Cold Iron Truth

I have become increasingly dismayed by reports of dermatologists who allow their nurse practitioners and physician assistants to practice independently.

That is, the employing dermatologists only see the patients, new or established, if they are asked to, and often are not even on the premises. In fact, they might be thousands of miles away.

A little background is in order. Physician assistants and nurse practitioners are formally trained in primary care, not in dermatology, although there are currently three 1-year programs to help them specialize in dermatology. When Congress authorized their independent payment in 1997, they envisioned primary care nurses traveling the hills, hollers, and inner cities improving health care. Unfortunately, this hasn’t happened, and instead they have moved into suburban America, and increasingly, are practicing specialty medicine.

It can be argued that decreased access to primary care, which was the reason midlevels were created, is more important than is access to dermatology. In particular, extenders have targeted office-based specialties such as dermatology, but also neurology and pain medicine. These specialties are office based, and credentialing by hospitals is not required to bill insurance plans. Also, these specialties have good-paying, seemingly simple, small procedures. They have accomplished this with the avid help of dermatologists, I might add. There will be an estimated 10,000 “dermatology” nurse practitioners and physician assistants next year.

Let me be clear: I am not opposed to a dermatology extender who works closely with a dermatologist and does intake histories and physicals, then staffs with the physician, assists with surgery, or sees routine follow-ups (think acne, psoriasis, atopy, suture removal, and warts) on an established protocol with the full knowledge of the patient.

This is not what we are seeing. We have nurse practitioners buying retiring dermatologists’ practices, physician assistants independently setting up remote clinics then hiring “supervising” dermatologists to visit once a week to sign and review charts, and independent “dermatology” clinics with a doctor thousands of miles away available, if really needed, by telephone or the Internet. (This is not really telemedicine, is it?) These extenders are listed as dermatologists on the Internet, or they hide behind the name of a dermatologist, and when you call their offices, and ask if you will see a “real” dermatologist, the answer is often “Oh, don’t worry, our nurse or PA specializes in dermatology.”

I think this is grossly unfair to patients, who, when they call the dermatology center listed on the Internet, can’t conceive that their dermatology appointment is not being made with a dermatologist, not even being made with a physician, but with a nurse practitioner or physician assistant! I also think it does a huge disservice to the specialty. The “collaborating” dermatologists enabling these extenders are renting out the good name of our specialty.

Patients seen by these extenders may also be subject to unnecessary biopsies. (If you don’t know what it is, you must biopsy it!) It also results in additional charges for pathology and additional medical misadventures.

In addition, I think it is unfair to the extender who is put in this situation. They may have worked in a dermatologist’s office for a few months or even years but are now being asked to pretend to be something they are not and being expected to perform at the level of a medical professional who has had many years of intense, focused training in dermatology. If they are not uncomfortable being thrust into this situation, then they are delusional.

I think it is unfair to the medical system who pays for the less informed opinion and unnecessary procedures. This is not a “good value” except to the rent-seeking dermatologists, who are the front men for this money-making deception.

This is an elephant in the room of dermatology, and I think we have to confront it. This trivializes our specialty and helps allow other specialties and regulatory agencies to ignore or exclude us from the networks and from the conversation. Unfortunately, many of our members and some of our leadership have been corrupted by the “easy money” or “easy time” afforded by this cheapening of the specialty.

Let me give you some examples. The rent seekers piously claim, “there is a shortage of dermatologists, and we are just trying to help save the world.” They also say “my nurses are special and great.”

The honest ones in private practice, however, say, “Man, I make $200,000 a year off my PA while I am off.” The honest academics say, “Listen, I work in a gulag, and I would never be able to travel if my nurses didn’t see my patients.” Time is money, and the academic who gets an extra 10 hours a week out of clinic is benefiting as much as the guy who makes $200,000 a year.

Of course, this situation is not sustainable and will become less viable because of a coming tsunami of malpractice claims, more focused insurer benchmarks revealing excessive test ordering and minor procedures, and patients getting wise. One obvious solution to this would be to reimburse extenders only for evaluation and management codes, which will take a change in law.

Meanwhile, I encourage all of you who feel the same nausea I do to ask candidates for your state and national dermatology organizations if they employ unsupervised extenders. Then check their website for the names of the extenders they employ. Then go to the Medicare data and look up their extenders and see if they bill independently for dermatologic procedures. I think you will be very disturbed, as I was and am.

I hope this stimulates a little self-examination among dermatologists.

Dr. Coldiron is a past-president of the American Academy of Dermatology. He is currently in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

I have become increasingly dismayed by reports of dermatologists who allow their nurse practitioners and physician assistants to practice independently.

That is, the employing dermatologists only see the patients, new or established, if they are asked to, and often are not even on the premises. In fact, they might be thousands of miles away.

A little background is in order. Physician assistants and nurse practitioners are formally trained in primary care, not in dermatology, although there are currently three 1-year programs to help them specialize in dermatology. When Congress authorized their independent payment in 1997, they envisioned primary care nurses traveling the hills, hollers, and inner cities improving health care. Unfortunately, this hasn’t happened, and instead they have moved into suburban America, and increasingly, are practicing specialty medicine.

It can be argued that decreased access to primary care, which was the reason midlevels were created, is more important than is access to dermatology. In particular, extenders have targeted office-based specialties such as dermatology, but also neurology and pain medicine. These specialties are office based, and credentialing by hospitals is not required to bill insurance plans. Also, these specialties have good-paying, seemingly simple, small procedures. They have accomplished this with the avid help of dermatologists, I might add. There will be an estimated 10,000 “dermatology” nurse practitioners and physician assistants next year.

Let me be clear: I am not opposed to a dermatology extender who works closely with a dermatologist and does intake histories and physicals, then staffs with the physician, assists with surgery, or sees routine follow-ups (think acne, psoriasis, atopy, suture removal, and warts) on an established protocol with the full knowledge of the patient.

This is not what we are seeing. We have nurse practitioners buying retiring dermatologists’ practices, physician assistants independently setting up remote clinics then hiring “supervising” dermatologists to visit once a week to sign and review charts, and independent “dermatology” clinics with a doctor thousands of miles away available, if really needed, by telephone or the Internet. (This is not really telemedicine, is it?) These extenders are listed as dermatologists on the Internet, or they hide behind the name of a dermatologist, and when you call their offices, and ask if you will see a “real” dermatologist, the answer is often “Oh, don’t worry, our nurse or PA specializes in dermatology.”

I think this is grossly unfair to patients, who, when they call the dermatology center listed on the Internet, can’t conceive that their dermatology appointment is not being made with a dermatologist, not even being made with a physician, but with a nurse practitioner or physician assistant! I also think it does a huge disservice to the specialty. The “collaborating” dermatologists enabling these extenders are renting out the good name of our specialty.

Patients seen by these extenders may also be subject to unnecessary biopsies. (If you don’t know what it is, you must biopsy it!) It also results in additional charges for pathology and additional medical misadventures.

In addition, I think it is unfair to the extender who is put in this situation. They may have worked in a dermatologist’s office for a few months or even years but are now being asked to pretend to be something they are not and being expected to perform at the level of a medical professional who has had many years of intense, focused training in dermatology. If they are not uncomfortable being thrust into this situation, then they are delusional.

I think it is unfair to the medical system who pays for the less informed opinion and unnecessary procedures. This is not a “good value” except to the rent-seeking dermatologists, who are the front men for this money-making deception.

This is an elephant in the room of dermatology, and I think we have to confront it. This trivializes our specialty and helps allow other specialties and regulatory agencies to ignore or exclude us from the networks and from the conversation. Unfortunately, many of our members and some of our leadership have been corrupted by the “easy money” or “easy time” afforded by this cheapening of the specialty.

Let me give you some examples. The rent seekers piously claim, “there is a shortage of dermatologists, and we are just trying to help save the world.” They also say “my nurses are special and great.”

The honest ones in private practice, however, say, “Man, I make $200,000 a year off my PA while I am off.” The honest academics say, “Listen, I work in a gulag, and I would never be able to travel if my nurses didn’t see my patients.” Time is money, and the academic who gets an extra 10 hours a week out of clinic is benefiting as much as the guy who makes $200,000 a year.

Of course, this situation is not sustainable and will become less viable because of a coming tsunami of malpractice claims, more focused insurer benchmarks revealing excessive test ordering and minor procedures, and patients getting wise. One obvious solution to this would be to reimburse extenders only for evaluation and management codes, which will take a change in law.

Meanwhile, I encourage all of you who feel the same nausea I do to ask candidates for your state and national dermatology organizations if they employ unsupervised extenders. Then check their website for the names of the extenders they employ. Then go to the Medicare data and look up their extenders and see if they bill independently for dermatologic procedures. I think you will be very disturbed, as I was and am.

I hope this stimulates a little self-examination among dermatologists.

Dr. Coldiron is a past-president of the American Academy of Dermatology. He is currently in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

I have become increasingly dismayed by reports of dermatologists who allow their nurse practitioners and physician assistants to practice independently.

