Derm being wrongly targeted by NYTimes

[dantt]

One thing I'm not quite clear about. How is one able to essentially do a charity case for self pay patients in some situations but not able to charge the insurance discount for other patients? We've heard over and over about self pay patients being charged and sued for more than any reasonable insurance negotiated price. The defense is some kind of argument that it's the law to "charge" everybody the same. What situations are one then allowed to do a charity case?

There are 10 Mohs trained guys in my state; I cannot speak for the three up north, but I am the only one of the remaining 7 that I am aware of who does not actively limit the number of self (no) pays. I live in a very poor state besieged by poor health, poor education, and general poor economics -- poor systems that have been greatly worsened by government regulations. Anyway... I probably do more charity cases than anyone as I do a couple hundred a year. My self pay Mohs cases are asked to bring $300 with them at the date of service if they can; no one is turned away. I always do whatever reconstruction I can as you simply cannot find a plastic surgeon willing to cut a deal -- even the University (especially the University) are douches to deal with. Their total bill never exceeds $1000 and I personally cannot remember charging more than $500. Excisions, regardless of repair, have been charged $250. I more often than not never see that; in 2013 I had accumulated over $350k in bad debt stretching back to June of 2010 -- the last time I purged the books of bad debt -- and this is at those discounts.

Yes, people who do what I do can be and often are paid well. We do it on volume and sheer work effort. I know that it may not be a popular or politically correct opinion to profess, but the people who self select for any given profession will play a significant determining role in how well that profession performs... and those of us who self select out for Mohs would trend toward the more productive.

What our dear M3 does not understand is that the income of the procedural dermatologist is not extravagantly high because he or she is paid better for any given service than any other specialty providing the same service; it's that we are quite busy and proficient at what we do... which drives a volume of services not matched by many... and the economics of it are such that greater revenues translate into greater profits in a nonlinear fashion.

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[MOHS_01]

One thing I'm not quite clear about. How is one able to essentially do a charity case for self pay patients in some situations but not able to charge the insurance discount for other patients? We've heard over and over about self pay patients being charged and sued for more than any reasonable insurance negotiated price. The defense is some kind of argument that it's the law to "charge" everybody the same. What situations are one then allowed to do a charity case?

It has to be done before the fact and on a case by case matter under the construct of "financial hardship". You will find yourself in murky areas you do not want to be in if, as a matter of policy, you provide services at a discount to Medicare or even some private insurers.

You have two groups who make the most noise about pricing: the uninsured and, increasingly, the insured with high deductibles. It's the latter group that poses a real problem as you are contractually obligated to a price structure and bound by the correct coding initiative requirements; any deviation from this is a breach of contract at best and likely to be construed criminally fraudulent.

Life is not as simple as some columnists (and medical students and ill informed physicians and politicians and lawyers and....) would like to believe.

 

[MOHS_01]

...and that's a slippery slope. It's easier in gen/med derm: "I'm sorry, insurance will not pay to have these benign skin tags removed. Thus it is classified as cosmetic and we would not get paid to perform this. Our policy is to not perform cosmetic procedures for free. Normal insurance co-pays do not cover the cost either."

If a skin tag is larger than 0.5 cm, I'll take it gratis and send it to path. I've found a pinkus tumor in a large 'skin tag' before. If there are multiple small ones, pt has to pay a cosmetic fee.

This is not as easy for a Mohs surgeon...they are dealing with skin cancer. Do you just turn away someone with SCC on their cheek because they can't pay? At most hospitals, there are at least sliding scale services that help. If your out in private practice, how do you handle that? It's not an easy thing to handle if you have a bunch of skin cancers with no insurance cards or dollar bills in their pocket knocking on your door.

Word. It's also a more difficult concept to pass along to referring providers as well.
...


TMI

 

[DermViser]

You are right and I am wrong. I admit this. I have no ego nor anything to prove. I honestly wish you well.

For some reason, I have a hard time believing you.

I realized that I have been in the wrong in this discussion and that I may have caused some dissension. For that I apologize.
In my personal experience with dermatologists I have been impressed with how intelligent, hard working and caring they have been. I hope you all do well.
I have erased my previous posts. Good luck to everyone.

Nothing is worse in medical school than a medical student who thinks he/she knows more than a resident or attending who ACTUALLY PRACTICES in the specialty. These are the same types of students who act up on rotations and think they know everything, and are shocked they got a "Pass" instead of "Honors".

You would rather believe a New York Times article which time after time in more areas than just this, has been known to leave out very important facts, exaggerate details, and use extreme examples. This is all in an attempt to demonize doctors (notice the same treatment is not done to more Democratic friendly groups like NPs who are showered with praise) to the public bc they know that we can't fight back to correct the record. But it sure met its goal of riling up the lay person who doesn't understand the realities and intricacies of these issues, and apparently, even a medical student, who most would think wouldn't fall for this crap, and have a more discerning eye.

 

[happygilmore]

For some reason, I have a hard time believing you.


Nothing is worse in medical school than a medical student who thinks he/she knows more than a resident or attending who ACTUALLY PRACTICES in the specialty. These are the same types of students who act up on rotations and think they know everything, and are shocked they got a "Pass" instead of "Honors".

You would rather believe a New York Times article which time after time in more areas than just this, has been known to leave out very important facts, exaggerate details, and use extreme examples. This is all in an attempt to demonize doctors (notice the same treatment is not done to more Democratic friendly groups like NPs who are showered with praise) to the public bc they know that we can't fight back to correct the record. But it sure met its goal of riling up the lay person who doesn't understand the realities and intricacies of these issues, and apparently, even a medical student, who most would think wouldn't fall for this crap, and have a more discerning eye.

I liked the article. I admitted the MOHs guy is smarter than me and that I'm a lowly med student who should never challenge any superior. You're right, I don't practice derm so I should not have any opinions on it.

Anyway, I've had too many attendings and the medical community berate and beat me up to have any sense of community or reverence for this profession. So when doctors are demonized I have to ask if I've known any demons at the hospital or even on sdn. The answer? Plenty. (Not my derm dept though, I already mentioned they were great).

I won't mind at all if our incomes all go down 50%. I think it may be good.

But yeah, you're right. I know very little on this subject. The other guy showed my ignorance. I don't have a discerning eye either. But I have to work with what God gave me.

Good luck.

 

[MOHS_01]

^^^ someone needs to rub a little salve on that....

 

[happygilmore]

^^^ someone needs to rub a little salve on that....

No kidding.

Multiple people at my med school have committed suicide in the last few years. I'm not suicidal in any way, but I understand + sympathize with how they could lose hope in this environment. Anyway, I think this is my last post in the derm thread, (edit: on second thought, probably my last post on SDN).

Good luck to all the derm people. I did honestly mean that some of my favorite doctors have been derm, so I really have no ill will towards derm in anyway. Best wishes.

 

[MOHS_01]

No kidding.

Multiple people at my med school have committed suicide in the last few years. I'm not suicidal in any way, but I understand + sympathize with how they could lose hope in this environment. Anyway, I think this is my last post in the derm thread, (edit: on second thought, probably my last post on SDN).

Good luck to all the derm people. I did honestly mean that some of my favorite doctors have been derm, so I really have no ill will towards derm in anyway. Best wishes.

Dude -- we all got kicked in the junk in medical school. It sucks. We know. For many it does not get any better upon graduation. It's not all rainbows and unicorns out here, you know... but some of us take some consolation in earning a good living, being able to provide well for our families, help those causes we hold dear, and hopefully have a chance to see our kids a little while they're growing up.

Try to not let your bitterness suck you over to the dark side... and quit throwing rocks blindly at people when you really don't know what is up. This is real life for some of us, not some horse**** exercise in abstract social justice.

 

[DermViser]

I liked the article. I admitted the MOHs guy is smarter than me and that I'm a lowly med student who should never challenge any superior. You're right, I don't practice derm so I should not have any opinions on it.
Anyway, I've had too many attendings and the medical community berate and beat me up to have any sense of community or reverence for this profession. So when doctors are demonized I have to ask if I've known any demons at the hospital or even on sdn. The answer? Plenty. (Not my derm dept though, I already mentioned they were great).
I won't mind at all if our incomes all go down 50%. I think it may be good.
But yeah, you're right. I know very little on this subject. The other guy showed my ignorance. I don't have a discerning eye either. But I have to work with what God gave me.
Good luck.

Nope try again. I know I'm humoring myself, but at least others can learn from your mistakes.
At least if you're going to walk off in the martyr/victimhood role, you should get it right of what you are doing wrong. It has nothing whatsoever to do with "challenging" a superior. It has everything to do with being so set and inflexible in your worldview of how things work, and not in any way trying to see a different analysis and reasoning with actual real life experience in the day-to-day workings of the issue at hand. Instead you hold your hands over your ears saying, "I can't hear you!" If you think I'm saying the solution is to hold your head down in shame and just say yes to what I say, bc I'm some malignant a-hole, then you're WRONG. If you do that on rotations you definitely will get a target put on your back on rotations, bc it shows you don't respect yourself and more importantly it reflects that you're not confident in your knowledge or your ability to make decisions which is even worse.

