The Dermatology Scam
I was reading at throwaway journal when I came across this gem called the Elephant in the room of dermatology. It was written by Brett Coldiron MD who is a past-president of the American Academy of Dermatology. In the piece, Coldiron explains what rich dermatologists are doing to get richer:
- I have become increasingly dismayed by reports of dermatologists who allow their nurse practitioners and physician assistants to practice independently That is, the employing dermatologists only see the patients, new or established, if they are asked to, and often are not even on the premises. In fact, they might be thousands of miles away.
- When Congress authorized their independent payment in 1997, they envisioned primary care nurses traveling the hills, hollers, and inner cities improving health care. Unfortunately, this hasn’t happened, and instead they have moved into suburban America, and increasingly, are practicing specialty medicine.
- It can be argued that decreased access to primary care, which was the reason midlevels were created, is more important than is access to dermatology.
- There will be an estimated 10,000 “dermatology” nurse practitioners and physician assistants next year.
- We have nurse practitioners buying retiring dermatologists’ practices, physician assistants independently setting up remote clinics then hiring “supervising” dermatologists to visit once a week to sign and review charts, and independent “dermatology” clinics with a doctor thousands of miles away available, if really needed, by telephone or the Internet.
- These extenders are listed as dermatologists on the Internet, or they hide behind the name of a dermatologist, and when you call their offices, and ask if you will see a “real” dermatologist, the answer is often “Oh, don’t worry, our nurse or PA specializes in dermatology.”
- The “collaborating” dermatologists enabling these extenders are renting out the good name of our specialty.
- I think it is unfair to the medical system who pays for the less informed opinion and unnecessary procedures.
Wow. This guys puts it on the line and I am sure the other dermatologists are going to be pissed at him. Will it matter? I doubt it because he mentions that some dermatologists make $200,000 a year off their PA while they are not even there. $200K! Family docs don’t even smell this level of income.
I am glad he blasts his own people while also blasting the altruistic NP/PA orgs that were going to go into rural areas to improve access*. Many have and that’s great but who is criticizing that ones that haven’t? Why has this gone unnoticed?
Coldiron does mention checking the websites of your big dermatologist practices for the names of the extenders they employ. You can then go to the Medicare data and look up their extenders and see if they bill independently for dermatologic procedures. “I think you will be very disturbed”, he says.
I am.
*Yes, I am quite aware that all the militant NPs and PAs will attack me again for criticizing them here. How dare I? Meanwhile, I hammer doctors (dermatologists) in this blog entry and my own profession mercilessly in other ones but that goes unnoticed. So go ahead, spread it around (yeah, that means you Dave) to your sites so they can send hate email to me again. I am used to it and will delete it.
And remind me again why all the patients paying for expensive derm proceedures which aren’t covered due to their cosmetic nature can’t be expected to pay ANYTHING for the care they actually NEED in a primary care office. The ” I forgot my check book” and ” I’ll send it in after payday” wears thin- especially when you see the evidence of money spent on unnecessary “care”. Dermatology for skin cancers and legit diseases excluded, of course. Let’s be real- that’s not where all the cash comes from.
Come on Doug. Militant NP’s? I work with and supervise one and guess what? She’s just
as disgusted at the state of primary care as the MD’s are. She’s retiring early.
I reviewed records of NP’s who keep perfect, excellent records and I query them and ask them
if they have better luck with patient compliance. To a “T”, they sigh and answer they don’t see
any higher levels of compliance than any physician practice. I believe Doug, you made the statement that the NP’s are going to get disgusted with primary care and take their skills to the
specialists. Well there you have it. 🙂
There was a great movie in 1966 (dating myself) called the Sand Pebbles with Steve McQueen. Basically the US Navy had a ship in China. The sailors hired the Chinese to do the work for them. The ship fell apart. Many similarities.
….HONEST TRUTH : I am a 21 yr FP Physician, executive & DOD Critical Care specialist (ICU Attending in Iraq 2005-06 & SOCOM 2008). I have worked every capacity.
I have only referred about 50 people in MY WHOLE 21 YEAR CAREER to either a DERMATOLOGIST OR RHEUMATOLOGIST……….In my strong opinion, if a PCM / ER / PEDS / IM Physician cannot take care of 99% of Dermatology & Rheumatology issues by themselves, then THEY NEED TO GO BACK TO MEDICAL SCHOOL.