That is, the employing dermatologists only see the patients, new or established, if they are asked to, and often are not even on the premises. In fact, they might be thousands of miles away.

A little background is in order. Physician assistants and nurse practitioners are formally trained in primary care, not in dermatology, although there are currently three 1-year programs to help them specialize in dermatology. When Congress authorized their independent payment in 1997, they envisioned primary care nurses traveling the hills, hollers, and inner cities improving health care. Unfortunately, this hasn’t happened, and instead they have moved into suburban America, and increasingly, are practicing specialty medicine.

It can be argued that decreased access to primary care, which was the reason midlevels were created, is more important than is access to dermatology. In particular, extenders have targeted office-based specialties such as dermatology, but also neurology and pain medicine. These specialties are office based, and credentialing by hospitals is not required to bill insurance plans. Also, these specialties have good-paying, seemingly simple, small procedures. They have accomplished this with the avid help of dermatologists, I might add. There will be an estimated 10,000 “dermatology” nurse practitioners and physician assistants next year.

Let me be clear: I am not opposed to a dermatology extender who works closely with a dermatologist and does intake histories and physicals, then staffs with the physician, assists with surgery, or sees routine follow-ups (think acne, psoriasis, atopy, suture removal, and warts) on an established protocol with the full knowledge of the patient.

This is not what we are seeing. We have nurse practitioners buying retiring dermatologists’ practices, physician assistants independently setting up remote clinics then hiring “supervising” dermatologists to visit once a week to sign and review charts, and independent “dermatology” clinics with a doctor thousands of miles away available, if really needed, by telephone or the Internet. (This is not really telemedicine, is it?) These extenders are listed as dermatologists on the Internet, or they hide behind the name of a dermatologist, and when you call their offices, and ask if you will see a “real” dermatologist, the answer is often “Oh, don’t worry, our nurse or PA specializes in dermatology.”

I think this is grossly unfair to patients, who, when they call the dermatology center listed on the Internet, can’t conceive that their dermatology appointment is not being made with a dermatologist, not even being made with a physician, but with a nurse practitioner or physician assistant! I also think it does a huge disservice to the specialty. The “collaborating” dermatologists enabling these extenders are renting out the good name of our specialty.

Patients seen by these extenders may also be subject to unnecessary biopsies. (If you don’t know what it is, you must biopsy it!) It also results in additional charges for pathology and additional medical misadventures.

In addition, I think it is unfair to the extender who is put in this situation. They may have worked in a dermatologist’s office for a few months or even years but are now being asked to pretend to be something they are not and being expected to perform at the level of a medical professional who has had many years of intense, focused training in dermatology. If they are not uncomfortable being thrust into this situation, then they are delusional.

I think it is unfair to the medical system who pays for the less informed opinion and unnecessary procedures. This is not a “good value” except to the rent-seeking dermatologists, who are the front men for this money-making deception.

This is an elephant in the room of dermatology, and I think we have to confront it. This trivializes our specialty and helps allow other specialties and regulatory agencies to ignore or exclude us from the networks and from the conversation. Unfortunately, many of our members and some of our leadership have been corrupted by the “easy money” or “easy time” afforded by this cheapening of the specialty.

Let me give you some examples. The rent seekers piously claim, “there is a shortage of dermatologists, and we are just trying to help save the world.” They also say “my nurses are special and great.”

The honest ones in private practice, however, say, “Man, I make $200,000 a year off my PA while I am off.” The honest academics say, “Listen, I work in a gulag, and I would never be able to travel if my nurses didn’t see my patients.” Time is money, and the academic who gets an extra 10 hours a week out of clinic is benefiting as much as the guy who makes $200,000 a year.

Of course, this situation is not sustainable and will become less viable because of a coming tsunami of malpractice claims, more focused insurer benchmarks revealing excessive test ordering and minor procedures, and patients getting wise. One obvious solution to this would be to reimburse extenders only for evaluation and management codes, which will take a change in law.

Meanwhile, I encourage all of you who feel the same nausea I do to ask candidates for your state and national dermatology organizations if they employ unsupervised extenders. Then check their website for the names of the extenders they employ. Then go to the Medicare data and look up their extenders and see if they bill independently for dermatologic procedures. I think you will be very disturbed, as I was and am.

I hope this stimulates a little self-examination among dermatologists.

Dr. Coldiron is a past-president of the American Academy of Dermatology. He is currently in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

It’s a great day for our patients! The Food and Drug Administration has proposed new tanning bed restrictions that would not allow those under 18 years old to use tanning beds and would require adults to sign a written acknowledgment that certifies that they have been warned of the risks of tanning beds. These are proposed rules, so it is important for you to write and support them (or ask for even more). The rule is available for review and comments are accepted through March 21, 2016, at www.regulations.gov.

The American Academy of Dermatology and numerous state dermatology societies have been advocating for such restrictions for many years.

The real question is why has it taken so long. At a meeting almost 6 years ago, an FDA advisory committee agreed that these devices were hazardous and recommended greater restrictions. The answer is multifactorial, long, but an important one for dermatologists who have been patient advocates on this issue for many long years.

First, we had to establish a scientific basis for our efforts. Many contributed to this, from establishing basic science of ultraviolet injury, to demonstration of ultraviolet carcinogenesis in an animal model (a fish no less!), to publishing compelling numbers confirming the epidemic of skin cancer (for which I will take some credit). Once the literature was in place, we had the good fortune to have a dermatologist (a former resident of mine and good friend) who was acting surgeon general (Dr. Boris Lushniak) and brought the Centers for Disease Control and Prevention on board and declared ultraviolet radiation exposure a national health crisis.

During this time, the tanning industry was not idle. They were not highly organized and were caught off guard by the imposition of a federal tanning tax several years ago. Since then, they have become more organized and have hired lobbyists (reportedly the same ones who represented big tobacco) and petitioned congress for relief as small businesses. They claim they provide something that is healthful (vitamin D is good, right?), are small businesses, and sell something that people can get by walking outside, but in a timelier manner. Never mind that they are clustered around high school and college campuses and sell their carcinogenic wares to unsuspecting teenage girls. I remember arguing with a tanning lobbyist at a state hearing who claimed that dermatologists were trying to line their pockets because we sell ultraviolet radiation in our offices.

There are powerful social drivers behind tanning bed use. A tan in our office cubicle-based work force implies wealth and success since no one really has time to sit around a pool and cultivate one. The young are healthy and indestructible and haven’t seen or won’t believe the carnage wrought by skin cancer. Some do buy the pictures of resultant wrinkling. The good news is that tanning is nowhere as nearly addictive as tobacco and should be easier to vanquish. As the data continue to roll in, and as more movie stars go under the knife for skin cancer, the momentum builds. We are making progress and we will continue the campaign because prevention efforts will save more anguish and lives than an army of dermatologists.

It has taken 50 years to turn the tide on cigarette smoking and with a similarly long cancer latency, tanning will take persistent effort. The problem, however, has been identified, the solution obvious, and an ultimate victory for our patients inevitable. Dermatologists everywhere should take great pride in this victory at the FDA. Remember, tanning is the new tobacco!

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

It’s a great day for our patients! The Food and Drug Administration has proposed new tanning bed restrictions that would not allow those under 18 years old to use tanning beds and would require adults to sign a written acknowledgment that certifies that they have been warned of the risks of tanning beds. These are proposed rules, so it is important for you to write and support them (or ask for even more). The rule is available for review and comments are accepted through March 21, 2016, at www.regulations.gov.

The American Academy of Dermatology and numerous state dermatology societies have been advocating for such restrictions for many years.

The real question is why has it taken so long. At a meeting almost 6 years ago, an FDA advisory committee agreed that these devices were hazardous and recommended greater restrictions. The answer is multifactorial, long, but an important one for dermatologists who have been patient advocates on this issue for many long years.

First, we had to establish a scientific basis for our efforts. Many contributed to this, from establishing basic science of ultraviolet injury, to demonstration of ultraviolet carcinogenesis in an animal model (a fish no less!), to publishing compelling numbers confirming the epidemic of skin cancer (for which I will take some credit). Once the literature was in place, we had the good fortune to have a dermatologist (a former resident of mine and good friend) who was acting surgeon general (Dr. Boris Lushniak) and brought the Centers for Disease Control and Prevention on board and declared ultraviolet radiation exposure a national health crisis.

During this time, the tanning industry was not idle. They were not highly organized and were caught off guard by the imposition of a federal tanning tax several years ago. Since then, they have become more organized and have hired lobbyists (reportedly the same ones who represented big tobacco) and petitioned congress for relief as small businesses. They claim they provide something that is healthful (vitamin D is good, right?), are small businesses, and sell something that people can get by walking outside, but in a timelier manner. Never mind that they are clustered around high school and college campuses and sell their carcinogenic wares to unsuspecting teenage girls. I remember arguing with a tanning lobbyist at a state hearing who claimed that dermatologists were trying to line their pockets because we sell ultraviolet radiation in our offices.