As an analogy, it's like an attending on IM in your MS-3 year explaining about using beta blockers in heart failure patients (which is counterintuitive), and a medical student telling that attending they are completely wrong bc "the book" or First Aid told you that beta blockers are completely contraindicated, when in reality, clinical trials show that beta blockers help in cardiac remodeling, thus actually helping in heart failure. There are so many instances in which clinical medicine does not match up with what you learned in basic sciences. If it did, we could all go home, and the PhDs could take over and see patients. If things were really that cookbookish, you can bet hospitals would be more than happy to hire PhDs and pay them a lot less, bc ANYONE could do it. So if even the story behind the medicine isn't always straightforward, don't you think the same applies to how billing works? It's important, bc you'll need to know it when you start having to pay off your student loans for real. Rainbows and Unicorn farts don't pay student loan payments.

Instead what do you do? You take it as a personal insult, "I've had too many attendings and the medical community berate and beat me up to have any sense of community or reverence for this profession". And yet you are still pursuing this profession (a profession u hate so much). Funny ain't it? This is why medical schools have now incorporated evaluating Professionalism of medical students on rotations as part of grades. Hence why being able to take constructive criticism (bc ALL of us have to be able to do so even as attendings, as none of us are perfect, not just from other doctors either), changing course of behavior when given mid-rotation feedback etc. is just as important as filling the correct bubbles on your shelf exam.

Too many students such as yourself come in on rotations with a huge level of entitlement so that if ANY level of criticism is given, you interpret it as people beating up on you, personally, hence why you completely missed the remark re: demonization of doctors (which you've twisted to fit your own personal vendetta). There's a reason residencies look at MS-3 comments so closely bc those who have trouble on their rotations due to interpersonal conflicts/not being able to take constructive criticism/taking things personally - are very toxic to residencies no matter what field you're going into. It doesn't matter how "smart" you are.
There's NO WAY you will survive internship (when you'll sometimes get blamed for **** you had nothing to do with) or residency where you're expected to keep your cool, without these skills, unless you plan on labeling them as "attendings and the medical community berat[ing] and beat[ing] me up" as well, which in that case, you definitely won't make it through.

But good luck to you, I'll give you the last word, as I realize that all of your thinking stems from lack of introspection. Don't think we haven't been through medical school ourselves, bc we have. But there's a healthy way to deal with it and a not so healthy way, and you seem to be content in doing the latter.

 

[ER BlueBlood]

There are 10 Mohs trained guys in my state; I cannot speak for the three up north, but I am the only one of the remaining 7 that I am aware of who does not actively limit the number of self (no) pays. I live in a very poor state besieged by poor health, poor education, and general poor economics -- poor systems that have been greatly worsened by government regulations. Anyway... I probably do more charity cases than anyone as I do a couple hundred a year. My self pay Mohs cases are asked to bring $300 with them at the date of service if they can; no one is turned away. I always do whatever reconstruction I can as you simply cannot find a plastic surgeon willing to cut a deal -- even the University (especially the University) are douches to deal with. Their total bill never exceeds $1000 and I personally cannot remember charging more than $500. Excisions, regardless of repair, have been charged $250. I more often than not never see that; in 2013 I had accumulated over $350k in bad debt stretching back to June of 2010 -- the last time I purged the books of bad debt -- and this is at those discounts.

Yes, people who do what I do can be and often are paid well. We do it on volume and sheer work effort. I know that it may not be a popular or politically correct opinion to profess, but the people who self select for any given profession will play a significant determining role in how well that profession performs... and those of us who self select out for Mohs would trend toward the more productive.

What our dear M3 does not understand is that the income of the procedural dermatologist is not extravagantly high because he or she is paid better for any given service than any other specialty providing the same service; it's that we are quite busy and proficient at what we do... which drives a volume of services not matched by many... and the economics of it are such that greater revenues translate into greater profits in a nonlinear fashion.

The article is def taking a swipe at docs, not the best way to get the message across...but, Similar to GI, Derm's time is almost up. Don't for a second think you are comp'd well because you have some superior efficiency lol, it's all about the reimbursements and once that goes, you go to 200k and noone will think much of it.

 

[NSight8]

Sounds like ERBlueBlood who picked a field completely under control of government reimbursement and completely at the mercy of hospital administrators is lashing out at a field that he was obviously too dumb to match into. It's okay ERBlueBlood, I know the high burnout rate in ER is tough, maybe you can next post in the Psych forum to get help with this.

 

[MOHS_01]

The article is def taking a swipe at docs, not the best way to get the message across...but, Similar to GI, Derm's time is almost up. Don't for a second think you are comp'd well because you have some superior efficiency lol, it's all about the reimbursements and once that goes, you go to 200k and noone will think much of it.

Sounds like ERBlueBlood who picked a field completely under control of government reimbursement and completely at the mercy of hospital administrators is lashing out at a field that he was obviously too dumb to match into. It's okay ERBlueBlood, I know the high burnout rate in ER is tough, maybe you can next post in the Psych forum to get help with this.

Maybe the rest of us will just have to start pulling 3 12's and walk away without restraint when that happens, huh.

Learn from the best. Heh.

p.s. you're wrong -- comprehension (or elementary math) fail.

 

[ER BlueBlood]

Sounds like ERBlueBlood who picked a field completely under control of government reimbursement and completely at the mercy of hospital administrators is lashing out at a field that he was obviously too dumb to match into. It's okay ERBlueBlood, I know the high burnout rate in ER is tough, maybe you can next post in the Psych forum to get help with this.

spoken like a true resident, you think you are protected? think again. as for the personal attack, that reflects poorly on you

 

[NSight8]

spoken like a true resident, you think you are protected? think again. as for the personal attack, that reflects poorly on you

Stop being a miserable troll. You talk like you are happy that reimbursement for other fields is going down. This is not a zero sum game. Continue with your Percocet vending, and leave the derm forum alone.

 

[ER BlueBlood]

Stop being a miserable troll. You talk like you are happy that reimbursement for other fields is going down. This is not a zero sum game. Continue with your Percocet vending, and leave the derm forum alone.

noone is talking like that, you are just channeling your inner butthurt. keep calm

 

[random1234]

See the quote above.

I think I understand your play here. The dermatologist only got paid $1400 for the $25,000 that was billed to this woman, hence it's not the dermatologist fault. Unfortunately, that's not how the patient sees it. They see a cumulative bill.

The standard response is, "oh, well the doctor doesn't get paid that much." Fair enough. But it's hard to deny that when you're doing things like this that the model isn't for profit. Maybe your practice is different but these things are happening. And since when is getting skin having a Mohs procedure done for 5k seen as chump change?

I'm curious, if the article is pure **** then answer these questions that I posed:

1. Is the mean salary for a Mohs surgeon priced at $516,000 appropriate compared to a pediatrician's $166,000?
2. Is it fair for an NP to remove a wart and have the office bill $915?
3. Should a 5 min mole removal bill for $500?

No, it's not the dermatologist who gets all that money and some payers will negotiate the prices down. The fact remains that many derm doctors are getting rich. The Mohs surgeons definitely are getting all of their half mil.

My brother and I had problems with warts growing up. A relative of mine is an ER physician and we would just freeze the warts at home (anyone can buy the freezing kit, it's like 15 bucks on Amazon). Once, that didn't work, so he injected our affected finger with some anesthesia and removed it with a scalpel. The whole process took less than 10 minutes and the the total cost was free...even if he had bought the scapel and local anesthesia, pretty sure it wouldn't come out to $915, lol.

 

[asmallchild]

My brother and I had problems with warts growing up. A relative of mine is an ER physician and we would just freeze the warts at home (anyone can buy the freezing kit, it's like 15 bucks on Amazon). Once, that didn't work, so he injected our affected finger with some anesthesia and removed it with a scalpel. The whole process took less than 10 minutes and the the total cost was free...even if he had bought the scapel and local anesthesia, pretty sure it wouldn't come out to $915, lol.

I'm not quite sure I get your angle here, I think we've established no one is getting 915 for excising anything, let alone destruction of benign lesions...

Oh, kudos to your relative for putting you through a scarring procedure that hasn't statistically proven to provide a better cure rate than numerous other less painful treatment options

 

[random1234]

I'm not quite sure I get your angle here, I think we've established no one is getting 915 for excising anything, let alone destruction of benign lesions...

Oh, kudos to your relative for putting you through a scarring procedure that hasn't statistically proven to provide a better cure rate than numerous other less painful treatment options

Actually it worked great. My brother and I never got another wart again and there is no scar. (I didn't know scarring was possible?) There wasn't any pain either, we were both just kids. We tried duct tape, freezing numerous times, etc, none of which worked. I guess I just meant that 915 is excessive no matter where or who is doing the procedure.

 

[MOHS_01]

Actually it worked great. My brother and I never got another wart again and there is no scar. (I didn't know scarring was possible?) There wasn't any pain either, we were both just kids. We tried duct tape, freezing numerous times, etc, none of which worked. I guess I just meant that 915 is excessive no matter where or who is doing the procedure.

It works as well as rubbing a potato on it and burying it in the backyard, but yeah, whatever works.. and really? You did not know that taking a knife to something can cause a scar?

