulnerable to cuts in reimbursement.

Between 1995 and 2008, skin biopsies increased by 76%, destructions by 64%, excisions by 17%, actinic keratoses (AKs) of 15 or greater by 17%, and use of pathology code 88305 by 81%. Even more striking - and potentially at the expense of cuts of up to 25%-30% in reimbursement for these procedures - Mohs surgery is up about 400%, according to the most recent data.

The powers that be aren't looking too favorably upon these increases, especially considering that from 1992 to 2002, the total reimbursed RVU pool percentage for dermatologists increased from 2.5% to 2.9%, while dermatologists accounted for only 1% of all physicians.

This increase is appropriate, given the overhead required for the surgical components of dermatology practice and the increased demand, but it has led to a view of dermatologists as greedy and overpaid.

I don't think we're the greedy dermatologists that many make us out to be; we're office-based, frontline specialists responding to an unrecognized epidemic. But those charged with cutting costs don't see it that way, because they either don't understand or refuse to acknowledge that there is a very real skin cancer epidemic in this country.

A review of multiple Medicare and Ambulatory Medical Care Service databases showed that the number of procedures for skin cancer increased 77% from nearly 1.2 million in 1992 to nearly 2.1 million in 2006. The most recent estimate is that the total number of nonmelanoma skin cancers in the U.S. population is about 4 million.

There are a number of misconceptions about dermatology that are contributing to the specialty's being under siege, and some of them are from dermatologists themselves.

Among the fundamental misconceptions by MedPAC, Congress, and the Centers for Medicare and Medicaid Services are the following:

• What dermatologists do is not important and is mostly cosmetic.

• The increase in RVUs comes from waste and abuse, and from unimportant minor-procedure codes that pay too much.

• There is no skin cancer epidemic.

• New money is not needed in the payment pool for health care.

Dermatologists themselves are also guilty of misconceptions about the specialty. For example, there is a misconception among dermatologists that training more dermatologists and physician extenders will benefit dermatology, when in actuality they will increase utilization and trigger more scrutiny and punishment in the form of cuts to reimbursement.

Similarly, promoting dermatology services to the public won't help until the utilization constraints on the payer side have been solved.

In the next 5 years, it is likely that physicians - and particularly specialists - will take the brunt of any cost-savings attempts by Congress. Dermatology, in particular, will be targeted for cuts because of increased utilization.

I also predict that in the next 5 years the skin cancer epidemic will continue as baby boomers age; that Mohs surgery will not regain its multiple surgery reduction exemption; that appropriateness criteria for Mohs, AK destruction, and perhaps even shaves, skin biopsies, and pathology will emerge; that existing ambulatory surgery centers will become more valuable because new centers will become difficult to license; that Mohs surgeons will band together in groups; and that cosmetic procedures will continue to increase as baby boomers age.

In the face of so many misconceptions and some dire predictions about the future of the specialty, it is imperative that dermatologists work together to educate Congress, MedPAC, and the CMS about the skin cancer epidemic, and prove that dermatologists are the solution, not the problem.
We have to show them that as their constituents live longer, they get more diseases per unit of time, and that we aren't making this up to make more money.

We also have to convince them that epidemics require new money to allow them to be addressed adequately.

This will require a coordinated agenda at the highest levels. Quality must be defined and measured on our terms, and utilization must be controlled or we will risk losing our specialty. We must define our peer groups within dermatology, and a list must be developed of acceptable and unacceptable nominees to the Independent Payment Advisory Board - the panel appointed by Congress to determine payment structure, which is perhaps the biggest threat to the specialty.

What else can you do? Join the American Medical Association (AMA), not because of their politics but because our representation is dependent on your membership. Also, donate to the SkinPAC. This is critical to get politicians elected who understand us. And elect strong, decisive people - not necessarily the nicest people - to your leadership and board of directors because there are some challenges and tough decisions ahead.

Dr. Coldiron is president of the American College of Mohs Surgery and a clinical assistant professor of dermatology at the University of Cincinnati. He has a private practice in Cincinnati.

Increases in the volume of dermatologic procedures over the past 15 years are the result of dermatology's reinvention of itself as a surgical specialty, as well as a result of what is a very real skin cancer epidemic.

