Challenges Facing Our Specialty

The health care environment is changing rapidly and the smart dermatologist will stay informed and respond proactively. Our strength lies in our unity and identity as dermatologists. There is strength in numbers, and for us to thrive, all dermatologists should be members of the American Academy of Dermatology (AAD) and the American Medical Association. These memberships ensure that we have a seat at the table when important decisions are being made. If you have let your membership lapse, I strongly encourage you to join. Our representation as a specialty depends on the number of members we have in each of these societies. The AAD provides many ways to stay informed, including member-to-member communications, Dermatology World, and special communications from the AAD president. Member alerts will let you know when critical action is required to affect pending legislation that impacts our specialty. Stay informed and respond when called upon.

Dermatologists face unprecedented challenges that pose a very real threat to patient access to high-quality care by a board-certified dermatologist and the future of private practice, including limited provider networks, challenges to fair reimbursement, and bad audit policies. Limited provider networks may represent the single greatest threat to the independent practice of medicine in the United States. Recent actions by payors have unenrolled large numbers of providers. In some cases, dermatologists have found that 20% of their patients became “out of network” overnight. Higher patient co-pays and difficulty with reimbursement may follow, limiting a patient’s ability to continue to see his/her physician. Challenges to fair reimbursement abound and tiered payments are becoming commonplace, with the criteria for tiering often driven by economics rather than quality. Medical necessity auditors have inappropriately used the ABCD public education tool for melanoma, applying it to medical records and ruling biopsies positive for melanoma as “not medically necessary” because the ABCDs were not documented in the physician’s note. In other cases, biopsies positive for skin cancer were ruled “not medically necessary” because of “lack of documentation of signs and symptoms.” Melanomas rarely itch, and the ABCD tool was designed for laypeople. Ignorance and lack of understanding of the care we provide jeopardizes patient access to care.

Even bigger challenges loom. Where will dermatology fit into the big picture as national health care priorities focus on large public health issues such as hypertension, diabetes, obesity, and depression? Dermatologists play a critical role in reducing the burden of skin cancer, preventing both death and morbidity, but most policymakers do not understand the critical services we provide. Individual physicians have a limited ability to respond to these challenges, and our state and subspecialty societies have limited resources to fight these battles. Over the last 2 years, the AAD has responded by transforming a good state affairs office into a superbly effective and nimble group of highly talented individuals with expertise in advocacy, law, and health policy. Our new Strategic Alliance Liaison Committee is designed to coordinate the efforts of patient advocacy groups and dermatology societies to help ensure an effective response. If your state or subspecialty society is not actively engaged with the AAD’s state affairs office, it is time to contact them.

It is critical that dermatologists project a unified voice. Dermatology is a small specialty, representing less than 2% of physicians, but we have always been successful in projecting a voice much larger than our numbers. Unity is key to our success. This past year, the AAD established a rapid response checklist to ensure that all critical steps fall into place when responding to a rapidly evolving critical issue, including coordination with key patient advocacy groups and other key dermatological societies such as the American Society of Dermatologic Surgery, the Mohs College, Mohs Society, American Society of Dermatopathology, the American Osteopathic College of Dermatology, and many others. There are many payment and scope of practice issues that are difficult for us to present without appearing self-serving, but these very same messages can succeed when the focus is on patient safety, quality of care, and patient access. Patient advocacy groups are our best allies because they fight for patient rights to timely and effective care for diseases of the skin.

Change is occurring quickly and there is a lot of work to be done. Key priorities fundamental to the future of our specialty include ensuring effective advocacy, establishing how dermatologists fit into new payment and care delivery models, obtaining the data we need to demonstrate the unique value dermatologists bring to patient care and the health care system, enhancing the image of our specialty, and optimizing our support of state and local dermatological societies as they confront a growing range of issues.