 

[DermViser]

The article is def taking a swipe at docs, not the best way to get the message across...but, Similar to GI, Derm's time is almost up. Don't for a second think you are comp'd well because you have some superior efficiency lol, it's all about the reimbursements and once that goes, you go to 200k and noone will think much of it.

LOL, an ER doctor of all people lecturing to dermatology about how reimbursement works, when his specialty is highly dependent on the govt. and their reimbursements.

You do realize that you're on the chopping block too right? Have you not seen the NY Times articles attacking Emergency Room doctors and their "exorbitant" ER prices? You really think that this just effects us? We understand you're trolling bc specialists are not available at your beckon call in the ER, due to not being able to do something yourself, as well as the high burnout rate in your specialty. Yes, we all should become the exalted ER doctor a specialty that's only been an official specialty since like 1990, when before it was actual internal medicine and surgery residents who took care of the ER.

 

[DermApp13]

Dear friends, lets just stop.

 

[droliver]

While the subtlties of billings versus collections were badly presented in the article, it did touch on some of the problematic issues with how MOHS has evolved. It's been comoditized/monetized beyond the indications for the procedure. There has been an irrational spike in utilization of MOHS, which is just a reflection of economic pressures on derm practices, particularly since the path exemption for MOHS was elininated. It just (predictably) made MOHS surgeons start doing more cases to sustain their incomes. These spikes in utilization are then tracked by CMS and will be used to force cuts in reimbursement to maintain budget targets.

Patients do not understand how a simple shave biopsy that takes seconds and uses <$10 in supplies results in (real) out of pocket costs exceeding what they take home in a week's salary on their job.

 

[MOHS_01]

While the subtlties of billings versus collections were badly presented in the article, it did touch on some of the problematic issues with how MOHS has evolved. It's been comoditized/monetized beyond the indications for the procedure. There has been an irrational spike in utilization of MOHS, which is just a reflection of economic pressures on derm practices, particularly since the path exemption for MOHS was elininated. It just (predictably) made MOHS surgeons start doing more cases to sustain their incomes. These spikes in utilization are then tracked by CMS and will be used to force cuts in reimbursement to maintain budget targets.

Patients do not understand how a simple shave biopsy that takes seconds and uses <$10 in supplies results in (real) out of pocket costs exceeding what they take home in a week's salary on their job.

Well now this is surely getting interesting. The loss of the multiple procedure reduction exemption was BS and continues to be misapplied to this day, but leaving that aside for a moment you are conflating two very distinct and separate issues here -- reimbursement and utilization. I'm sure that you have the data to back up that assertion? Because we have not seen it... in fact it was the increase in utilization that served as the driving impetus for removing the multiple procedure exemption.

Since utilization is the problem here -- and I agree that it is (at least in part) -- why don't we focus our efforts and discussion on that? There are two possible explanations for an increase in utilization: increased incidence and changes in treatment patterns. What we think we know is that there is an increase in the incidence, but the increase in Mohs utilization is increasingly more rapidly. This can represent a number of things (and likely does); first is a natural reflection of the increased availability of the procedure that results from an accelerating increase in the number of providers providing the service. This does not, by definition, constitute something amiss -- assuming that utilization criteria are still being followed. The second contributing factor -- and the one that deserves the most critical eye -- is any dilution of the criteria for selecting Mohs as the preferred treatment. This is a problem that I have seen first hand -- albeit by people who "do their own Mohs" predominantly.

p.s. "spikes in utilization are then tracked by CMS" == > that's not how the system was designed and is not how it is supposed to work.

Your last sentence is a gross misrepresentation that borders on complete and total horse****. You're better than that, RO.

 

[reno911]

While the subtlties of billings versus collections were badly presented in the article, it did touch on some of the problematic issues with how MOHS has evolved. It's been comoditized/monetized beyond the indications for the procedure. There has been an irrational spike in utilization of MOHS, which is just a reflection of economic pressures on derm practices, particularly since the path exemption for MOHS was elininated. It just (predictably) made MOHS surgeons start doing more cases to sustain their incomes. These spikes in utilization are then tracked by CMS and will be used to force cuts in reimbursement to maintain budget targets.

I'd love to see your data for the "irrational spike". There's a spike no doubt, but as MOHS_01 points out, given the rising incidence of skin cancer, the fact that our population is aging, and the fact that there are more and more Mohs surgeons being trained, there is obviously going to be an increase in the amount of Mohs being done. There are many people getting Mohs today that would not have had Mohs 30 years ago simply because there was no accessible Mohs surgeon to do it. And these people are absolutely receiving better care.

I'm sure there are also people (mostly, but not exclusively, non-fellowship-trained folks) out there doing some very questionable Mohs. However, that doesn't change the fact that a large part of the increase in utilization of Mohs is for completely legitimate reasons. Of course, one would not expect a sensationalist article like the NYT one to emphasize this, but it seems that a smart guy like you could figure it out.

Patients do not understand how a simple shave biopsy that takes seconds and uses <$10 in supplies results in (real) out of pocket costs exceeding what they take home in a week's salary on their job.

What does this have to do with Mohs? Is this just a complete non-sequitur? Or do you not understand what Mohs actually entails?

 

[JoBreeze]

This thread went from stupid to bitter real fast.

 

[dermathalon]

Wow. What the hell happened to this thread...why the fervent personal attacks on each other instead of discussing the issues.

I'm a derm and perform surgeries so can't brandish me off as an ER doc or an MS3.

This article highlights some clear misunderstandings. First off, people that take insurances with high deductibles are trying to have their cake and eat it too. Many of these plans allow for certain advantages in access and they knew they had high deductible plans. They had other options that likely did not have deductibles but elected against it. The article makes no mention of this and shows lack of knowledge on the author's part. That is only a drop in the bucket. This author was in over her head and really had no business writing an article in an area where she was poorly informed. Journalists do not need to go through the same peer review as evidence based publications but they get more bang for their buck despite.

I have seen many cases treated with Mohs that would have been just fine treated otherwise. It is overused. Many derms agree on this (some of you may not agree but you would be in the minority). And the Mohs surgeons are partly culprit so they can't just wash their hands of this as if it is something that "the others" are doing. Some practices will have one Mohs surgeon perform the excision and have another Mohs surgeon come in for the repair (and vice versa) so that they can bill each portion of the procedure separately on different physicians. If you think this doesn't happen, then you need to get out more often because it happens. These are Mohs surgeons...not a lot of them but happens enough that I've heard about it several times. So what do you say to that? Do you think that is ok? I think it is asinine. If one particular Mohs surgeon doesn't do it or if two don't do it, that is hardly evidence that it is not overused. Many things that are treated with Mohs would have done well with an excision.

Regardless, my problem with this article was not even the Mohs and I don't understand why everyone is perseverating on that (yes, yes, I get it that a general patient would not know this when getting the bill. But we know better and should call it how it is). The repair included a facility fee (why the hell do you need a facility fee in a private practice, oh that's right, because you are set up as a surgical center), an anesthesiologist (why the hell do you need an anesthesiologist), etc. that jacked the billing way way up. If anything, this article is a hit on those that perform repairs with bells and whistles that we all know is not justified. Whether you are going to admit it here or not, I'll bet many of you know derms that have a mini-surgical center so that they can jack their billing up (BTW, the repair was not done by the derm in the article so many are culprit of this). Not all, but there are quite a few out there.

Mohs get paid more because their codes are valued and it's not just that they are working harder. Gen derm folks can work extremely hard and definitely see more patients in a day but they don't get reimbursed like Mohs. Increased patient load does not automatically mean increased revenue. The value of the code is important. I think utilization is increasing with increased skin cancers but what bothers me more is that there are increasing cases where utilization is not justified.

droliver, you seemed to have had a reasonable point but your last statement is way out of line and almost invalidates your post. I have yet to do a simple shave biopsy that would be billed to the patient to be more than "what they take home in a week's salary on their job" that we couldn't work out in a reasonable way. If they were that stretched thin for money, they would likely have a HMO with controlled costs and they would only have had to pay a co-pay to see me rather than have a high deductible insurance which are typically more expensive on a monthly basis. If they are self pay, most of us are not so cut-throat to not try to take that into account and even the universities can mitigate the costs. One of my patients had her costs mitigated after visiting the university and they tried to work with her on a reasonable basis.


If you all think this is an issue, wait til the brachytherapy BS gets publicity...

 

[MOHS_01]

Wow. What the hell happened to this thread...why the fervent personal attacks on each other instead of discussing the issues.

If directed at me, as for @droliver - I know him. We trained at the same institution at the same time. While we do not agree on this matter -- nor the legitimacy of the multiple procedure reduction exemption loss -- I meant it when I said he was better than that. He's a pretty good guy. Good enough, at least.

I'm a derm and perform surgeries so can't brandish me off as an ER doc or an MS3.

This article highlights some clear misunderstandings. First off, people that take insurances with high deductibles are trying to have their cake and eat it too. Many of these plans allow for certain advantages in access and they knew they had high deductible plans. They had other options that likely did not have deductibles but elected against it. The article makes no mention of this and shows lack of knowledge on the author's part. That is only a drop in the bucket. This author was in over her head and really had no business writing an article in an area where she was poorly informed. Journalists do not need to go through the same peer review as evidence based publications but they get more bang for their buck despite.