But that, coupled with the disproportionate percentage of the total reimbursed relative value unit (RVU) pool going to dermatologists, has raised red flags for those charged with cutting costs, and has left the specialty particularly vulnerable to cuts in reimbursement.

Between 1995 and 2008, skin biopsies increased by 76%, destructions by 64%, excisions by 17%, actinic keratoses (AKs) of 15 or greater by 17%, and use of pathology code 88305 by 81%. Even more striking - and potentially at the expense of cuts of up to 25%-30% in reimbursement for these procedures - Mohs surgery is up about 400%, according to the most recent data.

The powers that be aren't looking too favorably upon these increases, especially considering that from 1992 to 2002, the total reimbursed RVU pool percentage for dermatologists increased from 2.5% to 2.9%, while dermatologists accounted for only 1% of all physicians.

This increase is appropriate, given the overhead required for the surgical components of dermatology practice and the increased demand, but it has led to a view of dermatologists as greedy and overpaid.

I don't think we're the greedy dermatologists that many make us out to be; we're office-based, frontline specialists responding to an unrecognized epidemic. But those charged with cutting costs don't see it that way, because they either don't understand or refuse to acknowledge that there is a very real skin cancer epidemic in this country.

A review of multiple Medicare and Ambulatory Medical Care Service databases showed that the number of procedures for skin cancer increased 77% from nearly 1.2 million in 1992 to nearly 2.1 million in 2006. The most recent estimate is that the total number of nonmelanoma skin cancers in the U.S. population is about 4 million.

There are a number of misconceptions about dermatology that are contributing to the specialty's being under siege, and some of them are from dermatologists themselves.

Among the fundamental misconceptions by MedPAC, Congress, and the Centers for Medicare and Medicaid Services are the following:

• What dermatologists do is not important and is mostly cosmetic.

• The increase in RVUs comes from waste and abuse, and from unimportant minor-procedure codes that pay too much.

• There is no skin cancer epidemic.

• New money is not needed in the payment pool for health care.

Dermatologists themselves are also guilty of misconceptions about the specialty. For example, there is a misconception among dermatologists that training more dermatologists and physician extenders will benefit dermatology, when in actuality they will increase utilization and trigger more scrutiny and punishment in the form of cuts to reimbursement.

Similarly, promoting dermatology services to the public won't help until the utilization constraints on the payer side have been solved.

In the next 5 years, it is likely that physicians - and particularly specialists - will take the brunt of any cost-savings attempts by Congress. Dermatology, in particular, will be targeted for cuts because of increased utilization.

I also predict that in the next 5 years the skin cancer epidemic will continue as baby boomers age; that Mohs surgery will not regain its multiple surgery reduction exemption; that appropriateness criteria for Mohs, AK destruction, and perhaps even shaves, skin biopsies, and pathology will emerge; that existing ambulatory surgery centers will become more valuable because new centers will become difficult to license; that Mohs surgeons will band together in groups; and that cosmetic procedures will continue to increase as baby boomers age.

In the face of so many misconceptions and some dire predictions about the future of the specialty, it is imperative that dermatologists work together to educate Congress, MedPAC, and the CMS about the skin cancer epidemic, and prove that dermatologists are the solution, not the problem.
We have to show them that as their constituents live longer, they get more diseases per unit of time, and that we aren't making this up to make more money.

We also have to convince them that epidemics require new money to allow them to be addressed adequately.

This will require a coordinated agenda at the highest levels. Quality must be defined and measured on our terms, and utilization must be controlled or we will risk losing our specialty. We must define our peer groups within dermatology, and a list must be developed of acceptable and unacceptable nominees to the Independent Payment Advisory Board - the panel appointed by Congress to determine payment structure, which is perhaps the biggest threat to the specialty.

What else can you do? Join the American Medical Association (AMA), not because of their politics but because our representation is dependent on your membership. Also, donate to the SkinPAC. This is critical to get politicians elected who understand us. And elect strong, decisive people - not necessarily the nicest people - to your leadership and board of directors because there are some challenges and tough decisions ahead.

Dr. Coldiron is president of the American College of Mohs Surgery and a clinical assistant professor of dermatology at the University of Cincinnati. He has a private practice in Cincinnati.