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Derms urged to be step ahead of evolving regulatory environment


For dermatologists, key concerns created by the Patient Protection and Affordable Care Act (ACA) and other elements of healthcare reform include patient access and provider payments, says an AAD official. Fortunately, he adds, the varied and largely office-based nature of dermatology could provide unique advantages in the evolving regulatory environment.


Miami Beach, Fla. - For dermatologists, key concerns created by the Patient Protection and Affordable Care Act (ACA) and other elements of healthcare reform include patient access and provider payments, says an American Academy of Dermatology (AAD) official. Fortunately, he adds, the varied and largely office-based nature of dermatology could provide unique advantages in the evolving regulatory environment.

The AAD is monitoring the impact of several ACA mandates including health insurance exchanges and accountable care organizations (ACOs) on patient care and the specialty of dermatology, says AAD President Brett Coldiron, M.D., who is in private practice in Cincinnati.

Regarding insurance exchanges, he says the academy is primarily concerned with ensuring that these arrangements “do not limit access for patients due to insufficient networks and high deductibles, which many people cannot afford.” Although the AAD has taken no official position on these entities, Dr. Coldiron says, “The academy is keenly interested in whether or not these new plans provide an adequate network of providers and do not hinder access to quality dermatologic care.”

Addressing ACOs

The AAD is also actively advocating for the broadening of Medicare Advantage networks, which have been cut, to the detriment of patients’ access, Dr. Coldiron says.

“AAD Executive Director and CEO Elaine Weiss, J.D., and I met with White House and key congressional officials in February to discuss the issue and relay the specialty’s concerns that narrowed networks will have devastating effects on patient access to quality care. The AAD Association (AADA) will continue to work with policymakers on this issue,” he says.

Regarding ACOs, Dr. Coldiron says that while several dermatologists are joining these organizations, “Right now ACOs are often hospital-based. The academy is particularly interested in the effect of these arrangements on solo practitioners like dermatologists, and the effects on access to specialty services - which remain unclear and varied at this point.”

It’s premature to predict whether the ACO payment system is here to stay, he says. However, “Some theories suggest that payment systems based on quality care, patient safety and cost effectiveness could replace fee-for-service systems.”



Preserving payments

On the reimbursement side, Dr. Coldiron says, “The Mohs micrographic surgery codes have already been reviewed and accepted in the 2014 Medicare Physician Fee Schedule. However, the academy is monitoring another provision that may affect key codes that dermatologists utilize.”

In the 2014 proposed fee schedule, he explains, the Centers for Medicare and Medicaid Services (CMS) proposed reducing physician payments for more than 200 codes for which the total payment - when the service is provided in an office or other nonfacility setting - exceeds the total Medicare payment when furnished in a hospital outpatient department or an ambulatory surgery center.

“The AADA strongly opposed this proposal,” Dr. Coldiron says. “In the 2014 final rule, CMS delayed finalizing the proposal, but is expected to address this issue in future rule-making. This proposed change would disproportionately affect two codes that are often used for psoriasis treatments: 96910 and 96912.”

Additionally, the Medicare Independent Payment Advisory Board (IPAB) is a 15-member appointed board tasked with reducing Medicare costs while retaining quality of care. It comes into play when Medicare spending overall exceeds certain targets.

“The academy is concerned because the IPAB would take the Medicare decision-making process away from our elected representatives in Congress and would give it to an unelected, unrepresentative and unaccountable advisory board. This panel has total authority to make decisions regarding Medicare funding, how to implement spending cuts within the Medicare program and how to allocate medical services,” Dr. Coldiron says.

Accordingly, he says that the academy has supported legislation to repeal the IPAB and commented to the White House and CMS on the ill-advised nature of this provision of the ACA as well. The 2014 omnibus spending bill, signed by president Obama is January, slashes $10 million from the IPAB’s original $15 million budget, and as of March, no IPAB members have been appointed, multiple accounts say.



Battling backlog

Additionally, Medicare audits have caused consternation among many specialties.

“For now,” Dr. Coldiron says, “the recovery audit contractor (RAC) audits have been suspended, and that is a relief for all physicians. However, the burdens these audits place on physicians continue to persist.”

Specifically, he says that a significant backlog in processing of Medicare claims appeals has delayed Administrative Law Judge (ALJ) hearings through CMS. Ordinarily, he says, an ALJ issues a decision within 90 days of receiving a hearing request. Physicians can expedite the appeals process by escalating to a Medicare Appeals Council (MAC) review within 60 days of being notified by the ALJ of the delay, Dr. Coldiron adds.

Additionally, “The physician can request a MAC review outside of the 60 days if they can show ‘good cause’ as to why they did not file an appeal on time. The backlog of appeals only adds to the expense and frustration of dermatologists who want to appeal RAC audits.”

Going forward, he says, “We are facing an array of changes and potential challenges as Congress, CMS and private payers attempt to control healthcare spending, and dermatologists should remain informed on the issues facing the specialty. We should also be engaged and respond when the academy calls on us to take action on these important issues.

As Dirk Elston, M.D., immediate past-president of the AAD, noted in his “Dermatology Is Under Siege” Presidential Alert1, dermatologists need to be aware of the changing paradigms and assume responsibility to be part of the solutions.

Dermatologists also must seize opportunities created by the ACA, Dr. Coldiron says.

“Dermatology is a unique profession in that we diagnose and treat more than 3,000 diseases and many genetic disorders,” he says. In caring for patients of all ages, our unique training enables us to incorporate patient-centered efficiencies into our practices as we provide a wide range of services, from diagnostic laboratory services to surgical treatment, primarily within our individual offices.”

As long as insurance exchanges offer adequate provider networks, he says, “Dermatologists can add significant value to the coordinated-care team, especially for the increasing number of newly insured Americans.”

Disclosures: Dr. Coldiron is president of the AAD.


1 Elston DM. Dermatology is under siege. http://www.aad.org/members/practice-and-advocacy-resource-center/payment-and-reimbursement/payment-101/Dermatology-is-under-siege. Accessed March 4, 2014.

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