She's a Harvard trained MD; her ignorance is not exactly innocent and benign here. She's pushing an agenda.

I have seen many cases treated with Mohs that would have been just fine treated otherwise. It is overused. Many derms agree on this (some of you may not agree but you would be in the minority). And the Mohs surgeons are partly culprit so they can't just wash their hands of this as if it is something that "the others" are doing. Some practices will have one Mohs surgeon perform the excision and have another Mohs surgeon come in for the repair (and vice versa) so that they can bill each portion of the procedure separately on different physicians. If you think this doesn't happen, then you need to get out more often because it happens. These are Mohs surgeons...not a lot of them but happens enough that I've heard about it several times. So what do you say to that? Do you think that is ok? I think it is asinine. If one particular Mohs surgeon doesn't do it or if two don't do it, that is hardly evidence that it is not overused. Many things that are treated with Mohs would have done well with an excision.

Yeah -- that's the utilization problem I spoke to. Those of us actively involved in this matter have been trying to address this since 2005 (at least). This resulted in the appropriate use criteria app last year; if it is appropriate, use it -- if not, don't expect to get paid. If anything, I personally believe the appropriateness as determined by this app is too generous. It's not a simple matter of "could I have gotten away with an excision" (you can always 'get away' with an excision).

I have a 99% outside referral practice. The decision for Mohs is not made by me; in fact, I will often do an excision, local destruction, or write a Rx for imiquimod on something referred to me. In the same vein, however, I see many previous excisions and destructions that I believe were inappropriate.... and spend much of my day digging down to periosteum on recurrences. There's a lot of **** that I'd really rather not have to cut out that ultimately has to come out due to poor management -- but that is the nature of the beast.

As for the two Mohs guy in one practice -- urban legend (or urban crooks or urban idiots lol) -- it really makes no difference in $$ as it does not work that way. You bill in accordance to your practice tax ID number; everyone in the same practice bills under the same tax ID. The multiple procedure reduction still applies. They may gain efficiencies, but they're not bilking anyone for additional money.

Regardless, my problem with this article was not even the Mohs and I don't understand why everyone is perseverating on that (yes, yes, I get it that a general patient would not know this when getting the bill. But we know better and should call it how it is). The repair included a facility fee (why the hell do you need a facility fee in a private practice, oh that's right, because you are set up as a surgical center), an anesthesiologist (why the hell do you need an anesthesiologist), etc. that jacked the billing way way up. If anything, this article is a hit on those that perform repairs with bells and whistles that we all know is not justified. Whether you are going to admit it here or not, I'll bet many of you know derms that have a mini-surgical center so that they can jack their billing up (BTW, the repair was not done by the derm in the article so many are culprit of this). Not all, but there are quite a few out there.

Mohs get paid more because their codes are valued and it's not just that they are working harder. Gen derm folks can work extremely hard and definitely see more patients in a day but they don't get reimbursed like Mohs. Increased patient load does not automatically mean increased revenue. The value of the code is important. I think utilization is increasing with increased skin cancers but what bothers me more is that there are increasing cases where utilization is not justified.

droliver, you seemed to have had a reasonable point but your last statement is way out of line and almost invalidates your post. I have yet to do a simple shave biopsy that would be billed to the patient to be more than "what they take home in a week's salary on their job" that we couldn't work out in a reasonable way. If they were that stretched thin for money, they would likely have a HMO with controlled costs and they would only have had to pay a co-pay to see me rather than have a high deductible insurance which are typically more expensive on a monthly basis. If they are self pay, most of us are not so cut-throat to not try to take that into account and even the universities can mitigate the costs. One of my patients had her costs mitigated after visiting the university and they tried to work with her on a reasonable basis.


If you all think this is an issue, wait til the brachytherapy BS gets publicity...

yeah, the XRT stuff is problematic -- at least we're not as bad as the urology guys (yet).

Most of my revenue actually comes from reconstructions -- maybe I'm doing it wrong. ?

 

[reno911]

Wow. What the hell happened to this thread...why the fervent personal attacks on each other instead of discussing the issues.

I don't really see any fervent personal attacks. Maybe I just have a thick skin, but it seems like most everyone is just vigorously discussing the topic.

This article highlights some clear misunderstandings. First off, people that take insurances with high deductibles are trying to have their cake and eat it too. Many of these plans allow for certain advantages in access and they knew they had high deductible plans. They had other options that likely did not have deductibles but elected against it. The article makes no mention of this and shows lack of knowledge on the author's part. That is only a drop in the bucket. This author was in over her head and really had no business writing an article in an area where she was poorly informed. Journalists do not need to go through the same peer review as evidence based publications but they get more bang for their buck despite.

Agreed.

I have seen many cases treated with Mohs that would have been just fine treated otherwise. It is overused. Many derms agree on this (some of you may not agree but you would be in the minority). And the Mohs surgeons are partly culprit so they can't just wash their hands of this as if it is something that "the others" are doing. Some practices will have one Mohs surgeon perform the excision and have another Mohs surgeon come in for the repair (and vice versa) so that they can bill each portion of the procedure separately on different physicians. If you think this doesn't happen, then you need to get out more often because it happens. These are Mohs surgeons...not a lot of them but happens enough that I've heard about it several times. So what do you say to that? Do you think that is ok? I think it is asinine. If one particular Mohs surgeon doesn't do it or if two don't do it, that is hardly evidence that it is not overused. Many things that are treated with Mohs would have done well with an excision.

No one is saying that Mohs is never done inappropriately. We could use this argument for almost any procedure in medicine: I have seen lesions biopsied that clearly didn't need to be biopsied. Biopsies are overdone. I have seen people admitted to the hospital that didn't need to be. Too many people are admitted. Etc. The fact is that any procedure is done inappropriately by some people is almost a given. Sure it happens in Mohs. But there are also very legitimate reason for there to be increases in the utilization of Mohs. No one really knows exactly how much of the increase is due to inappropriate utilization and how much is due to legitimate use. Not even you, despite all of the anecdotes I'm sure you could provide.

Regardless, my problem with this article was not even the Mohs and I don't understand why everyone is perseverating on that (yes, yes, I get it that a general patient would not know this when getting the bill. But we know better and should call it how it is). The repair included a facility fee (why the hell do you need a facility fee in a private practice, oh that's right, because you are set up as a surgical center), an anesthesiologist (why the hell do you need an anesthesiologist), etc. that jacked the billing way way up. If anything, this article is a hit on those that perform repairs with bells and whistles that we all know is not justified. Whether you are going to admit it here or not, I'll bet many of you know derms that have a mini-surgical center so that they can jack their billing up (BTW, the repair was not done by the derm in the article so many are culprit of this). Not all, but there are quite a few out there.

I would probably agree with this, but without hearing from all sides and seeing a photograph of the defect, I'm going to reserve judgement on whether what was done in that particular case was reasonable. One thing that we have to understand is that for the most part our non-Mohs colleagues are, in general, not very comfortable doing even moderately complicated repairs in an office setting with local anesthesia alone. I have yet to meet the plastic surgeon who does any kind of cartilage graft or even a bilobed flap in their office. I do those things all of the time with no problems at all. Heck, to a non-Mohs surgeon, doing a forehead flap in the office would be crazy, but to many Mohs surgeons it is very straightforward. Different docs have extremely different ideas on what "needs" an OR.

Mohs get paid more because their codes are valued and it's not just that they are working harder. Gen derm folks can work extremely hard and definitely see more patients in a day but they don't get reimbursed like Mohs. Increased patient load does not automatically mean increased revenue. The value of the code is important. I think utilization is increasing with increased skin cancers but what bothers me more is that there are increasing cases where utilization is not justified.

This is just plain untrue. I'm a quite a busy Mohs surgeon, and I know that I could make as much or even more doing high volume general derm w/ cosmetics. I know many general derms in my area that make more than I do. In a private practice, derms also have a much greater ability to cultivate ancillary revenue streams. A Mohs surgeon whose practice is limited to Mohs and is only doing cases referred to him by other dermatologists does not have these opportunities. If you're talking about guys who basically just do their own Mohs (and do a lot of general derm to generate that), that's a different story. But you have to remember, those guys get a lot of revenue from their general derm as well.

The pure Mohs surgeons that make the most money just do an insanely high volume of cases. These guys are in referral based practices, so someone else is actually referring the patient for Mohs and believes it is appropriate. The reason why they make so much more than you would expect is because once you reach a certain critical mass of cases, profits increase dramatically. If you are a low volume Mohs surgeon, your overhead really cuts into your bottom line, but once you hit a certain number of cases (and it is a very high number) your overhead has already been covered and the marginal costs of doing the extra case are very limited, so almost all of the revenue generated by the case is profit. However to reach this number of cases, a Mohs surgeon must work very hard.

If you all think this is an issue, wait til the brachytherapy BS gets publicity...

Agreed.

