Commentary: Prepare for Reimbursement Turbulence
Increases in the volume of dermatologic procedures over the past 15 years are the result of dermatology's reinvention of itself as a surgical specialty, as well as a result of what is a very real skin cancer epidemic.
But that, coupled with the disproportionate percentage of the total reimbursed relative value unit (RVU) pool going to dermatologists, has raised red flags for those charged with cutting costs, and has left the specialty particularly vulnerable to cuts in reimbursement.
Between 1995 and 2008, skin biopsies increased by 76%, destructions by 64%, excisions by 17%, actinic keratoses (AKs) of 15 or greater by 17%, and use of pathology code 88305 by 81%. Even more striking - and potentially at the expense of cuts of up to 25%-30% in reimbursement for these procedures - Mohs surgery is up about 400%, according to the most recent data.
The powers that be aren't looking too favorably upon these increases, especially considering that from 1992 to 2002, the total reimbursed RVU pool percentage for dermatologists increased from 2.5% to 2.9%, while dermatologists accounted for only 1% of all physicians.
This increase is appropriate, given the overhead required for the surgical components of dermatology practice and the increased demand, but it has led to a view of dermatologists as greedy and overpaid.
I don't think we're the greedy dermatologists that many make us out to be; we're office-based, frontline specialists responding to an unrecognized epidemic. But those charged with cutting costs don't see it that way, because they either don't understand or refuse to acknowledge that there is a very real skin cancer epidemic in this country.
A review of multiple Medicare and Ambulatory Medical Care Service databases showed that the number of procedures for skin cancer increased 77% from nearly 1.2 million in 1992 to nearly 2.1 million in 2006. The most recent estimate is that the total number of nonmelanoma skin cancers in the U.S. population is about 4 million.
There are a number of misconceptions about dermatology that are contributing to the specialty's being under siege, and some of them are from dermatologists themselves.
Among the fundamental misconceptions by MedPAC, Congress, and the Centers for Medicare and Medicaid Services are the following:
- What dermatologists do is not important and is mostly cosmetic.
- The increase in RVUs comes from waste and abuse, and from unimportant minor-procedure codes that pay too much.
- There is no skin cancer epidemic.
- New money is not needed in the payment pool for health care.
Dermatologists themselves are also guilty of misconceptions about the specialty. For example, there is a misconception among dermatologists that training more dermatologists and physician extenders will benefit dermatology, when in actuality they will increase utilization and trigger more scrutiny and punishment in the form of cuts to reimbursement.