Should dermatologists change the way we do business?

Several weeks ago an editorial appeared in our local newspaper, which is not known for its high journalistic quality or thought-provoking content (read that as not the New York Times or Washington Post), under the title of:  “Doctors Must Change the Way They Do Business.”

Upon closer inspection this editorial was “borrowed” from the October 26, 2014 edition of the LA Times.  Regardless of its origin, the basic premise of this editorial is that we doctors aren’t doing enough “to control healthcare costs.” This is in spite of the availability of an $840 million grant program under the ACA “to teach Medicare and Medicaid doctors new ways to offer higher-quality, better-coordinated, more cost-effective care.” 

The editorial goes on to state that “there’s just no easy way to put a lid on healthcare costs.” Further, the editorial states that “this is largely due to the multitude of forces that drive up healthcare expenditures, including new technologies and medications, the prevalence of chronic disease and payment systems that give doctors and hospitals incentives to perform ever-more procedures.” 

The challenge, the editorial states, “is figuring out how doctors can prosper by delivering better care at lower cost and shift the incentives so that doctors and patients alike are motivated to reduce the demand for care.” The grant program is supposed to identify those cost-saving techniques and “spread them to 150,000 doctors across America.” Of course, like all governmental programs, “to guard against waste, the program requires grantees to set explicit numerical goals and track their progress.”  However, the editorial goes on to say “these statistics won’t be the ultimate measure of the program…[that] will be whether doctors fundamentally change the way they do business.” 

Dermatologists practice efficiently and cost effectively

I take issue with the basic premise of this editorial that doctors are the cause of high healthcare costs, especially for the specialty of dermatology. From my experience as a practicing dermatologist in both academics and private practice, I have always felt that the specialty of dermatology was extremely cost effective while delivering high quality care to our patients.

As examples, dermatologists only rarely require laboratory tests, radiological studies or specialized equipment to diagnose or treat the vast majority of our patients. With a simple skin scraping, some KOH, a glass slide and a microscope, we can quickly diagnose most superficial fungal diseases and immediately start appropriate therapy.

The training dermatologists receive allows us to quickly visually examine a patient’s skin for the presence of atypical growths, premalignant or even malignant lesions. Furthermore, with the use of the inexpensive dermatoscope, additional information about an irregular pigmented lesion can be quickly obtained. If a suspicious lesion is identified, a superficial shave or punch biopsy can be safely performed at the same outpatient visit to confirm the diagnosis. If additional treatment is required, cryosurgery, curettage or surgical excision can be safely and effectively performed in the outpatient setting at a reduced cost over the same procedure done in an operating room. 

In some cases, the patient can even be treated with use of a topical chemotherapy cream at home. If an aggressive or extensive malignancy is diagnosed, Mohs micrographic surgery has proven to be a safe, cost-effective outpatient procedure typically performed under local anesthesia.

Dermatologists do use high technology instrumentation. Think of the improved quality of care provided to dermatologic patients with port wine stains, keloids, hypertrophic scars, certain refractory warts, angiokeratomas and Kaposi’s sarcoma by the availability of the pulsed dye laser. Also, use of the newer, expensive biologic agents for treating a number of dermatologic conditions, including extensive or refractory psoriasis, has also greatly improved the quality of life for a myriad of patients for whom either no or only ineffective treatment previously existed. There are hundreds of additional examples I could provide to demonstrate the cost-effectiveness and high quality of care provided by dermatologists to their patients with skin diseases. However, I believe I’ll just leave it with these few examples and let the reader fill in the blanks.

Next >> Most physicians are trying to reduce costs

Most physicians are trying to reduce costs

Do dermatologists have any responsibility for the rising cost of healthcare? Sure, no specialty is without some blame, and every specialty can likely cite examples where they employ cost-effective procedures in lieu of using a more expensive technology. One recent personal experience I would like to give as an example:  

Two weeks ago, I broke my ankle. While I’d like to say it happened while climbing Mt. Everest, it really happened while doing some landscaping in my yard. So, off to the orthopedist I went who obtained the necessary x-rays to determine the damage. When it demonstrated a fracture, I was fully expecting that I would need surgery. Much to my chagrin, I was told that surgery for my type of injury was rarely ever performed since studies had shown that patients heal faster and with fewer complications by just using elevation and a compression walking boot. So instead of heading to the operating room and weeks of convalescing in a cast, here I am walking around nearly pain free in an inflatable compression boot at a fraction of the cost.

The only reason I include this example is to underscore my belief that most physicians are already trying to reduce the costs of healthcare. If one took the time to query every specialty, I am virtually certain that a large compendium of examples of this effort could be quickly put together. Do we really need to spend $840 million in grants to find cost effective techniques that can then be shared with other doctors? I don’t think so! Why not try a simpler and more cost-effective way to quickly gather that kind of information and disseminate it from there? Bureaucracy doesn’t always have to prevail, especially when thoughtful people put their heads together and work cooperatively.

However, when looking at the rising cost of healthcare and assigning blame, it is extremely important to recognize that, in my opinion, at least some of the expense of providing high quality care requires that expensive, high-technology equipment, procedures and medications must be used or the physician may be charged with providing inadequate or incompetent care by patients, medical boards and malpractice attorneys. 

Therein lies the rub - damned if you do use expensive high technology, and damned if you don’t.   Somehow, the standard of care must be factored into this whole equation. Providing high quality healthcare at a reasonable cost is not only incredibly difficult but also extremely complex. But, in my opinion, dermatologists certainly don’t need to radically “change the way we do business.”