 

[MOHS_01]

You punish the bad for bad behavior -- novel concept, sure... but that's the way it is supposed to be done. You don't limit vehicles to 15mph simply because school zones exist.... and you don't demonize someone for driving 55mph in a 55mph zone.

I'm not sure why this is so difficult.

 

[doctalaughs]

Wow. What the hell happened to this thread...why the fervent personal attacks on each other instead of discussing the issues.

I'm a derm and perform surgeries so can't brandish me off as an ER doc or an MS3.

This article highlights some clear misunderstandings. First off, people that take insurances with high deductibles are trying to have their cake and eat it too. Many of these plans allow for certain advantages in access and they knew they had high deductible plans. They had other options that likely did not have deductibles but elected against it. The article makes no mention of this and shows lack of knowledge on the author's part. That is only a drop in the bucket. This author was in over her head and really had no business writing an article in an area where she was poorly informed. Journalists do not need to go through the same peer review as evidence based publications but they get more bang for their buck despite.

I have seen many cases treated with Mohs that would have been just fine treated otherwise. It is overused. Many derms agree on this (some of you may not agree but you would be in the minority). And the Mohs surgeons are partly culprit so they can't just wash their hands of this as if it is something that "the others" are doing. Some practices will have one Mohs surgeon perform the excision and have another Mohs surgeon come in for the repair (and vice versa) so that they can bill each portion of the procedure separately on different physicians. If you think this doesn't happen, then you need to get out more often because it happens. These are Mohs surgeons...not a lot of them but happens enough that I've heard about it several times. So what do you say to that? Do you think that is ok? I think it is asinine. If one particular Mohs surgeon doesn't do it or if two don't do it, that is hardly evidence that it is not overused. Many things that are treated with Mohs would have done well with an excision.

Regardless, my problem with this article was not even the Mohs and I don't understand why everyone is perseverating on that (yes, yes, I get it that a general patient would not know this when getting the bill. But we know better and should call it how it is). The repair included a facility fee (why the hell do you need a facility fee in a private practice, oh that's right, because you are set up as a surgical center), an anesthesiologist (why the hell do you need an anesthesiologist), etc. that jacked the billing way way up. If anything, this article is a hit on those that perform repairs with bells and whistles that we all know is not justified. Whether you are going to admit it here or not, I'll bet many of you know derms that have a mini-surgical center so that they can jack their billing up (BTW, the repair was not done by the derm in the article so many are culprit of this). Not all, but there are quite a few out there.

Mohs get paid more because their codes are valued and it's not just that they are working harder. Gen derm folks can work extremely hard and definitely see more patients in a day but they don't get reimbursed like Mohs. Increased patient load does not automatically mean increased revenue. The value of the code is important. I think utilization is increasing with increased skin cancers but what bothers me more is that there are increasing cases where utilization is not justified.

droliver, you seemed to have had a reasonable point but your last statement is way out of line and almost invalidates your post. I have yet to do a simple shave biopsy that would be billed to the patient to be more than "what they take home in a week's salary on their job" that we couldn't work out in a reasonable way. If they were that stretched thin for money, they would likely have a HMO with controlled costs and they would only have had to pay a co-pay to see me rather than have a high deductible insurance which are typically more expensive on a monthly basis. If they are self pay, most of us are not so cut-throat to not try to take that into account and even the universities can mitigate the costs. One of my patients had her costs mitigated after visiting the university and they tried to work with her on a reasonable basis.


If you all think this is an issue, wait til the brachytherapy BS gets publicity...

I'm also a gen derm who does a ton of procedures and I think dermathalon hit the nail in the head. The article was of course total BS and represents a gross distortion and ignorance on the part of author. However we are no question training to many mohs people. Overutilization is a big problem (as is in many areas of medicine) because (some) mohs surgeons would be hurting for work and therefore are doing at lot of surgeries on things that could be treated more efficiently with excision - or moreover with ED&C. The number of in-situ lesions that I've seen treated with mohs makes me cringe. Some areas of the country routinely send any non-melanoma skin cancer of *ANY* histology and size on the face to mohs...

On the other hand there is no question that mohs is probably more efficient for 99% of appropriate tumors both cost and outcome-wise than sending to nearly any other outside specialty that often takes patients to the OR for things that don't need it (plastics, H&N etc). The cost of doing that is probably 10x what the mohs surgeon would cost.

I agree with mohs01 that the criteria for mohs should have been a LOT more strict, but I think that would have put a lot of mohs people out of business and therefore was fought against. In the end we general derms can blame ourselves as well because we are sending most of the referals- I think this may stem from older dermatologists who are less comfortable with procedures and will probably decrease over time.

 

[reno911]

Some areas of the country routinely send any non-melanoma skin cancer of *ANY* histology and size on the face to mohs...

I agree with mohs01 that the criteria for mohs should have been a LOT more strict, but I think that would have put a lot of mohs people out of business and therefore was fought against. In the end we general derms can blame ourselves as well because we are sending most of the referals- I think this may stem from older dermatologists who are less comfortable with procedures and will probably decrease over time.

If you're referring to the fairly recent Mohs Appropriate Use Criteria, it probably could have been more strict in some areas. But you have to remember that most of the people on the panel were NOT Mohs surgeons. This was of course by design to avoid your exact criticism (i.e. everyone would just assume that a bunch of Mohs surgeons would have an incentive to say that everything needs Mohs). Some of the recommendations were actually on the conservative side. For example the AUC says that it would be inappropriate to treat a 10 cm superficial BCC on the chest which has recurred after two excisions with Mohs. I disagree with that one.

As far as referring every single facial NMSC for Mohs, it is hard to blame the Mohs surgeon for that. If you're going to blame anyone, you should blame the referring physician, who has often convinced the patient that he needs Mohs. But I don't think that even the referring doc deserves blame. If one is going by the AUC, there are very few NMSC on the face for which Mohs is considered inappropriate. Most are appropriate or uncertain. So referring every single facial one would actually be very close to recently published evidence based guidelines. Moreover, I really don't think most of the inappropriate Mohs that people are up in arms about is actually stuff that is on the face. It's the tiny lesions below the neck that I think make up the bulk of the "inappropriate" Mohs. Despite the uninformed implications of the author of the NYT article, I think most dermatologists (and Mohs surgeons) would agree that doing Mohs for ANY eyelid BCC is not inappropriate.

As an aside, I do see a fair number of Mohs patients that are referred for lesions on the face which I think could be treated effectively in other ways, so I don't treat them with Mohs surgery. I also know many other fellowship-trained Mohs surgeons that practice the same way. There are a lot of Mohs surgeons out there that are trying to do things the right way. Certainly more than you think.

 

[dermathalon]

Mohs_01, not directing anything at you in particular. I just saw a lot of non-discussion related comments that had nothing to do with the article that kinda took away from the discussion. Mohs_01, I actually like your philosophy on how you treat patients. We have few in our area that act the same way and we love them because they are amazing surgeons who really provide an invaluable service. I get that. For heavens' sake, I'm a derm and know what it means to appreciate a great surgeon.

If that author of that article is a Harvard MD, that is even more sad. I'm too cynical to give journalists the benefit of the doubt when they write a piece like this to chalk it up to innocence or being benign. As a Harvard MD, it's even more profoundly pathetic. I have been asked to give interviews with journalists and I have found many of them to be very thoughtful and meticulous in their research. I will think twice about anything I read from this one.

BTW, let me reiterate that my issue is not with Mohs misutilization in this article. No one is going to disagree to that Mohs on an eyelid is appropriate. If you are thinking that people are arguing against using Mohs on an eyelid, you are are on your own island concocting your own argument in your head. I'm sure everyone agrees it's appropriate except for maybe some brachytherapy aficionados (tongue firmly planted in cheek). It's the surgery center issue that bother me. BTW, several Mohs surgeons I know have these set up too. How can they justify it when they know that they don't need it for their closure? It's purely economical and I have heard it from the horse's mouth when I interviewed for positions. For every one of these, there are many Mohs surgeons whom I truly respect. But all you need is a drop of black to make milk look brown.

I do want to address another point though. To say that you did surgery because someone else deemed that Mohs surgery was appropriate is akin to saying I will biopsy an SK because the referral said concern for melanoma. YOU are the derm and you make the final judgement. A Mohs surgeon may get a referral from a general derm but there are a lot of gray area diagnoses where you have to make the decision. Some biopsy reports are outright called basal cell or squamous cell and so you're hands are tied in these cases. However, I know dermpaths that will call the reports for the gray area that it is. Some things really are hypertrophic AKs, etc. In these cases, you have to make the decision as a Mohs surgeon. That is why you got the referral. You're the expert. No one else can deem to you that Mohs was appropriate...that is your decision. To say otherwise cheapens the expertise of a Mohs surgeon to nothing more than monkey see monkey do. We are all better than that. If you don't think so, then the recharge committees will decide that for you. The ball is in our court (myself included as a derm). We can't cry spilt milk when we see the cracks ahead of time.

You punish the bad for bad behavior -- novel concept, sure... but that's the way it is supposed to be done. You don't limit vehicles to 15mph simply because school zones exist.... and you don't demonize someone for driving 55mph in a 55mph zone.

I'm not sure why this is so difficult.

Agreed.