There are powerful social drivers behind tanning bed use. A tan in our office cubicle-based work force implies wealth and success since no one really has time to sit around a pool and cultivate one. The young are healthy and indestructible and haven’t seen or won’t believe the carnage wrought by skin cancer. Some do buy the pictures of resultant wrinkling. The good news is that tanning is nowhere as nearly addictive as tobacco and should be easier to vanquish. As the data continue to roll in, and as more movie stars go under the knife for skin cancer, the momentum builds. We are making progress and we will continue the campaign because prevention efforts will save more anguish and lives than an army of dermatologists.

It has taken 50 years to turn the tide on cigarette smoking and with a similarly long cancer latency, tanning will take persistent effort. The problem, however, has been identified, the solution obvious, and an ultimate victory for our patients inevitable. Dermatologists everywhere should take great pride in this victory at the FDA. Remember, tanning is the new tobacco!

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

It’s a great day for our patients! The Food and Drug Administration has proposed new tanning bed restrictions that would not allow those under 18 years old to use tanning beds and would require adults to sign a written acknowledgment that certifies that they have been warned of the risks of tanning beds. These are proposed rules, so it is important for you to write and support them (or ask for even more). The rule is available for review and comments are accepted through March 21, 2016, at www.regulations.gov.

The American Academy of Dermatology and numerous state dermatology societies have been advocating for such restrictions for many years.

The real question is why has it taken so long. At a meeting almost 6 years ago, an FDA advisory committee agreed that these devices were hazardous and recommended greater restrictions. The answer is multifactorial, long, but an important one for dermatologists who have been patient advocates on this issue for many long years.

First, we had to establish a scientific basis for our efforts. Many contributed to this, from establishing basic science of ultraviolet injury, to demonstration of ultraviolet carcinogenesis in an animal model (a fish no less!), to publishing compelling numbers confirming the epidemic of skin cancer (for which I will take some credit). Once the literature was in place, we had the good fortune to have a dermatologist (a former resident of mine and good friend) who was acting surgeon general (Dr. Boris Lushniak) and brought the Centers for Disease Control and Prevention on board and declared ultraviolet radiation exposure a national health crisis.

During this time, the tanning industry was not idle. They were not highly organized and were caught off guard by the imposition of a federal tanning tax several years ago. Since then, they have become more organized and have hired lobbyists (reportedly the same ones who represented big tobacco) and petitioned congress for relief as small businesses. They claim they provide something that is healthful (vitamin D is good, right?), are small businesses, and sell something that people can get by walking outside, but in a timelier manner. Never mind that they are clustered around high school and college campuses and sell their carcinogenic wares to unsuspecting teenage girls. I remember arguing with a tanning lobbyist at a state hearing who claimed that dermatologists were trying to line their pockets because we sell ultraviolet radiation in our offices.

There are powerful social drivers behind tanning bed use. A tan in our office cubicle-based work force implies wealth and success since no one really has time to sit around a pool and cultivate one. The young are healthy and indestructible and haven’t seen or won’t believe the carnage wrought by skin cancer. Some do buy the pictures of resultant wrinkling. The good news is that tanning is nowhere as nearly addictive as tobacco and should be easier to vanquish. As the data continue to roll in, and as more movie stars go under the knife for skin cancer, the momentum builds. We are making progress and we will continue the campaign because prevention efforts will save more anguish and lives than an army of dermatologists.

It has taken 50 years to turn the tide on cigarette smoking and with a similarly long cancer latency, tanning will take persistent effort. The problem, however, has been identified, the solution obvious, and an ultimate victory for our patients inevitable. Dermatologists everywhere should take great pride in this victory at the FDA. Remember, tanning is the new tobacco!

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

We have actively avoided benchmarks in medicine since time immemorial. There is a strong argument that rote, one-size-fits-all parameters for care medicine are bad for our patients, and obviously they interfere with our flexibility in dealing with complex obscure diseases. This flexibility is critical in dermatology, where we deal with over 3,000 diseases, and there truly is more art than science involved in treating some of them.

Nonetheless, here come the benchmarks. Since we have not provided them, they have been provided for us. Look no further than United Health Care’s Optum program, or Cigna’s star ratings, both of which rank on average costs, without regard to subspecialty or intensity of disease.

Benchmarks have proven useful in industry and have improved quality there. I expect they will be most annoying to practicing physicians. There are also great variations in practice patterns we must make sure are accounted for. A pediatric dermatologist, for example, does radically fewer skin biopsies than a Mohs surgeon, and diagnoses many fewer malignancies. However, some things are inexplicable, even after opening two standard deviations, and you need to be aware they may be coming.

The Medicare data release was an eye opener for many. This information is readily available on multiple web sites in numeric and graphic display. You should look yourself and your “peers” up on the Wall Street Journal or ProPublicaweb sites. For example, it is hard to fathom how every closure can be a flap, or how every Mohs case is four stages. Or even more bizarre, how you can do Mohs and never have a second stage. It is hard to understand how most dermatologists have a certain number of skin biopsies or shave excisions per patient encounter and others ten times as many. With this in mind, I encourage all of you to look at your own ratios of procedures compared to your peers. Recall that Medicare data lag two years before publication. Areas that could be under scrutiny include:

• Number of skin biopsies per encounter.

• Number of repeat patient encounters per year.

• Number of lesion destructions per patient.

• Ratio of first to additional layers of Mohs.

• Number of Mohs procedures on trunk and extremities, compared with head and neck.

• Percentage of closures done with adjacent tissue transfers.

• Number of shave excisions per patient.

• Number of complex closures, compared with layered closures, particularly on the trunk and extremities.

• Number of diagnostic frozen sections.

• Frequency of use of special stains on pathology specimens.

We need to be actively involved in the development of these so that we are not forced into a one size fits all mold. I expect this will start with the private insurers, including Medicare advantage plans, since they have real time data analysis, and a keen desire to save money. These “benchmarks” will be a work in progress and will infuriate some of you. They are, however, more credible, and better, than the current state of affairs, where insurance companies rank you by simply averaging your costs under your tax identification number.

So heads up, benchmarks are coming your way. Review your own public data, compared with your peers and see if you are an outlier, and if so, ponder the reason why. It is not too late to take corrective action.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

We have actively avoided benchmarks in medicine since time immemorial. There is a strong argument that rote, one-size-fits-all parameters for care medicine are bad for our patients, and obviously they interfere with our flexibility in dealing with complex obscure diseases. This flexibility is critical in dermatology, where we deal with over 3,000 diseases, and there truly is more art than science involved in treating some of them.

Nonetheless, here come the benchmarks. Since we have not provided them, they have been provided for us. Look no further than United Health Care’s Optum program, or Cigna’s star ratings, both of which rank on average costs, without regard to subspecialty or intensity of disease.

Benchmarks have proven useful in industry and have improved quality there. I expect they will be most annoying to practicing physicians. There are also great variations in practice patterns we must make sure are accounted for. A pediatric dermatologist, for example, does radically fewer skin biopsies than a Mohs surgeon, and diagnoses many fewer malignancies. However, some things are inexplicable, even after opening two standard deviations, and you need to be aware they may be coming.

The Medicare data release was an eye opener for many. This information is readily available on multiple web sites in numeric and graphic display. You should look yourself and your “peers” up on the Wall Street Journal or ProPublicaweb sites. For example, it is hard to fathom how every closure can be a flap, or how every Mohs case is four stages. Or even more bizarre, how you can do Mohs and never have a second stage. It is hard to understand how most dermatologists have a certain number of skin biopsies or shave excisions per patient encounter and others ten times as many. With this in mind, I encourage all of you to look at your own ratios of procedures compared to your peers. Recall that Medicare data lag two years before publication. Areas that could be under scrutiny include:

• Number of skin biopsies per encounter.

• Number of repeat patient encounters per year.

• Number of lesion destructions per patient.

• Ratio of first to additional layers of Mohs.

• Number of Mohs procedures on trunk and extremities, compared with head and neck.

• Percentage of closures done with adjacent tissue transfers.

• Number of shave excisions per patient.

• Number of complex closures, compared with layered closures, particularly on the trunk and extremities.

• Number of diagnostic frozen sections.

• Frequency of use of special stains on pathology specimens.

We need to be actively involved in the development of these so that we are not forced into a one size fits all mold. I expect this will start with the private insurers, including Medicare advantage plans, since they have real time data analysis, and a keen desire to save money. These “benchmarks” will be a work in progress and will infuriate some of you. They are, however, more credible, and better, than the current state of affairs, where insurance companies rank you by simply averaging your costs under your tax identification number.

So heads up, benchmarks are coming your way. Review your own public data, compared with your peers and see if you are an outlier, and if so, ponder the reason why. It is not too late to take corrective action.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

We have actively avoided benchmarks in medicine since time immemorial. There is a strong argument that rote, one-size-fits-all parameters for care medicine are bad for our patients, and obviously they interfere with our flexibility in dealing with complex obscure diseases. This flexibility is critical in dermatology, where we deal with over 3,000 diseases, and there truly is more art than science involved in treating some of them.

Nonetheless, here come the benchmarks. Since we have not provided them, they have been provided for us. Look no further than United Health Care’s Optum program, or Cigna’s star ratings, both of which rank on average costs, without regard to subspecialty or intensity of disease.

