To improve outsiders’ view of specialty, derms must police own ranks

Miami Beach, Fla. - Other physicians’ negative perceptions of dermatologists won’t change unless dermatologists police their own ranks more aggressively and step up in their communities, an expert says.

According to a survey of physicians outside dermatology, other physicians generally perceive dermatologists as assets to the medical community (Garner LA. AAD Annual Meeting. March 16-20, 2012. San Diego). However, this survey also revealed that non-dermatologist physicians find it tough for their patients to get appointments with dermatologists to whom they refer, and that dermatologists appear unwilling to work as hard as many other specialists.

“The first reason other doctors don’t like us is because we didn’t suffer enough in residency, and we don’t suffer enough now,” says Cincinnati dermatologist Brett Coldiron, M.D., American Academy of Dermatology president-elect. Dr. Coldiron spoke at the 71st annual AAD meeting. Dr. Coldiron says, however, that communicating the fact that many dermatologists were trained in other specialties before becoming dermatologists may help the specialty gain credibility.

Regarding lifestyle, Dr. Coldiron admits that versus specialties such as internists and pediatricians, dermatologists’ hospital call requirements “aren't bad.” He points out that in his practice, however, “I leave my home phone number on the answering machine. Patients have direct access to me 24 hours a day. And I can handle most complications in the office.”

Hospital consults

The reason dermatologists rarely do hospital consultations boils down to dollars, Dr. Coldiron says. For a dermatologist, “Going to the hospital, tracking the patient down, looking at their rash and taking a skin biopsy takes several hours. Hospital consults should be rewarded at three to four times what they pay now.”

Moreover, he says that other specialties such as surgery or orthopedics intrinsically require that their members practice in hospitals - which rely on these specialists’ admissions financially. These specialists make no more than dermatologists do for hospital consults, Dr. Coldiron says. “But they get paid back in other ways,” such as in staff or equipment. Nevertheless, he adds that as the accountable care organization (ACO) care model gains traction, “You will see dermatologists doing more hospital consults, because the ACOs will demand it.”

Regarding the concern that dermatologists enjoy a better lifestyle than most other physicians, Dr. Coldiron says dermatologists indeed rank among the highest-paid specialists per work-hour. But the 13.8 percent increase in Relative Value Scale Update Committee (RUC) expenditures for dermatology that occurred between 1998 and 2002 was mainly compensating for the fact that before then, dermatologists were not being paid for the fact that they “run their own operating rooms in their offices,” he says.

Reimbursement cuts

Still, one healthcare policy analyst claims that specialty services such as Mohs surgery should be paid at the same level as cognitive services - about $150 per hour (after expenses).

“That’s what primary care physicians (PCPs) make with their evaluation and management (E&M) services,” Dr. Coldiron says, but it won’t cover a procedure that a dermatologist might perform during the same visit. PCPs don’t make as much as neurosurgeons because PCPs’ work is far less intense, he adds.

Unfortunately, Dr. Coldiron says, many cognitive specialists - and the Medicare Payment Advisory Committee (MedPAC) - have embraced the crusade to cut dermatologists’ reimbursements.

“MedPAC likes primary care; they believe that it saves money and improves outcomes. But the more I look at primary care versus specialists, primary care really doesn’t fix anything. They can triage people and treat chronic disease, but they can’t fix skin cancer or replace a joint.”

For the past 15 years, “We’ve been under this constant deluge of how important primary care is. And I believe we've been sold down the river - it’s time we speak up. I won’t take a vow of poverty to please the cognitive specialists.”

Other means of combating negative perceptions of dermatology include being more active in one’s local hospital, community and medical society, Dr. Coldiron says. Simultaneously, he says, dermatologists must root out bad apples such as former dermatologist Michael Rosin, who was convicted in 2006 for fraudulently diagnosing and treating nonexistent skin cancers in 865 senior citizens. “This kind of news is devastating” for dermatology as a specialty.

Accordingly, Dr. Coldiron suggests solutions such as requiring independent verification of all frozen diagnostic sections, and randomly auditing Mohs cases.

“Right now, we’ve got no way to control skin biopsies. There are biopsies for dollars being done out there. The public and the politicians want assurances that the care we provide is appropriate and necessary.”

Disclosures: Dr. Coldiron reports no relevant financial interests.