 

[MOHS_01]

Maybe my practice is unique; I see very few referrals from non-dermatologists. Similarly, those who do refer tend toward the procedural side themselves and refer out in a pretty defined manner: aggressive histology in cosmetically sensitive areas, recurrences, excisions with positive margins, and, of course, pain in the ass patients. That particular mix, while maybe Mohs appropriate, makes for some harder ditch digging than say what a Mohs guy with a large built in friendly referral base may have. It's all fine and good until they start whacking away indiscriminately at reimbursements... but then the **** gets real real fast! LOL

It does hit a little close to home, though, knowing that you are getting inappropriately taken down as collateral damage because they are too lazy or incompetent to identify or address the real issue.

 

[MOHS_01]

If you're referring to the fairly recent Mohs Appropriate Use Criteria, it probably could have been more strict in some areas. But you have to remember that most of the people on the panel were NOT Mohs surgeons. This was of course by design to avoid your exact criticism (i.e. everyone would just assume that a bunch of Mohs surgeons would have an incentive to say that everything needs Mohs). Some of the recommendations were actually on the conservative side. For example the AUC says that it would be inappropriate to treat a 10 cm superficial BCC on the chest which has recurred after two excisions with Mohs. I disagree with that one.

This. +1

As far as referring every single facial NMSC for Mohs, it is hard to blame the Mohs surgeon for that. If you're going to blame anyone, you should blame the referring physician, who has often convinced the patient that he needs Mohs. But I don't think that even the referring doc deserves blame. If one is going by the AUC, there are very few NMSC on the face for which Mohs is considered inappropriate. Most are appropriate or uncertain. So referring every single facial one would actually be very close to recently published evidence based guidelines. Moreover, I really don't think most of the inappropriate Mohs that people are up in arms about is actually stuff that is on the face. It's the tiny lesions below the neck that I think make up the bulk of the "inappropriate" Mohs. Despite the uninformed implications of the author of the NYT article, I think most dermatologists (and Mohs surgeons) would agree that doing Mohs for ANY eyelid BCC is not inappropriate.

As an aside, I do see a fair number of Mohs patients that are referred for lesions on the face which I think could be treated effectively in other ways, so I don't treat them with Mohs surgery. I also know many other fellowship-trained Mohs surgeons that practice the same way. There are a lot of Mohs surgeons out there that are trying to do things the right way. Certainly more than you think.

Agreed. In fact, did the NCCI not issue a statement just a while back along the lines of "any NMSC treated by destructive technique on the head and neck must be accompanied by the explicit informed consent that this treatment choice has a higher level of recurrence"? That's not saying it's inappropriate -- but not a glowing recommendation for that particular indication either. Sounds analogous to a black box warning to me; I still do them selectively -- but selectively.

 

[doctalaughs]

If you're referring to the fairly recent Mohs Appropriate Use Criteria, it probably could have been more strict in some areas. But you have to remember that most of the people on the panel were NOT Mohs surgeons. This was of course by design to avoid your exact criticism (i.e. everyone would just assume that a bunch of Mohs surgeons would have an incentive to say that everything needs Mohs). Some of the recommendations were actually on the conservative side. For example the AUC says that it would be inappropriate to treat a 10 cm superficial BCC on the chest which has recurred after two excisions with Mohs. I disagree with that one.

As far as referring every single facial NMSC for Mohs, it is hard to blame the Mohs surgeon for that. If you're going to blame anyone, you should blame the referring physician, who has often convinced the patient that he needs Mohs. But I don't think that even the referring doc deserves blame. If one is going by the AUC, there are very few NMSC on the face for which Mohs is considered inappropriate. Most are appropriate or uncertain. So referring every single facial one would actually be very close to recently published evidence based guidelines. Moreover, I really don't think most of the inappropriate Mohs that people are up in arms about is actually stuff that is on the face. It's the tiny lesions below the neck that I think make up the bulk of the "inappropriate" Mohs. Despite the uninformed implications of the author of the NYT article, I think most dermatologists (and Mohs surgeons) would agree that doing Mohs for ANY eyelid BCC is not inappropriate.

As an aside, I do see a fair number of Mohs patients that are referred for lesions on the face which I think could be treated effectively in other ways, so I don't treat them with Mohs surgery. I also know many other fellowship-trained Mohs surgeons that practice the same way. There are a lot of Mohs surgeons out there that are trying to do things the right way. Certainly more than you think.

I think this is a interesting discussion and much more relevant than the drivel written in that article. As I mentioned, I personally don't think the appropriate use criteria went far enough, but that's just my opinoin. One problem is that although most of the people on the panel were not mohs surgeons, there are a lot of general dermatologists who are in practices that have a big interest in mohs because it generates a lot of revenue for them. So I wouldn't say their opinions are "totally unbiased" (not that it's easy to have anyone that is unbiased). I personally think the best / most appropriate situation is how mohs01 is practicing- referrals mostly from derm, mostly, high-risk or recurrent tumors in cosmetically sensitive locations. Unfortunately there are not enough of those cases going around to keep all our mohs people busy.

I guess you can't fault anyone for sending all head and neck tumors to mohs based on these criteria. However, there (in my opinion) are so many situations where that is not necessarily the best management (ie the 90 yr old patient who's getting 10 tiny nodular BCCs on the face a year, the ones with huge superficial BCC or SCCIS all over the face where basically anywhere you biopsy will show tumor, etc). No one is going to argue an eyelid lesion should probably go to mohs.

 

[reno911]

I think this is a interesting discussion and much more relevant than the drivel written in that article. As I mentioned, I personally don't think the appropriate use criteria went far enough, but that's just my opinoin. One problem is that although most of the people on the panel were not mohs surgeons, there are a lot of general dermatologists who are in practices that have a big interest in mohs because it generates a lot of revenue for them. So I wouldn't say their opinions are "totally unbiased" (not that it's easy to have anyone that is unbiased). I personally think the best / most appropriate situation is how mohs01 is practicing- referrals mostly from derm, mostly, high-risk or recurrent tumors in cosmetically sensitive locations. Unfortunately there are not enough of those cases going around to keep all our mohs people busy.

I really don't know enough about the practices and financial arrangements of the panelists to know if this is true or not, and I would be quite surprised if you do. Nevertheless, if you want to look at it from a purely financial standpoint there is almost no realistic financial arrangement a dermatologist could have with a Mohs surgeon that would make referring a patient for Mohs more financially beneficial for themselves than treating the tumor themselves and receiving the payment for that. So it would be very difficult for the incentives to line up as you are suggesting.

 

[doctalaughs]

I really don't know enough about the practices and financial arrangements of the panelists to know if this is true or not, and I would be quite surprised if you do. Nevertheless, if you want to look at it from a purely financial standpoint there is almost no realistic financial arrangement a dermatologist could have with a Mohs surgeon that would make referring a patient for Mohs more financially beneficial for themselves than treating the tumor themselves and receiving the payment for that. So it would be very difficult for the incentives to line up as you are suggesting.

You are right - I don't know so I could be wrong. It may be my bias in the two cities I've practiced in (fairly saturated cities) but it seems that there are very few solo mohs guys. Most mohs here occurs in practices of 4-15 dermatologists and they have all hired 1-2 (young) mohs people to do all the cases so zero referrals out... therefore while the partners certainly pay RVU-based they are also benefiting themselves from increasing mohs volumes in the practice (a lot of them also have in-house path). Again, this could be my bias, but it's how the majority of mohs is being done at least where I've lived.

 

[dermathalon]

I agree that this discussion is way more interesting than that article.

Nevertheless, if you want to look at it from a purely financial standpoint there is almost no realistic financial arrangement a dermatologist could have with a Mohs surgeon that would make referring a patient for Mohs more financially beneficial for themselves than treating the tumor themselves and receiving the payment for that. So it would be very difficult for the incentives to line up as you are suggesting.

I'm gonna have to disagree on this one. reno911, general derms are now building group practices that include a Mohs surgeon as part of their crew. Also practitioners perform Mohs on their own patients so even a "general derm" can be practicing a Mohs excision on their patients (you don't have to go to an ACGME fellowship to practice Mohs on your own patients since there are other certification agencies. If you think these are getting phased out, that fine, but it's still an ongoing practice as of now and there are some young dermatologists doing this so don't think they will be stopping any time soon). So, yes, there are financial and legal arrangements that allow for Mohs revenue for the "general derm." Multiple recent graduates tell me that when they interviewed, they looked at jobs in group practices that would bring them on as a Mohs surgeon and a general dermatologist for the practice so that they can keep the Mohs cases in house. It's not a bad thing to have dermatologists on these panels as we need representation, but we can't think that there are no financial incentives.

 

[dermathalon]

You are right - I don't know so I could be wrong. It may be my bias in the two cities I've practiced in (fairly saturated cities) but it seems that there are very few solo mohs guys. Most mohs here occurs in practices of 4-15 dermatologists and they have all hired 1-2 (young) mohs people to do all the cases so zero referrals out... therefore while the partners certainly pay RVU-based they are also benefiting themselves from increasing mohs volumes in the practice (a lot of them also have in-house path). Again, this could be my bias, but it's how the majority of mohs is being done at least where I've lived.