Benchmarks have proven useful in industry and have improved quality there. I expect they will be most annoying to practicing physicians. There are also great variations in practice patterns we must make sure are accounted for. A pediatric dermatologist, for example, does radically fewer skin biopsies than a Mohs surgeon, and diagnoses many fewer malignancies. However, some things are inexplicable, even after opening two standard deviations, and you need to be aware they may be coming.

The Medicare data release was an eye opener for many. This information is readily available on multiple web sites in numeric and graphic display. You should look yourself and your “peers” up on the Wall Street Journal or ProPublicaweb sites. For example, it is hard to fathom how every closure can be a flap, or how every Mohs case is four stages. Or even more bizarre, how you can do Mohs and never have a second stage. It is hard to understand how most dermatologists have a certain number of skin biopsies or shave excisions per patient encounter and others ten times as many. With this in mind, I encourage all of you to look at your own ratios of procedures compared to your peers. Recall that Medicare data lag two years before publication. Areas that could be under scrutiny include:

• Number of skin biopsies per encounter.

• Number of repeat patient encounters per year.

• Number of lesion destructions per patient.

• Ratio of first to additional layers of Mohs.

• Number of Mohs procedures on trunk and extremities, compared with head and neck.

• Percentage of closures done with adjacent tissue transfers.

• Number of shave excisions per patient.

• Number of complex closures, compared with layered closures, particularly on the trunk and extremities.

• Number of diagnostic frozen sections.

• Frequency of use of special stains on pathology specimens.

We need to be actively involved in the development of these so that we are not forced into a one size fits all mold. I expect this will start with the private insurers, including Medicare advantage plans, since they have real time data analysis, and a keen desire to save money. These “benchmarks” will be a work in progress and will infuriate some of you. They are, however, more credible, and better, than the current state of affairs, where insurance companies rank you by simply averaging your costs under your tax identification number.

So heads up, benchmarks are coming your way. Review your own public data, compared with your peers and see if you are an outlier, and if so, ponder the reason why. It is not too late to take corrective action.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

One afternoon, after seeing your last patient, you’re doing the old-school thing, with your feet up, opening and reading your paper mail after a hard day’s work at the dermatology ranch. You see an odd form letter – a green sticker on the outside, certified mail – stating that you have been terminated from a Medicare advantage plan, no reason given.

At first, you don’t care so much. After all, this plan pays you only 95% of Medicare. Then you think about it and realize that this plan represents 50% of all Medicare beneficiaries in your area. You start to freak out, and you immediately go to the American Academy of Dermatology website where you read Rob Portman’s article about how to fight a termination notice and respond expeditiously.

Later that night, your spouse asks why you were singled out. “Are you a bad doctor? What did you do wrong? Can the kids still go to college?

The answer, most often, is that you did nothing wrong. You’ve just been caught up in the insurer’s network management software, Optum 360.

Optum 360 is a large health care information and management subsidiary of UnitedHealthcare. It was created as a joint venture by the Optum insight (health technology) unit of UnitedHealthcare, and Dignity Health (claims processing), forming Optum 360.

Optum claims that its software measures the efficiency of providers, saving insurers money and improving the quality of care – the Valhalla of health care managers everywhere. Unfortunately, Optum doesn’t deliver this vision of heaven on earth, at least not for dermatology.

Optum 360does little more than aggregate and average the costs of individual providers with no recognition of severity of disease or case mix. The physician with the most reimbursement during an episode of care for a given ICD-9 code (now for a group of ICD-10 codes) gets credited with all the expenses under that code. For example, you do two stages of Mohs surgery on a big basal cell on the nose that you send to plastics for repair. If the reimbursement for the Mohs surgery exceeds the plastics reimbursement, the Optum software designates you as the responsible provider. The cost of the plastics repair accrues to you; the hospital OR facility charges accrue to you (facilities are not considered a provider); and the anesthesiologist charges are credited to you. In addition, the superficial basal cell carcinoma on the patient’s back, treated a week later by the referring doctor, is also attributed to you as part of the original episode of care. There are no quality parameters and no subspecialty recognition.

If your patient load regularly includes patients who have Mohs surgery, the dermatologist down the street who does Mohs only once a week looks much better to Optum than you do. The referral-only medical dermatologist in town, who treats very sick patients and routinely prescribes biologics, and (heaven forbid) intravenous immunoglobulin, is similarly tagged for termination from the insurer’s network.

So it looks as though dermatologists who handle the toughest patients lose out. But who really loses the most? The sickest patients! The dermatologist can always fill the schedule with patients with other insurance coverage and reduce the backlog or, if worse comes to worse, he can take the Canadian cure and go on vacation. The sickest patients, however, get eliminated from the system when their doctors get eliminated by UnitedHealthcare’s software. Then patients often cannot find another doctor because most insurer’s physician rosters are 70% inaccurate (JAMA Dermatol. 2014 Dec;150[12]:1290-7).

In some circumstances, the sickest patients have reported either being unable to find other dermatologists willing to provide the special service they need or having to wait up to 6 months for an open appointment. These patients then try to drop back into fee-for-service Medicare, only to find they cannot afford the gap insurance, which costs five times as much. Why? Because those patients now have a preexisting condition. Yes, preexisting conditions still apply in the world of gap insurance.

This is obviously not optimal nor even acceptable. To quote Michael Keaton from the 1982 movie “Night Shift”: “Is this a great country or what?” The answer is a resounding “yes” for medical insurance companies who are booking record profits, but “no” for the sickest patients.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

One afternoon, after seeing your last patient, you’re doing the old-school thing, with your feet up, opening and reading your paper mail after a hard day’s work at the dermatology ranch. You see an odd form letter – a green sticker on the outside, certified mail – stating that you have been terminated from a Medicare advantage plan, no reason given.

At first, you don’t care so much. After all, this plan pays you only 95% of Medicare. Then you think about it and realize that this plan represents 50% of all Medicare beneficiaries in your area. You start to freak out, and you immediately go to the American Academy of Dermatology website where you read Rob Portman’s article about how to fight a termination notice and respond expeditiously.

Later that night, your spouse asks why you were singled out. “Are you a bad doctor? What did you do wrong? Can the kids still go to college?

The answer, most often, is that you did nothing wrong. You’ve just been caught up in the insurer’s network management software, Optum 360.

Optum 360 is a large health care information and management subsidiary of UnitedHealthcare. It was created as a joint venture by the Optum insight (health technology) unit of UnitedHealthcare, and Dignity Health (claims processing), forming Optum 360.

Optum claims that its software measures the efficiency of providers, saving insurers money and improving the quality of care – the Valhalla of health care managers everywhere. Unfortunately, Optum doesn’t deliver this vision of heaven on earth, at least not for dermatology.

Optum 360does little more than aggregate and average the costs of individual providers with no recognition of severity of disease or case mix. The physician with the most reimbursement during an episode of care for a given ICD-9 code (now for a group of ICD-10 codes) gets credited with all the expenses under that code. For example, you do two stages of Mohs surgery on a big basal cell on the nose that you send to plastics for repair. If the reimbursement for the Mohs surgery exceeds the plastics reimbursement, the Optum software designates you as the responsible provider. The cost of the plastics repair accrues to you; the hospital OR facility charges accrue to you (facilities are not considered a provider); and the anesthesiologist charges are credited to you. In addition, the superficial basal cell carcinoma on the patient’s back, treated a week later by the referring doctor, is also attributed to you as part of the original episode of care. There are no quality parameters and no subspecialty recognition.

If your patient load regularly includes patients who have Mohs surgery, the dermatologist down the street who does Mohs only once a week looks much better to Optum than you do. The referral-only medical dermatologist in town, who treats very sick patients and routinely prescribes biologics, and (heaven forbid) intravenous immunoglobulin, is similarly tagged for termination from the insurer’s network.

So it looks as though dermatologists who handle the toughest patients lose out. But who really loses the most? The sickest patients! The dermatologist can always fill the schedule with patients with other insurance coverage and reduce the backlog or, if worse comes to worse, he can take the Canadian cure and go on vacation. The sickest patients, however, get eliminated from the system when their doctors get eliminated by UnitedHealthcare’s software. Then patients often cannot find another doctor because most insurer’s physician rosters are 70% inaccurate (JAMA Dermatol. 2014 Dec;150[12]:1290-7).

In some circumstances, the sickest patients have reported either being unable to find other dermatologists willing to provide the special service they need or having to wait up to 6 months for an open appointment. These patients then try to drop back into fee-for-service Medicare, only to find they cannot afford the gap insurance, which costs five times as much. Why? Because those patients now have a preexisting condition. Yes, preexisting conditions still apply in the world of gap insurance.

This is obviously not optimal nor even acceptable. To quote Michael Keaton from the 1982 movie “Night Shift”: “Is this a great country or what?” The answer is a resounding “yes” for medical insurance companies who are booking record profits, but “no” for the sickest patients.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

One afternoon, after seeing your last patient, you’re doing the old-school thing, with your feet up, opening and reading your paper mail after a hard day’s work at the dermatology ranch. You see an odd form letter – a green sticker on the outside, certified mail – stating that you have been terminated from a Medicare advantage plan, no reason given.