If I were dictator, I would scale back BOTH specialty residency slots & INCENTIVISE all other Physicians to STOP BEING LAZY by doing a ‘minor procedure’ for pay & then referring to a Dermatologist/Rheumatologist to ‘COVER ONE’S A**’ ….just like the ‘OVERUSE of EXTENDERS’ is dumbing down medicine, so is the apathetic Physicians who don’t do things which they should do. The next time a Surgeon “consults” me at 2 AM to “Manage the patient’s BP & medical condition”, I am going to tell that surgeon to stick his resume’ up his a**, because it is not worth the paper it is written on.. LOL :)….. JP.
Thanks. You remind me of a different time when we earned our honor. Thanks.
Until just a few years ago I would have shouted ” Amen ” to your post! I am still in agreement with a lot of it. I managed my husband’s private solo Family Practice for 25 years. Then our office, which we owned burned down and we thought that might be the time to be the employee instead of the employer, as we anticipated retiring fairly soon. Moving in with two local docs ( I use the term under duress ) only to realize that though one had been practicing longer the we had and one minimally less they both were clueless. It is absolutely frightening the level of care(lessness) that is out there. Some practitioners really SHOULD be consulting everything out- that way their patients have a chance! I wish I were making this up, sadly, I’m not. Here’s a quote. One of them was asked where he gets vaccine schedule/recommendation information from. His response…”drug reps”.
2 reasons for the problem.
1. Greedy, money hungry Dermatologists. Fact ; Most physicians who go into Dermatology do it for the bucks and pull in about 500k a year. Pure capitalists like the Wall street crowd. They are attracted to the rich areas of the country, not the shortage areas…because they are in it for the $.
2. Shortage of Dermatologists. Where I practice in a rural Florida area it takes 2 -3 mos on average to get a Derm appt. Would be even worse w/o PA and NPs.
the flip side….
I have a primary care practice with a doc as a minority % owner
I see all the patients, and consult as needed with the doc. I have been a PA for just under 15 years and most my questions I direct to the specialists, as they are specialty level questions….
So recently I received a request from a local dermatologist who was considering starting a patient on a medicine for Bullous Pemphigus (steroid sparing). He in short order told me that he did not want to talk to me, only the doc as I was not a physician. I explained to him that I am the PCP as stated by state law, and my training, and that in fact I know my patients very well. He then asked (ignoring this statement) that the physician write a letter stating it is okay for this patient to start this medicine. As I had previously treated Bullous Phemphigus twice in collaboration with a different local derm doc, and had brushed up on not just the management, but also the issues with meds and the disqualifying historical events I stated I was more then happy to write this letter as requested in fact citing this issues that needed to be addressed.
He flatly refused and stated “I am not biased against you as a PA, I just know this is a complex issue that only a physician can understand.” In spite of my offer to write the letter, and being able to verbatim list off that this patient was indeed a candidate for the treatment he continually came back to the fact that I was not a physician and he would not accept it. We agreed that we were both small practice owners (he was surprised I owned the majority of my practice) and we both have to practice medicine the way we see fit.
So, I will write the letter and sign it. Time will tell if he will accept it.
As a side note – the patient and their family have already stated they will get another Derm (no small feet) instead of another PCP. I did not inquire further as to why as it is not up to me.
The point is, I am a 15 year PCP/PA with four degrees, two masters and a high commitment to serving my patients and staying abreast with advances in medicine. This has no connection to what initials are after my name. I practice great medicine, and respect my patients.
PA/NPs are not the problem. The problem is a broken system where proceduralists make huge incomes and this in turn could support a huge income to a practice employing a PA/NP. But realize that the medical establishment, in large part, has come to be what it is as a result of decisions the formal medical community has taken – ie the DRG’s, CPT coding/ AMA decisions. It is the very physicians that are making the $200,000 profit from a PA/NP who you should be talking to, no a PA/NP trying to help their patients in a legal, lawful, established, medically accepted manor (which does indeed happen to be the way the future is going)
There really is no such entity as “bullous pemphigus”. There is bullous pemphigoid. There is pemphigus vulgaris. Very different diseases and treatments. Not knowing the difference, but being allowed to actually treat those patients is scary as hell.