I'm seeing the same trend as well for both in house path and in house Mohs.

 

[icpshootyz]

To add my unnecessary $.02, I'm a path-trained dermpath that gets specimens from both derms and Mohs, and I'm privy to a wide range of ethical to unethical behavior. I have a Mohs that sends to me that called to complain that I call too many things AK, and that if I don't call it at least SCCIS he can't do Mohs on them. I politely replied that if I see SCCIS I diagnose it as SCCIS. If I see AK, I diagnose it as AK. Can't say I've seen too many specimens from him since that call. My group also has to engage in ridiculous TC/PC arrangements where the derms are client billing and giving us a fraction of the PC reimbursement. I love what I do, but there's plenty of shady stuff going on out there. This article overdoes it for sure, but there's certainly plenty of real world greed and immorality out there giving writers like this plenty of ammo.

 

[MOHS_01]

To add my unnecessary $.02, I'm a path-trained dermpath that gets specimens from both derms and Mohs, and I'm privy to a wide range of ethical to unethical behavior. I have a Mohs that sends to me that called to complain that I call too many things AK, and that if I don't call it at least SCCIS he can't do Mohs on them. I politely replied that if I see SCCIS I diagnose it as SCCIS. If I see AK, I diagnose it as AK. Can't say I've seen too many specimens from him since that call. My group also has to engage in ridiculous TC/PC arrangements where the derms are client billing and giving us a fraction of the PC reimbursement. I love what I do, but there's plenty of shady stuff going on out there. This article overdoes it for sure, but there's certainly plenty of real world greed and immorality out there giving writers like this plenty of ammo.

Yes -- we saw the same **** when I was a resident reading at the scope with the different dermpath groups. The excisions that come in measure 1cm wide and 7cm long.... the multiple excisions on SCCIS, all with positive margins, multiple biopsies from the same anatomic location, etc. Everyone knew who the culprits were, no one liked or respected them, yet it went on...

We really need more honest clinicians... maybe an anonymous whistleblowing apparatus would help.

 

[smartparts]

while i think mohs surgery is an incredible innovation in dermatology, i really think it highlights the problem of how doctors are compensated for their time. its easy to itemize and bill for procedures (not necessarily wrong tho) but hard (if not impossible) to bill for counseling. correct me if im wrong, but i think this is why most psychiatrists dont accept insurance/medicare/medicaid anymore. i thought the article unfairly targeted the mohs surgeon in that story. im guessing he wasnt sure if he would be able to close the defect safely (ectropion is a common complication of such cases) and thats why he called plastics?

 

[reno911]

I agree that this discussion is way more interesting than that article.



I'm gonna have to disagree on this one. reno911, general derms are now building group practices that include a Mohs surgeon as part of their crew. Also practitioners perform Mohs on their own patients so even a "general derm" can be practicing a Mohs excision on their patients (you don't have to go to an ACGME fellowship to practice Mohs on your own patients since there are other certification agencies. If you think these are getting phased out, that fine, but it's still an ongoing practice as of now and there are some young dermatologists doing this so don't think they will be stopping any time soon). So, yes, there are financial and legal arrangements that allow for Mohs revenue for the "general derm." Multiple recent graduates tell me that when they interviewed, they looked at jobs in group practices that would bring them on as a Mohs surgeon and a general dermatologist for the practice so that they can keep the Mohs cases in house. It's not a bad thing to have dermatologists on these panels as we need representation, but we can't think that there are no financial incentives.

You're wrong. Here's why:

A lot of what you are saying is true, but it doesn't refute the point I'm trying to make.

First of all, when I said most of the panel were not Mohs surgeons, that means most were dermatologists that do not do Mohs at all. I believe that there was at least one Mohs society guy (i.e., non-Fellowship trained person who does Mohs), but he would count as a Mohs surgeon for bias purposes. So, once again, the majority of the panelists were people who do zero Mohs (I have spoken with one of the authors about the paper and that is the source of my information). If you have information that suggests most of the panelists do Mohs (fellowship-trained or not), I would be interested in hearing about that.

Therefore the suggestions that the panel may have been tainted by a large number of general derms who are not fellowship-trained Mohs surgeons but still do their own Mohs is incorrect (as far as I am aware).

So, what we're left with is the suggestion that these non-Mohs surgeon dermatologists have some sort of financial incentive to refer more tumors for Mohs. As I stated in my last post that is basicially impossible. There is no realistic financial arrangement that a referring MD can have with a Mohs surgeon that will pay the referring dermatologist more money than if the dermatolgist treated the tumor himself. It basically can't be done.

Perhaps what you are getting tripped up by is the desire for groups to have a Mohs surgeon in house. There IS an incentive to do that because the general derm that is part of a group with a Mohs surgeon will benefit more if his Mohs surgeon does the case than if an outside Mohs surgeon does the case. However, they would benefit even more (financially) if they just treated the tumor themselves (by excision or ED&C for example).

In other words, the financial incentive, as far as the dermatologist is concerned is still overwhelmingly for a tumor to be designated as one that doesn't need Mohs. When that is the case, they can treat the tumor themselves and make the most money. If a tumor is designated as something that should be treated with Mohs, then they will make less money (assuming do not do Mohs themselves, which was the case for most of the panelists) however they can mitigate this potentially lost revenue by referring to an in house Mohs surgeon, rather than an outside one. But, in the end, they would have still done the best (financially) if it was something that they could have just treated themselves.

 

[dermathalon]

I think you are misjudging how people practice.

If a derm is going to do a biopsy on the nose, near the eye, etc (high cosmetic area) and they are not a Mohs surgeon, they are not going to excise or ED&C as an option. We all have certain ethics and we are not just going to do whatever it takes to make an extra dime (which would be the premise to you argument that there is no financial incentive possible). However, many of these cases are things that the derm would have never treated. In that case, having a Mohs surgeon in house is a financial incentive. You go from the baseline of referring (not, from treating it themselves) to now having an option to refer into the practice and retain a portion of the collections to the practice. You assume every derm would potentially do every procedure. Many derms have the sense NOT to ED&C or excise something on the nose/eye (or similarly important location) and risk it coming back and ruining their reputation. Furthermore if you are a high volume practice and you are growing to the point that you are thinking about hiring a Mohs surgeon, it means that you have the volume such that you have decided that you cannot surgically treat everything and that you are going to be referring to the point that it is financially beneficial to have an in house Mohs surgeon. That means, the derm was not going to be doing the procedure themselves because they have too many cases. It is in that setting that getting an in house Mohs surgeon makes financial sense anyway. So your premise is based on a one dimensional argument without taking real life into account. People do not hire in house Mohs surgeon for s*** and gi**** unless it makes financial sense for the practice. Sure the Mohs may need to see some general derm but they are banking on more return to have the Mohs surgeon within the practice than outside (because their case loads are high enough to sustain that).

Next comes the environment in academics. Many derms in these setting are perfectly happy to not do any surgery and focus on teaching/med derm/research etc. So these derms were never going to be excising these lesions anyway and would have referred every single time. If you don't think that this is common, please check in with your local academic department. When I was in residency and tried to refer for Mohs outside of the department at the patient's request, you better believe that I didn't get an administrator asking me to justify why we couldn't have our in house Mohs surgeon doing it.

Then you have the practices that focus on cosmetics who will be willing to do an occasional biopsy so that they can retain their clients by providing some basic medical services. They hire their on in house Mohs too because they would never do the surgery but they have gotten enough of these biopsies coming back positive that they would rather retain the Mohs collections within the practice. This practice used to refer but now they have enough cases that it makes sense to have their own in house Mohs surgeon. I don't make this stuff up and it is happening in our community. These derms were straight cosmetics and they have no desire to be doing surgeries. Again, the baseline that they would make more money doing their own excisions and ED&Cs is just not true because they are booked to the nines with cosmetics patients and would rather focus on that.

Yes, it's makes financial incentive.

 

[sore eye asses]

Wait, what's a mohs again?

 

[reno911]

I think you are misjudging how people practice.

If a derm is going to do a biopsy on the nose, near the eye, etc (high cosmetic area) and they are not a Mohs surgeon, they are not going to excise or ED&C as an option. We all have certain ethics and we are not just going to do whatever it takes to make an extra dime (which would be the premise to you argument that there is no financial incentive possible). However, many of these cases are things that the derm would have never treated. In that case, having a Mohs surgeon in house is a financial incentive. You go from the baseline of referring (not, from treating it themselves) to now having an option to refer into the practice and retain a portion of the collections to the practice. You assume every derm would potentially do every procedure. Many derms have the sense NOT to ED&C or excise something on the nose/eye (or similarly important location) and risk it coming back and ruining their reputation. Furthermore if you are a high volume practice and you are growing to the point that you are thinking about hiring a Mohs surgeon, it means that you have the volume such that you have decided that you cannot surgically treat everything and that you are going to be referring to the point that it is financially beneficial to have an in house Mohs surgeon. That means, the derm was not going to be doing the procedure themselves because they have too many cases. It is in that setting that getting an in house Mohs surgeon makes financial sense anyway. So your premise is based on a one dimensional argument without taking real life into account. People do not hire in house Mohs surgeon for s*** and gi**** unless it makes financial sense for the practice. Sure the Mohs may need to see some general derm but they are banking on more return to have the Mohs surgeon within the practice than outside (because their case loads are high enough to sustain that).