At first, you don’t care so much. After all, this plan pays you only 95% of Medicare. Then you think about it and realize that this plan represents 50% of all Medicare beneficiaries in your area. You start to freak out, and you immediately go to the American Academy of Dermatology website where you read Rob Portman’s article about how to fight a termination notice and respond expeditiously.

Later that night, your spouse asks why you were singled out. “Are you a bad doctor? What did you do wrong? Can the kids still go to college?

The answer, most often, is that you did nothing wrong. You’ve just been caught up in the insurer’s network management software, Optum 360.

Optum 360 is a large health care information and management subsidiary of UnitedHealthcare. It was created as a joint venture by the Optum insight (health technology) unit of UnitedHealthcare, and Dignity Health (claims processing), forming Optum 360.

Optum claims that its software measures the efficiency of providers, saving insurers money and improving the quality of care – the Valhalla of health care managers everywhere. Unfortunately, Optum doesn’t deliver this vision of heaven on earth, at least not for dermatology.

Optum 360does little more than aggregate and average the costs of individual providers with no recognition of severity of disease or case mix. The physician with the most reimbursement during an episode of care for a given ICD-9 code (now for a group of ICD-10 codes) gets credited with all the expenses under that code. For example, you do two stages of Mohs surgery on a big basal cell on the nose that you send to plastics for repair. If the reimbursement for the Mohs surgery exceeds the plastics reimbursement, the Optum software designates you as the responsible provider. The cost of the plastics repair accrues to you; the hospital OR facility charges accrue to you (facilities are not considered a provider); and the anesthesiologist charges are credited to you. In addition, the superficial basal cell carcinoma on the patient’s back, treated a week later by the referring doctor, is also attributed to you as part of the original episode of care. There are no quality parameters and no subspecialty recognition.

If your patient load regularly includes patients who have Mohs surgery, the dermatologist down the street who does Mohs only once a week looks much better to Optum than you do. The referral-only medical dermatologist in town, who treats very sick patients and routinely prescribes biologics, and (heaven forbid) intravenous immunoglobulin, is similarly tagged for termination from the insurer’s network.

So it looks as though dermatologists who handle the toughest patients lose out. But who really loses the most? The sickest patients! The dermatologist can always fill the schedule with patients with other insurance coverage and reduce the backlog or, if worse comes to worse, he can take the Canadian cure and go on vacation. The sickest patients, however, get eliminated from the system when their doctors get eliminated by UnitedHealthcare’s software. Then patients often cannot find another doctor because most insurer’s physician rosters are 70% inaccurate (JAMA Dermatol. 2014 Dec;150[12]:1290-7).

In some circumstances, the sickest patients have reported either being unable to find other dermatologists willing to provide the special service they need or having to wait up to 6 months for an open appointment. These patients then try to drop back into fee-for-service Medicare, only to find they cannot afford the gap insurance, which costs five times as much. Why? Because those patients now have a preexisting condition. Yes, preexisting conditions still apply in the world of gap insurance.

This is obviously not optimal nor even acceptable. To quote Michael Keaton from the 1982 movie “Night Shift”: “Is this a great country or what?” The answer is a resounding “yes” for medical insurance companies who are booking record profits, but “no” for the sickest patients.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

I just returned from the American Academy of Dermatology’s Washington “fly-in” and wanted to share some of my experiences. Every year, 180 or so dermatologists (all are invited!) and patient advocates spend 3 days in D.C., getting informed, trained, and organized to deliver our message to Congress. Each year, members and AAD staff winnow our many “wants” down to three reasonable “asks.” Background is given and our message rehearsed, for delivery in congressional and Senate offices. On the third day, appointments are kept with your representatives, and you get to try and convince them that your particular ask is beneficial to the country and, most importantly, patients.

This year, our “asks” were for better access to medications, specifically the ability to compound medications in the office (think diluting Kenalog for injection, come on!), which new Food and Drug Administration rules will interfere with; emphasizing the unfairness of narrow Medicare advantage networks; and our last, and usually annual, request for increased research funding for skin disease research.

The fly-in is a fascinating, and often fun, experience, which does affect how the U.S. government works. Truly, the squeaky (and most coherent and organized, thanks to AAD staff) wheel gets the grease.

This year, we had the additional weapon of a Government Accountability Office report released the day before our Hill visit, which independently confirmed our allegations regarding the unfairness of narrow networks to patients.

You may recall that last year, the Center for Medicare & Medicaid Services published detailed rules on increasing the accuracy of provider networks, which would have corrected many of the current problems we face. The only deficiency was that CMS has no procedures to review, audit, or enforce the rules they wrote. At the prodding of the AAD, the GAO took CMS to the mat and pummeled them, including such choice quotes as “99% of current provider networks have never been reviewed for accuracy” and “exemptions to insurers with inadequate provider access are approved routinely and never reviewed again.” The GAO made several sweeping recommendations for increased accountability, and the Department of Health & Human Services agreed with all of them.

Boring? Hardly. Think of this as taking the wooden stake created by your AAD, which was adopted by one government agency, and having it driven through the heart of insurance company deceit by another. It made for great emphasis on the Hill, and I expect big changes (and moaning and groaning from Medicare advantage plan insurance providers) in the coming months.

We also made great progress (you can tell by the interest by the staffers and members in our topics) on our other issues. I want to emphasize how effective our patient advocates were in explaining how expensive generics and cost of new drugs adversely affects them, how they have seen their doctors “delisted” from their insurance because their care is expensive, and why research into skin disease is so important to them. They “tie it all together” and bring it home.

I often talk about my “Washington Epiphany,” which can be summarized as, “politicians don’t worry about doctors, but they do about patients.” When you talk to politicians, bureaucrats, policy wonks, or the public about the woes of medical practice, always align it with the needs of patients, and you will be well received. In short, take care of your patients and they will take care of you.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

I just returned from the American Academy of Dermatology’s Washington “fly-in” and wanted to share some of my experiences. Every year, 180 or so dermatologists (all are invited!) and patient advocates spend 3 days in D.C., getting informed, trained, and organized to deliver our message to Congress. Each year, members and AAD staff winnow our many “wants” down to three reasonable “asks.” Background is given and our message rehearsed, for delivery in congressional and Senate offices. On the third day, appointments are kept with your representatives, and you get to try and convince them that your particular ask is beneficial to the country and, most importantly, patients.

This year, our “asks” were for better access to medications, specifically the ability to compound medications in the office (think diluting Kenalog for injection, come on!), which new Food and Drug Administration rules will interfere with; emphasizing the unfairness of narrow Medicare advantage networks; and our last, and usually annual, request for increased research funding for skin disease research.

The fly-in is a fascinating, and often fun, experience, which does affect how the U.S. government works. Truly, the squeaky (and most coherent and organized, thanks to AAD staff) wheel gets the grease.

This year, we had the additional weapon of a Government Accountability Office report released the day before our Hill visit, which independently confirmed our allegations regarding the unfairness of narrow networks to patients.

You may recall that last year, the Center for Medicare & Medicaid Services published detailed rules on increasing the accuracy of provider networks, which would have corrected many of the current problems we face. The only deficiency was that CMS has no procedures to review, audit, or enforce the rules they wrote. At the prodding of the AAD, the GAO took CMS to the mat and pummeled them, including such choice quotes as “99% of current provider networks have never been reviewed for accuracy” and “exemptions to insurers with inadequate provider access are approved routinely and never reviewed again.” The GAO made several sweeping recommendations for increased accountability, and the Department of Health & Human Services agreed with all of them.

Boring? Hardly. Think of this as taking the wooden stake created by your AAD, which was adopted by one government agency, and having it driven through the heart of insurance company deceit by another. It made for great emphasis on the Hill, and I expect big changes (and moaning and groaning from Medicare advantage plan insurance providers) in the coming months.

We also made great progress (you can tell by the interest by the staffers and members in our topics) on our other issues. I want to emphasize how effective our patient advocates were in explaining how expensive generics and cost of new drugs adversely affects them, how they have seen their doctors “delisted” from their insurance because their care is expensive, and why research into skin disease is so important to them. They “tie it all together” and bring it home.

I often talk about my “Washington Epiphany,” which can be summarized as, “politicians don’t worry about doctors, but they do about patients.” When you talk to politicians, bureaucrats, policy wonks, or the public about the woes of medical practice, always align it with the needs of patients, and you will be well received. In short, take care of your patients and they will take care of you.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

I just returned from the American Academy of Dermatology’s Washington “fly-in” and wanted to share some of my experiences. Every year, 180 or so dermatologists (all are invited!) and patient advocates spend 3 days in D.C., getting informed, trained, and organized to deliver our message to Congress. Each year, members and AAD staff winnow our many “wants” down to three reasonable “asks.” Background is given and our message rehearsed, for delivery in congressional and Senate offices. On the third day, appointments are kept with your representatives, and you get to try and convince them that your particular ask is beneficial to the country and, most importantly, patients.

