PODCAST: A changing landscape

The landscape of dermatology is rapidly changing and every practicing dermatologist will almost certainly be affected. Dermatology Times Editorial Advisory Board member Norman Levine, M.D., asked Dirk Elston, M.D., president of the American Academy of Dermatology, to address some of these issues so that we may all have a better idea of what lies ahead for our specialty.

NORMAN LEVINE, M.D.: The so-called fix for Medicare payment reform is coming. Could you describe in what way this impacts dermatologists?

DR. ELSTON: The Sustainable Growth Rate is the formula that was put in place a number of years ago that results in us facing a cliff each year that gets higher and higher. The fix that we get from Congress - sometimes it’s a six-month fix, sometimes it’s a one-year fix to give a positive update or at least not a negative update to Medicare reimbursement - by law, has to be paid back. Each year, the cliff gets higher and higher.

As by law, any fix from prior years has to be paid back. An SGR fix would wipe the slate clean and change the formula so that we don’t face that kind of cliff going forward. The issue is what’s the pay for and what’s the transition. The good news is that although there are a lot of payment transitions from the fee-for-service to pay-for-performance pot of money, at least we are held to one single program rather than an ever increasing, ever more complicated series of multiple programs that you would have to report on for the quality payments. So we wanted that simplicity in the fix.

The detail is, that with that one program, is it something in which specialist can participate, or is it so geared towards primary care that we really as specialists have little role in it? Perhaps it’s not applicable to us, and we can’t compete for what will be an ever-increasing portion of reimbursement.

DR. LEVINE: My son happens to be a surgeon. He gets paid not much more for removing a gallbladder than I do for removing a basal cell carcinoma and doing a complex closure. How do we go into the negotiations and justify our worth and our rates?

DR. ELSTON: A gallbladder surgery is very intensive in use of operating room nurses, the operating room space, which is paid for separately on the facility side. The RUC (Relative Value Scale Update Committee) reimbursement rate for the procedure focuses mainly on physician work; physician time. So the question is not “Do you need an expensive OR? Do you need lots of equipment? Do you need lots of nursing support?” The question is: What is the intensity of the service and the time required for the physician? So does a gallbladder take the physician more time to do than a basal cell and repair on the face? Those come closer together, which is why the reimbursement is closer together.

DR. LEVINE: Let’s switch gears to the issue of pathology services performed by dermatologists. What’s the issue and what are the potential outcomes here?

DR. ELSTON: Well, dermatologists receive training in dermatopathology. It is part of the scope of our specialty; it is part of our training. One of the issues that we have is because dermatologists can run a lab and they can sign out pathology cases, there are some among our number who have abused it. There is unfortunately some very good and consistent data in the U.S. Government Accountability Office Report indicating that when dermatologists, urologists or gastroenterologists purchase their own labs, the number of biopsies performed per patient goes up and yet the detection of cancer does not go up. There is similar data with imaging studies. It’s unlikely that there would have been that rapid of a change in the patient population demographic of each practice. It points to a profit motive, which is coming back to hurt all of the specialties that were implicated. The majority of physicians are honest and they want to be paid fairly for the work they do; there are smaller numbers who are unethically taking profits that will hurt the remaining physicians, our patients, our specialty. That’s unfortunately what we are facing right now.

DR. LEVINE: Is there anything that the American Academy of Dermatology can do to address this issue?

DR. ELSTON: We have put out a statement of all the challenges faced in our specialty. It’s not simply this one issue; there are unprecedented challenges to the RUC process, to fee-for-service, to direct access to specialty care. The limited provider networks, to my mind, will be the single most transformative change in terms of the practice of medicine.

Large payers and purchasers are looking to cut deals, make and enter into agreements where they get very low rates from a limited number of providers and those providers get all the services; all the patients have to go to them or they are out-of-network. In some states, the majority of dermatologists have received disenrollment letters from some plans saying, “Your patients are out-of-network if they continue to see you.” That’s a huge issue for us.

So the ethics issue is important, but it is one of many issues that the specialty needs to tackle and that is why I wrote the “Dermatology is Under Siege” message to all the members of the academy, because people need to know what’s going on. It’s not business as usual. There are big changes coming down, and we all have a role to play. Some of this is misunderstanding on a payer level; some of it is in the legislature; it’s really a call to action. It’s a call to action on many fronts, and then the follow-up is in Dermatology World and in the Member-to-Member e-newsletter, which I hope every AAD member is reading. There are updates, and each issue is taken in detail including what you, as the individual member, should be doing to help solve the problems.

DR. LEVINE: My understanding is that the Mohs surgeons are in the process of getting “readjusted,” I guess is the nice way to say it. What’s the nature of the problem and is there something that we can do about it?

DR. ELSTON: Again, it’s never just from one aspect. The limited provider networks affect them, the issues of self-referral and who can run a lab; and if you are about to do an adjacent tissue transfer and notice a subtle lesion that’s also suspicious for basal cell, can you do a frozen section biopsy and process it on the spot in the lab if there is no exemption to Stark - that is at risk right now. So there are lots of things that directly affect patient care.

DR. LEVINE: Do you see a move to limit the scope of what a Mohs surgeon will treat being mandated by others?

DR. ELSTON: That has been a risk for some time, which is why the academy took leadership and developed the Appropriate Use Criteria for Mohs surgery. They were developed by the accepted RAND methodology. It is a multi-stakeholder process. When it is all done properly, which was a lot of work, a lot of expense went into that, proper vetting through all the appropriate societies - the Mohs Society, the Mohs College, the ASDS (American Society for Dermatologic Surgery), as well as the AAD - that then has a lot of credibility, and the payers and purchasers tend to accept it, rather than coming up with their own policy. So we have a lot of work ahead of us for Appropriate Use Criteria, for things that unfortunately are sometimes over-utilized inappropriately, but we need to maintain access for the patients who need the procedure.

DR. LEVINE: Where does the AAD stand with regard to physician extenders in terms of training, certification, education?

DR. ELSTON: The reality is that about half of our members - probably a little better than half - have nonphysician providers of some sort in their practice. If you look at medical assistants, not just physician’s assistants and nurse practitioners, almost all of us in our office have someone providing care whether it’s suture removal, helping to run a light box, or applying patch test. There are people who make us more efficient at our work because we are able to duplicate ourselves and provide more needed services. And since in most of the countries there is shortage of dermatological care, there are significant incentives for people to build care teams within their practice so that they can deliver care in the most efficient manner.

The AAD’s stand is that we do embrace team-based care - because that is the reality of healthcare in the United States going forward - the dermatologist should always be the head of that team for skincare. We do not endorse independent, unsupervised practice of dermatology by non-dermatologists. What we endorse is properly supervised team-based care and we have published standards of what that supervision should consist of.

DR. LEVINE: How do HIPAA regulations impact dermatology and are there AAD resources that we can use to help us familiarize ourselves with the new realities?

DR. ELSTON: The answer of course is that there are AAD resources for anything that affects you and your practice. That’s the AAD’s role. We are the voice of dermatology and we are the support for all dermatologists in the U.S. and Canada. HIPAA rules continue to change; all of those rules have been in flux and continue to be in flux, and the AAD has resources. The website has been redesigned, so it’s much more user-friendly, much easier to do searches: You put in HIPAA in the search engine and it takes you right to the various resources, so you can match up what you need.