Next comes the environment in academics. Many derms in these setting are perfectly happy to not do any surgery and focus on teaching/med derm/research etc. So these derms were never going to be excising these lesions anyway and would have referred every single time. If you don't think that this is common, please check in with your local academic department. When I was in residency and tried to refer for Mohs outside of the department at the patient's request, you better believe that I didn't get an administrator asking me to justify why we couldn't have our in house Mohs surgeon doing it.

Then you have the practices that focus on cosmetics who will be willing to do an occasional biopsy so that they can retain their clients by providing some basic medical services. They hire their on in house Mohs too because they would never do the surgery but they have gotten enough of these biopsies coming back positive that they would rather retain the Mohs collections within the practice. This practice used to refer but now they have enough cases that it makes sense to have their own in house Mohs surgeon. I don't make this stuff up and it is happening in our community. These derms were straight cosmetics and they have no desire to be doing surgeries. Again, the baseline that they would make more money doing their own excisions and ED&Cs is just not true because they are booked to the nines with cosmetics patients and would rather focus on that.

Yes, it's makes financial incentive.

I don't understand why you think this is somehow argues against what I wrote. You have not really refuted what I said.

I'll try one more time. Let's start with the obvious. Even if financial incentives were the number one thing the panelists based their recommendations on, there would be some tumors for which the evidence is overwhelming that Mohs is the right thing to do (e.g. infiltrative BCC on the nose). There are also cases on the other end of the spectrum that so obviously don't need Mohs. These sorts of super-obvious, slam-dunk kinds of cases are not under discussion. Obviously, we are talking about the ones in the middle, the questionable cases where financial incentive may tip the scales. Admittedly, there are lots of cases in the middle. In those cases, as I have maintained repeatedly, but you have yet to refute, the financial incentive for the dermatologist overwhelmingly favors the tumor being designated as something that doesn't need Mohs, because then they can treat it themselves and make more money.

Your whole 1st paragraph seems to make two points:
1. Some tumors are never going to be treated w/ anything other than Mohs
2. It makes sense for groups to have a Mohs surgeon rather than to send stuff out.

Both of those things are true, but don't change the point that I'm making one bit.
1. Because we're really only talking about the questionable cases
2. In the questionable cases, as I thought I made clear in my last post, (doing it oneself) > (referring to in house Mohs) > (referring to outside Mohs) as far as financial incentives are concerned. So it would be more beneficial to a dermatologist that doesn't do Mohs for such a tumor to be designated as one that doesn't need Mohs.

You also think that I "assume every derm would potentially do every procedure." I never make that assumption.

In your second and third paragraphs, it seems you list scenarios where dermatologists have a selective financial incentive. Somehow they don't actually have the financial incentive to want to do the case, but once that decision is made, then it switches on. There are probably some people that fall into that subset, but it's not a lot. Cosmetic-only or even >50% cosmetic practices are not that common (lots of people would love to have them, but they are not that easy to set up). Same with academics, they are a minority. I worked in academics as well, and I had plenty of colleagues (non-Mohs surgeons) that did all sorts of skin cancer procedures on the face for a variety of reasons. There are others who never did any. Of those that do none, you are suggesting that there is a large subset of them who care so little about money that they 1. went in to academia and 2. don't want to reap the financial benefits of the doing the procedure. However, they care enough that they want to harvest the SMALL benefit of a tumor being classifeed as one that needs Mohs.

The reason why the benefit is small in this scenario is because if the tumor is not designated as something that needs Mohs the can still refer it to an in-house colleague to do an excision (for example). So they still would get the benefits of keeping the procedure in house, the only thing they would lose on is the difference between an excision and Mohs. That is a much bigger difference to the Mohs surgeon doing the case than it is to the referring physician who can only reap an extremely attenuated financial benefit. Someone who is going to let that small an amount of money influence their treatment recommendations is very unlikely to have gone into academics in the first place. I'm not saying such a person doesn't exist, but they're probably not that common.

 

[reno911]

deleted, posted twice.

 

[dermathalon]

Most of my revenue actually comes from reconstructions -- maybe I'm doing it wrong. ?

I'm guessing you don't have a surgical recovery center with an anesthesiologist on hand. I think reconstructions should be reimbursed well since it's clearly a finely tuned skill.

 

[dermathalon]

Even if financial incentives were the number one thing the panelists based their recommendations on, there would be some tumors for which the evidence is overwhelming that Mohs is the right thing to do (e.g. infiltrative BCC on the nose).

Clearly, I agree on this. I just said that Mohs is appropriate in several clear areas. Please do not concoct a fake disagreement.

There are also cases on the other end of the spectrum that so obviously don't need Mohs. These sorts of super-obvious, slam-dunk kinds of cases are not under discussion.

I would like to agree with you but clearly there is ample Mohs that are being done on SCCis and on superficial BCCs that probably don't need to be done. That said, referring these SCCis and superficial BCCs to an in house Mohs surgeon would help the overall practice growth. icpshootyz highlights the issues of trying to have AKs called as SCCis and I have unfortunately seen this as well.

Admittedly, there are lots of cases in the middle. In those cases, as I have maintained repeatedly, but you have yet to refute, the financial incentive for the dermatologist overwhelmingly favors the tumor being designated as something that doesn't need Mohs, because then they can treat it themselves and make more money.

You argument is based on solo practices. Those days are dying. In group practices where partners have a share in the profits and benefit from overall increased volume, they will send gray areas to in-house Mohs and work on another excision case that does not need Mohs consideration. Patients have huge waiting times to get in to see derms and so we have more than enough excisions to go around as long as you don't overgrow the practice.

In the questionable cases, as I thought I made clear in my last post, (doing it oneself) > (referring to in house Mohs) > (referring to outside Mohs) as far as financial incentives are concerned. So it would be more beneficial to a dermatologist that doesn't do Mohs for such a tumor to be designated as one that doesn't need Mohs.

Physicians tend to be conservative (I realize not all of them). Ask any financial manager and most often, physicians are conservative in how they make decisions. It took a long time to get to where we are and we aren't going to make decisions that may make us look any less desirable in a patient's eye (especially in the era of online grading systems, YELP, etc.) - and especially when these are our patients that we would like to retain in our practices. By definition, a "questionable case" is not one that most will do by themself (sure, some will do it but I've talked to both junior and senior dermatologists that tell me that they just won't take that risk if it's really questionable) so you need to take this out of the equation and we are left with (referring to in house Mohs) > (referring to outside Mohs).

You also think that I "assume every derm would potentially do every procedure." I never make that assumption.

See above post. Yes you do. You are assuming that a general derm will opt to do it themselves on questionable cases. I'm not sure that's accurate.

Somehow they don't actually have the financial incentive to want to do the case, but once that decision is made, then it switches on.

This makes no sense. I'm saying that derms who are already referring things out for Mohs may decide that that they could keep the cases in house if it becomes financially beneficial. This is nothing special to dermatology. It happens all the time. Businesses will realize that they have a financial opportunity on a pre-existing habit (routinely referring something for Mohs) and realize they could capture the profit from it too (realizing that they could set up the Mohs in house). Nothing unique or absurd here. Happens all the time in all areas of life.

Cosmetic-only or even >50% cosmetic practices are not that common (lots of people would love to have them, but they are not that easy to set up).

Agreed, and even they are setting up in house Mohs.

Same with academics, they are a minority. I worked in academics as well, and I had plenty of colleagues (non-Mohs surgeons) that did all sorts of skin cancer procedures on the face for a variety of reasons. There are others who never did any. Of those that do none, you are suggesting that there is a large subset of them who care so little about money that they 1. went in to academia and 2. don't want to reap the financial benefits of the doing the procedure. However, they care enough that they want to harvest the SMALL benefit of a tumor being classifeed as one that needs Mohs.

The system is set up such that for the overall practice (the academic department), they keep the Mohs in house as it leads to higher profits for the department. Many of the faculty will not do surgery and they are happy with that. That's great that you have plenty of colleagues that did all sorts of skin cancer procedures on the face, but I have have plenty of colleagues that do not. In fact, the majority of my colleagues in academics do not do much more than a few surgeries a month. A far cry from the hired Mohs surgeon who ends up getting more of the cases. Keeping the Mohs in house is a financial incentive, especially if you are an owner of the practice or in an academic department. Also, in academics, a lot of departments are moving toward having Mohs surgeons get all of the head and neck cancers in this new era of needing procedural fellowship training.


Like I said, the proof is in the pudding. Why are Mohs surgeons being hired into groups? Why sink money into getting a lab set up (or sinking it into a mobile Mohs rental)? Because it makes financial sense to the non-Mohs dermatologists in that group.

 

[MOHS_01]

I'm guessing you don't have a surgical recovery center with an anesthesiologist on hand. I think reconstructions should be reimbursed well since it's clearly a finely tuned skill.

True.

The real problem here is a frequent one: bad medicine pays better than good medicine.