This year, our “asks” were for better access to medications, specifically the ability to compound medications in the office (think diluting Kenalog for injection, come on!), which new Food and Drug Administration rules will interfere with; emphasizing the unfairness of narrow Medicare advantage networks; and our last, and usually annual, request for increased research funding for skin disease research.

The fly-in is a fascinating, and often fun, experience, which does affect how the U.S. government works. Truly, the squeaky (and most coherent and organized, thanks to AAD staff) wheel gets the grease.

This year, we had the additional weapon of a Government Accountability Office report released the day before our Hill visit, which independently confirmed our allegations regarding the unfairness of narrow networks to patients.

You may recall that last year, the Center for Medicare & Medicaid Services published detailed rules on increasing the accuracy of provider networks, which would have corrected many of the current problems we face. The only deficiency was that CMS has no procedures to review, audit, or enforce the rules they wrote. At the prodding of the AAD, the GAO took CMS to the mat and pummeled them, including such choice quotes as “99% of current provider networks have never been reviewed for accuracy” and “exemptions to insurers with inadequate provider access are approved routinely and never reviewed again.” The GAO made several sweeping recommendations for increased accountability, and the Department of Health & Human Services agreed with all of them.

Boring? Hardly. Think of this as taking the wooden stake created by your AAD, which was adopted by one government agency, and having it driven through the heart of insurance company deceit by another. It made for great emphasis on the Hill, and I expect big changes (and moaning and groaning from Medicare advantage plan insurance providers) in the coming months.

We also made great progress (you can tell by the interest by the staffers and members in our topics) on our other issues. I want to emphasize how effective our patient advocates were in explaining how expensive generics and cost of new drugs adversely affects them, how they have seen their doctors “delisted” from their insurance because their care is expensive, and why research into skin disease is so important to them. They “tie it all together” and bring it home.

I often talk about my “Washington Epiphany,” which can be summarized as, “politicians don’t worry about doctors, but they do about patients.” When you talk to politicians, bureaucrats, policy wonks, or the public about the woes of medical practice, always align it with the needs of patients, and you will be well received. In short, take care of your patients and they will take care of you.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected].

Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.

Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.

No, it is not fine, because there are no validated quality measures for dermatologists.

Well great, you say, then dermatologists can’t be ranked.

No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.

Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.

Yes, some dermatologists get credit and a star for something that has nothing to do with them.

The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.

This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.

Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.

Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”

Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.

The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.

Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected]

Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.

Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.

No, it is not fine, because there are no validated quality measures for dermatologists.

Well great, you say, then dermatologists can’t be ranked.

No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.

Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.

Yes, some dermatologists get credit and a star for something that has nothing to do with them.

The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.

This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.

Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.

Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”

Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.

The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.

Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected]

Tiering is the “ranking” of physicians by insurance companies. These rankings are used to decide who gets to participate in the networks, how you get paid, the patient’s copay, and on and on. The rankings are also published. Insurance companies want to save money, and are attempting to do this under the guise of enhancing quality.

Fine, you say, I am an efficient dermatologist and ready to be ranked against anyone.

No, it is not fine, because there are no validated quality measures for dermatologists.

Well great, you say, then dermatologists can’t be ranked.

No, unfortunately, dermatologists are getting ranked anyway, and the process is little more than just making up a ranking.

Let me give you an example. Cigna has a two star system and ranks specialists according to “practice of evidence-based medicine” and “quality of care.” (See “How are specialists chosen for Cigna Care Designation” on Frequently Asked Questions on the Cigna web site). If there aren’t any quality measures for dermatologists, how can they do it? Well, they give the first star to a dermatologist if primary care doctors in their medical group check glycosylated hemoglobins and blood pressures.

Yes, some dermatologists get credit and a star for something that has nothing to do with them.

The second measure of quality is even more preposterous. Cigna uses cost-per-patient software, and the least expensive dermatologist gets the second star – no matter who or what they are treating, or what procedures they are performing.

This approach introduces multiple perversions into the system. First, the primary care doctors are under huge pressure to get their patients to comply with testing measures. Consequently, the systems they work for are insisting that they “fire” patients who do not come in for their checkups and get their blood checks.

Closer to home, dermatologists who do Mohs surgery full time, or who are in solo or small practices, or who prescribe expensive medications are penalized.

Cigna is one of six health insurers tiering dermatologists, but soon all insurers will be doing the same. Representatives from the American Academy of Dermatology, including myself, have met with Cigna and pointed out how meaningless it is to rank dermatologists without having specialty-specific quality parameters. The less-than-adequate response has been that “the lack of quality measures is a problem with several specialties.”

Given the lack of validated quality measures for dermatology, I find it bizarre that Health and Human Services Secretary Sylvia M. Burwell has set the goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. I’m afraid this is going to be a very blunt axe resulting in splintered health care.

The AAD is doing its best to delay this deadline, at least until there are some relevant quality measures for dermatology, and has launched a major data collection initiative – DataDerm. Amassing that information should give us some decent benchmarks in a few years. DataDerm will ultimately provide benchmark reports, access to clinically relevant data, quality measurement, and information to improve patient care.

Until then we will argue, reason, and cajole as best we can. Meanwhile, the AAD will need your help with DataDerm, and it won’t do any good for you to stomp your feet and just say ‘no.’ In future columns, I will discuss the impacts of UnitedHealth Group’s misguided “lab benefit program” and the unfortunate Optum360 physician profiling software.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at [email protected]

I recently returned from the DASS (Dermatology and Allied Specialties Summit) in New Delhi. It was interesting and thought provoking. New Delhi, and India in general, are modern and ancient, growing like Topsy, crushed into one another, in a hyperkinetic mix, something like Mexico on amphetamines.

I generally find conferences far afield introduce novel ideas. It helps greatly that these conferences almost always use English as the official language.

The underlying concept for DASS is multidisciplinary, which is unusual in dermatology. It was rewarding to discuss skin cancer treatment with surgical oncologists, plastic and general surgeons, and medical oncologists. There were also discussions on polycystic ovary disease, rosacea and the “red face,” current treatment of Hansen disease, man-eating psoriasis and urticaria, and of course, botulinum toxin, fillers, lasers, and chemical peels. Of great interest were new “old” treatments for skin disease, since biologics are generally not affordable.

I also got into lively discussions at the World Congress of Dermatology in Vancouver a few weeks earlier. The problem in many countries is funding of dermatologic treatments (particularly Mohs) within a fixed dermatology budget. We in the United States can vote with our feet, and generally seek out treatment we decide is best. Over the past 30 years, 70% of skin cancer has migrated from hospital-based surgical specialties to office-based dermatology, at great cost savings to the health care system.

In most of the world, the government allocates money, and tells hospitals and doctors to make do. This results in a static, change-resistant budget process, where patients have even fewer choices than in the U.S. Hospitals always win in these budget battles, to the detriment of office-based medicine and patient choice, and innovation.

Internationally, correcting this may require dermatologists going to politicians and not saying, “we need more money,” but rather saying, “we can save you money.” For example, if 99% of skin cancer treatment moves out of the hospital to the office setting, where it should be, the budgeteers should be delighted to pay your office costs, which are a fraction of those for an operating room. The budget should reflect that X number of new operating rooms do not need to be built, X number of scrub nurses do not need to trained or can be reassigned, X number of support staff are not needed, or that wait times, a chronic complaint around the world, can shrink.

There will be resistance to this approach from hospital-dependent specialists, and the hospitals. They will argue it isn’t safe, and that the costs aren’t defined. However, these issues have been worked out in detail and the data published.

The same argument can be made for the use of biologics. How many erythrodermic hospitalizations will be avoided? How many missed days of work will not be missed?

It is far easier to budge a bureaucracy by emphasizing cost savings rather than quality, though these are opportunities for dermatologists to improve both.

Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].

I recently returned from the DASS (Dermatology and Allied Specialties Summit) in New Delhi. It was interesting and thought provoking. New Delhi, and India in general, are modern and ancient, growing like Topsy, crushed into one another, in a hyperkinetic mix, something like Mexico on amphetamines.

I generally find conferences far afield introduce novel ideas. It helps greatly that these conferences almost always use English as the official language.

The underlying concept for DASS is multidisciplinary, which is unusual in dermatology. It was rewarding to discuss skin cancer treatment with surgical oncologists, plastic and general surgeons, and medical oncologists. There were also discussions on polycystic ovary disease, rosacea and the “red face,” current treatment of Hansen disease, man-eating psoriasis and urticaria, and of course, botulinum toxin, fillers, lasers, and chemical peels. Of great interest were new “old” treatments for skin disease, since biologics are generally not affordable.

I also got into lively discussions at the World Congress of Dermatology in Vancouver a few weeks earlier. The problem in many countries is funding of dermatologic treatments (particularly Mohs) within a fixed dermatology budget. We in the United States can vote with our feet, and generally seek out treatment we decide is best. Over the past 30 years, 70% of skin cancer has migrated from hospital-based surgical specialties to office-based dermatology, at great cost savings to the health care system.

In most of the world, the government allocates money, and tells hospitals and doctors to make do. This results in a static, change-resistant budget process, where patients have even fewer choices than in the U.S. Hospitals always win in these budget battles, to the detriment of office-based medicine and patient choice, and innovation.

Internationally, correcting this may require dermatologists going to politicians and not saying, “we need more money,” but rather saying, “we can save you money.” For example, if 99% of skin cancer treatment moves out of the hospital to the office setting, where it should be, the budgeteers should be delighted to pay your office costs, which are a fraction of those for an operating room. The budget should reflect that X number of new operating rooms do not need to be built, X number of scrub nurses do not need to trained or can be reassigned, X number of support staff are not needed, or that wait times, a chronic complaint around the world, can shrink.

There will be resistance to this approach from hospital-dependent specialists, and the hospitals. They will argue it isn’t safe, and that the costs aren’t defined. However, these issues have been worked out in detail and the data published.

The same argument can be made for the use of biologics. How many erythrodermic hospitalizations will be avoided? How many missed days of work will not be missed?

It is far easier to budge a bureaucracy by emphasizing cost savings rather than quality, though these are opportunities for dermatologists to improve both.

Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].

I recently returned from the DASS (Dermatology and Allied Specialties Summit) in New Delhi. It was interesting and thought provoking. New Delhi, and India in general, are modern and ancient, growing like Topsy, crushed into one another, in a hyperkinetic mix, something like Mexico on amphetamines.

I generally find conferences far afield introduce novel ideas. It helps greatly that these conferences almost always use English as the official language.

The underlying concept for DASS is multidisciplinary, which is unusual in dermatology. It was rewarding to discuss skin cancer treatment with surgical oncologists, plastic and general surgeons, and medical oncologists. There were also discussions on polycystic ovary disease, rosacea and the “red face,” current treatment of Hansen disease, man-eating psoriasis and urticaria, and of course, botulinum toxin, fillers, lasers, and chemical peels. Of great interest were new “old” treatments for skin disease, since biologics are generally not affordable.

I also got into lively discussions at the World Congress of Dermatology in Vancouver a few weeks earlier. The problem in many countries is funding of dermatologic treatments (particularly Mohs) within a fixed dermatology budget. We in the United States can vote with our feet, and generally seek out treatment we decide is best. Over the past 30 years, 70% of skin cancer has migrated from hospital-based surgical specialties to office-based dermatology, at great cost savings to the health care system.

In most of the world, the government allocates money, and tells hospitals and doctors to make do. This results in a static, change-resistant budget process, where patients have even fewer choices than in the U.S. Hospitals always win in these budget battles, to the detriment of office-based medicine and patient choice, and innovation.

Internationally, correcting this may require dermatologists going to politicians and not saying, “we need more money,” but rather saying, “we can save you money.” For example, if 99% of skin cancer treatment moves out of the hospital to the office setting, where it should be, the budgeteers should be delighted to pay your office costs, which are a fraction of those for an operating room. The budget should reflect that X number of new operating rooms do not need to be built, X number of scrub nurses do not need to trained or can be reassigned, X number of support staff are not needed, or that wait times, a chronic complaint around the world, can shrink.

There will be resistance to this approach from hospital-dependent specialists, and the hospitals. They will argue it isn’t safe, and that the costs aren’t defined. However, these issues have been worked out in detail and the data published.

The same argument can be made for the use of biologics. How many erythrodermic hospitalizations will be avoided? How many missed days of work will not be missed?

It is far easier to budge a bureaucracy by emphasizing cost savings rather than quality, though these are opportunities for dermatologists to improve both.

Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].

I have been a traveling road show for the last 2 years, explaining the value of dermatology to insurers. It is amazing how poorly understood we are by payers.

Let me give you an example. Currently, dermatologists treat about 70% of all skin cancers. This is up from the 10% we treated 30 years ago, but if you think about it, it should be 98% or 99%. There were 5.4 million skin cancers in the United States in 2012. The great majority were nonmelanoma skin cancers (at an interesting ratio of 1:1 for basal cell carcinoma and squamous cell carcinoma), and only about 75,000 were melanomas. About 80% of all melanomas are less than 1 mm in thickness and undoubtedly appropriate for local excision in the office. Dermatologists treat these skin cancers at less than ¹/₅ the cost of treatment in a facility. We, and a few primary care physicians, are the only physicians who are not operating room dependent. We can remove these cancers under local anesthesia in the office, without an anesthesiologist, multiple nurses, intravenous lines, preop labs, and the other high fixed costs associated with a hospital procedure, and we can do it promptly. Insurers should be pounding their drums to demand that the vast majority of skin cancers be treated in the office setting, rather than in a hospital. Maybe all skin cancer patients should be required to get “precertified” by a dermatologist before they are sent to a hospital for a procedure. This would improve quality and greatly cut costs.

Insurers always drop their jaws when I explain this to them. They have never matched up the costs of the physicians and the costs of the facilities where procedures are performed. They need to consider the value of the dermatologist in providing an accurate, quick diagnosis, with immediate exclusion of benign lesions and elimination of the long wait times to get a cancer removed. It costs less to get a skin cancer diagnosed and removed by a dermatologist than to get a new set of car tires installed, and we can often do it in about the same amount of time. Compare that with $150,000 spent annually to treat metastatic melanoma.

In addition, fewer dermatologists mean longer wait times to see the dermatologist, causing what I call the “spillover” effect. When patients cannot get in to see the dermatologist, they call their primary care physician, who sends them down to the hospital to see their general surgeon on lumps and bumps day. Everything gets removed, benign or not, in the hospital outpatient department.

That is why it is insane for insurers to be eliminating dermatologists wholesale from their “tight” networks. Their software tells them they will save money in the short term, but they won’t because of the spillover, and it is very foolish in the long term. With the advent of the Affordable Care Act, patients cannot be excluded for preexisting conditions, and these patients all become long-term clients of one insurer or another. What is neglected today becomes a nightmare tomorrow. Dermatology offers an extraordinarily high value quotient, but only if insurers have enough sense to let the patients see us.

Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].

I have been a traveling road show for the last 2 years, explaining the value of dermatology to insurers. It is amazing how poorly understood we are by payers.

Let me give you an example. Currently, dermatologists treat about 70% of all skin cancers. This is up from the 10% we treated 30 years ago, but if you think about it, it should be 98% or 99%. There were 5.4 million skin cancers in the United States in 2012. The great majority were nonmelanoma skin cancers (at an interesting ratio of 1:1 for basal cell carcinoma and squamous cell carcinoma), and only about 75,000 were melanomas. About 80% of all melanomas are less than 1 mm in thickness and undoubtedly appropriate for local excision in the office. Dermatologists treat these skin cancers at less than ¹/₅ the cost of treatment in a facility. We, and a few primary care physicians, are the only physicians who are not operating room dependent. We can remove these cancers under local anesthesia in the office, without an anesthesiologist, multiple nurses, intravenous lines, preop labs, and the other high fixed costs associated with a hospital procedure, and we can do it promptly. Insurers should be pounding their drums to demand that the vast majority of skin cancers be treated in the office setting, rather than in a hospital. Maybe all skin cancer patients should be required to get “precertified” by a dermatologist before they are sent to a hospital for a procedure. This would improve quality and greatly cut costs.

Insurers always drop their jaws when I explain this to them. They have never matched up the costs of the physicians and the costs of the facilities where procedures are performed. They need to consider the value of the dermatologist in providing an accurate, quick diagnosis, with immediate exclusion of benign lesions and elimination of the long wait times to get a cancer removed. It costs less to get a skin cancer diagnosed and removed by a dermatologist than to get a new set of car tires installed, and we can often do it in about the same amount of time. Compare that with $150,000 spent annually to treat metastatic melanoma.

In addition, fewer dermatologists mean longer wait times to see the dermatologist, causing what I call the “spillover” effect. When patients cannot get in to see the dermatologist, they call their primary care physician, who sends them down to the hospital to see their general surgeon on lumps and bumps day. Everything gets removed, benign or not, in the hospital outpatient department.

That is why it is insane for insurers to be eliminating dermatologists wholesale from their “tight” networks. Their software tells them they will save money in the short term, but they won’t because of the spillover, and it is very foolish in the long term. With the advent of the Affordable Care Act, patients cannot be excluded for preexisting conditions, and these patients all become long-term clients of one insurer or another. What is neglected today becomes a nightmare tomorrow. Dermatology offers an extraordinarily high value quotient, but only if insurers have enough sense to let the patients see us.

Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].

I have been a traveling road show for the last 2 years, explaining the value of dermatology to insurers. It is amazing how poorly understood we are by payers.

Let me give you an example. Currently, dermatologists treat about 70% of all skin cancers. This is up from the 10% we treated 30 years ago, but if you think about it, it should be 98% or 99%. There were 5.4 million skin cancers in the United States in 2012. The great majority were nonmelanoma skin cancers (at an interesting ratio of 1:1 for basal cell carcinoma and squamous cell carcinoma), and only about 75,000 were melanomas. About 80% of all melanomas are less than 1 mm in thickness and undoubtedly appropriate for local excision in the office. Dermatologists treat these skin cancers at less than ¹/₅ the cost of treatment in a facility. We, and a few primary care physicians, are the only physicians who are not operating room dependent. We can remove these cancers under local anesthesia in the office, without an anesthesiologist, multiple nurses, intravenous lines, preop labs, and the other high fixed costs associated with a hospital procedure, and we can do it promptly. Insurers should be pounding their drums to demand that the vast majority of skin cancers be treated in the office setting, rather than in a hospital. Maybe all skin cancer patients should be required to get “precertified” by a dermatologist before they are sent to a hospital for a procedure. This would improve quality and greatly cut costs.

Insurers always drop their jaws when I explain this to them. They have never matched up the costs of the physicians and the costs of the facilities where procedures are performed. They need to consider the value of the dermatologist in providing an accurate, quick diagnosis, with immediate exclusion of benign lesions and elimination of the long wait times to get a cancer removed. It costs less to get a skin cancer diagnosed and removed by a dermatologist than to get a new set of car tires installed, and we can often do it in about the same amount of time. Compare that with $150,000 spent annually to treat metastatic melanoma.

In addition, fewer dermatologists mean longer wait times to see the dermatologist, causing what I call the “spillover” effect. When patients cannot get in to see the dermatologist, they call their primary care physician, who sends them down to the hospital to see their general surgeon on lumps and bumps day. Everything gets removed, benign or not, in the hospital outpatient department.

That is why it is insane for insurers to be eliminating dermatologists wholesale from their “tight” networks. Their software tells them they will save money in the short term, but they won’t because of the spillover, and it is very foolish in the long term. With the advent of the Affordable Care Act, patients cannot be excluded for preexisting conditions, and these patients all become long-term clients of one insurer or another. What is neglected today becomes a nightmare tomorrow. Dermatology offers an extraordinarily high value quotient, but only if insurers have enough sense to let the patients see us.

Dr. Coldiron is in private practice, but maintains a clinical assistant professorship of dermatology at the University of Cincinnati. Email him at [email protected].

The reporter wanted to nail me, and shot me the zinger, “Doctor why do you get paid $106 to do a skin biopsy, and they only get $30 in Germany”?

I paused for minute (she was sure she had me), and then I said, “They only get $30? That stinks. You know I do get $49.”

The reporter said, “No, no, I see here in the Medicare database that doctors in the United States get paid $106.”

I explained to her that $57 of that was for equipment, staff, and supplies, and that doctors in Germany do everything in the hospital setting, where they don’t have to pay for any of that.

Oh.

This is an error that is repeated again and again, and you need to know the reason you get paid “so much.” The second year’s worth of the Medicare data were released last month, with a wrinkle: They removed the cost of medications. They floated the surgeons, oncologists, and ophthalmologists down and floated dermatology up to near the top, just under radiation oncology.

Let’s think about this for a minute. How many radiation oncologists have linear accelerators in their offices, and how many cardiologists have cath labs? How many ophthalmologists do cataract procedures in the office? The same is true for almost every other specialty. Most practitioners of procedural medicine do procedures in a hospital, where they pay no practice expenses. They may have a small office for consultations and suture removals, but for anything else they say, “Meet me at the hospital.” Often, the hospital supplies the office space for free or at a discount.

Now I don’t envy the primary care doctors, who also do everything in their offices, but guess what? Practice expense is only about 20% of the valuation of the evaluation and management codes. Think about this again. They don’t have power tables, OR lights, prep kits, sutures, hand tools, gauze, sponges, bandages, etc., to pay for, so it makes sense.

This means that most procedural physicians keep (before the huge tax bill we all are subject to) almost every Medicare dollar or insurance dollar they receive. Dermatologists’ reimbursements are 60% for practice expenses overall, with some even higher. Mohs surgery, for example, costs an average of 66% to provide. Dermatologists do almost nothing in the hospital, and instead provide more care for patients in the office setting. So, when the reporter tries to zing you about collecting $300,000 from Medicare, you explain that your dollars aren’t the same as everyone else’s dollars, and you really took $120,000 to the tax man (not that any of this is really their business anyway).

And, by the way, tell them you only get $24 for a second biopsy, which is just as much work as the first.

I think we should ask CMS to pull the practice expense out of its Medicare numbers in the next report. A dollar spent for surgical supplies is the same as a dollar spent for medications. It’s all money the doctor never sees.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

The reporter wanted to nail me, and shot me the zinger, “Doctor why do you get paid $106 to do a skin biopsy, and they only get $30 in Germany”?

I paused for minute (she was sure she had me), and then I said, “They only get $30? That stinks. You know I do get $49.”

The reporter said, “No, no, I see here in the Medicare database that doctors in the United States get paid $106.”

I explained to her that $57 of that was for equipment, staff, and supplies, and that doctors in Germany do everything in the hospital setting, where they don’t have to pay for any of that.

Oh.

This is an error that is repeated again and again, and you need to know the reason you get paid “so much.” The second year’s worth of the Medicare data were released last month, with a wrinkle: They removed the cost of medications. They floated the surgeons, oncologists, and ophthalmologists down and floated dermatology up to near the top, just under radiation oncology.

Let’s think about this for a minute. How many radiation oncologists have linear accelerators in their offices, and how many cardiologists have cath labs? How many ophthalmologists do cataract procedures in the office? The same is true for almost every other specialty. Most practitioners of procedural medicine do procedures in a hospital, where they pay no practice expenses. They may have a small office for consultations and suture removals, but for anything else they say, “Meet me at the hospital.” Often, the hospital supplies the office space for free or at a discount.

Now I don’t envy the primary care doctors, who also do everything in their offices, but guess what? Practice expense is only about 20% of the valuation of the evaluation and management codes. Think about this again. They don’t have power tables, OR lights, prep kits, sutures, hand tools, gauze, sponges, bandages, etc., to pay for, so it makes sense.

This means that most procedural physicians keep (before the huge tax bill we all are subject to) almost every Medicare dollar or insurance dollar they receive. Dermatologists’ reimbursements are 60% for practice expenses overall, with some even higher. Mohs surgery, for example, costs an average of 66% to provide. Dermatologists do almost nothing in the hospital, and instead provide more care for patients in the office setting. So, when the reporter tries to zing you about collecting $300,000 from Medicare, you explain that your dollars aren’t the same as everyone else’s dollars, and you really took $120,000 to the tax man (not that any of this is really their business anyway).

And, by the way, tell them you only get $24 for a second biopsy, which is just as much work as the first.

I think we should ask CMS to pull the practice expense out of its Medicare numbers in the next report. A dollar spent for surgical supplies is the same as a dollar spent for medications. It’s all money the doctor never sees.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

The reporter wanted to nail me, and shot me the zinger, “Doctor why do you get paid $106 to do a skin biopsy, and they only get $30 in Germany”?

I paused for minute (she was sure she had me), and then I said, “They only get $30? That stinks. You know I do get $49.”

The reporter said, “No, no, I see here in the Medicare database that doctors in the United States get paid $106.”

I explained to her that $57 of that was for equipment, staff, and supplies, and that doctors in Germany do everything in the hospital setting, where they don’t have to pay for any of that.

Oh.

This is an error that is repeated again and again, and you need to know the reason you get paid “so much.” The second year’s worth of the Medicare data were released last month, with a wrinkle: They removed the cost of medications. They floated the surgeons, oncologists, and ophthalmologists down and floated dermatology up to near the top, just under radiation oncology.

Let’s think about this for a minute. How many radiation oncologists have linear accelerators in their offices, and how many cardiologists have cath labs? How many ophthalmologists do cataract procedures in the office? The same is true for almost every other specialty. Most practitioners of procedural medicine do procedures in a hospital, where they pay no practice expenses. They may have a small office for consultations and suture removals, but for anything else they say, “Meet me at the hospital.” Often, the hospital supplies the office space for free or at a discount.

Now I don’t envy the primary care doctors, who also do everything in their offices, but guess what? Practice expense is only about 20% of the valuation of the evaluation and management codes. Think about this again. They don’t have power tables, OR lights, prep kits, sutures, hand tools, gauze, sponges, bandages, etc., to pay for, so it makes sense.

This means that most procedural physicians keep (before the huge tax bill we all are subject to) almost every Medicare dollar or insurance dollar they receive. Dermatologists’ reimbursements are 60% for practice expenses overall, with some even higher. Mohs surgery, for example, costs an average of 66% to provide. Dermatologists do almost nothing in the hospital, and instead provide more care for patients in the office setting. So, when the reporter tries to zing you about collecting $300,000 from Medicare, you explain that your dollars aren’t the same as everyone else’s dollars, and you really took $120,000 to the tax man (not that any of this is really their business anyway).

And, by the way, tell them you only get $24 for a second biopsy, which is just as much work as the first.

I think we should ask CMS to pull the practice expense out of its Medicare numbers in the next report. A dollar spent for surgical supplies is the same as a dollar spent for medications. It’s all money the doctor never sees.

Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.

Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.