My mistake – the problem with reading the internet at bed time……
Clarification: I do house calls, and patients are unable to get out – Derm is always consulted, they are managing but I assist with follow up.
Yes this disease is a challenge to manage and requires team-work approach for the home bound senior. Sorry on my misstatement.
Back to the original statement about working together as a team.
Also, proofread before posting.
http://www.houstonchronicle.com/local/prognosis/article/Study-backs-quality-of-nurse-practitioner-6854264.php
Exactly! Anyone can do it! I was thinking that we should let the elderly treat patients in an adult daycare setting. That way they can feel useful. Then we can wait a few months to check on their billing records (the best way to check on skill level) and use one problem (like sore throat) and see how they do. I mean all they have to do is swab a throat and treat if the line comes up. It’s easy and anyone can do this job! Why have any training?
Since we are talking about dermatologists, let me share what I have seen in recent years. For one, dermatologists are selling creams and makeup that they have little knowledge of. The MBA negotiates with the salesperson and these products can be changed anytime the profit margin will increase with the new product. Two, they sell services to help people look better that are of no or marginal benefit and people with less training than a PA are doing the procedures. Last, often the patient sees the doctor for a quick look then other personnel actually do the procedures. The 5 minute rule.
So, Dave is right on top of this and will spread it to his site whereupon the vitriol will ensue. I called that one. Oh, and Dave, now you have proof that outcomes and quality in dermatology is the same between PAs/NPs and dermatologists?
Let me ask you two questions. One is do you have any proof of inferior outcomes? If there are Medicare would know as would the local ERs, etc.
I mean studies. Not my friend knew someone…
Two, there was no anger or vitriol in my comments. I am a member of the Authentic Medicine community. I get the emails. Am I not supposed to give my personal side or do you only get to sling the arrows? If you want me off the site, I will leave but I said nothing except we are following our physician colleagues and practicing legally. What more could you possibly ask for?
Dave
Actually, Dave, if you look at the verbiage of the blog entry itself, I was nice to PA/NPs but of course you took it the wrong way. You know, as well as I, that training matters. Always. I won’t get into the same argument. You always say that we created this mess and now we have to live with it. Exactly. The derms are abusing it and it is disgusting. That was my whole point. The creation of NPs/PAs was to go the rural areas (which I said some have which was great) but why aren’t you screaming at your own for the ones that don’t?
Dave, I hope you stay. Hearing your side of things reinforces my great desire to find a way out of medicine, hopefully running a micro-brewery one day. Then the only PA’s I’ll need to think about will have “I” in front of them (India Pale Ales).
Slainte’
Having once again last week been screamed at by an immature patient, I find it hard to mount energetic resistance against the precipitous decline of care. Everybody wants in on the “just the same” and “just as good” carousel.
After twenty years of practice, I find that there are two types of skin conditions – ones that are old friends, and ones that are strangers. I treat the friends, and send the strangers to dermatology. They often come back with the diagnosis of “eczema” and the treatment being the steroid du jour.
Every genuine observation provokes a hurt and defensive protest from somebody, so I try to avoid observing things. Patients wish phone conferences to discuss the content of observations I place in the chart. I realize I document too completely, in this sense. I will stick to “grandmother’s birthweight” and “recent changes in glove size” to paint by numbers.
If they had “paint-by-numbers” in Cezanne’s time, we wouldn’t have so much irrelevant drudgery and massive bundles of names to memorize for Art History. One size of excellence fits all. It’s eczema, it needs an antibiotic/fungal/steroid treatment. That’s Dermatology these days.
You guys are threatened. The vast majority of PAs and NPs-but let me speak more for PAs, are working hand in hand abiding by the law, with dermatologists. All legal and 100% allowable. Many PAs have postgraduate training, some formally, and yes, most from the group of dermatologists they are working with. The quality of care is not an issue. Outcomes are not an issue. And yes, economics is a mover of people into derm as it is in the physician world. PAs bring in much more that $200,000 revenue into a practice. But it’s all legal and the medicine is good.
Sorry, the world changes. I know you will just shove your BS like “we don’t know what we don’t know” and all the other stuff. It’s OK, we are increasing access to care, and yes, unfortunately we are, like you, in this case following the money as PA school loans are coming up to the size of medical school loans. You asked us to come. BUT, we are not the bad guys. And if you make us the bad guys, you will be making a tragic mistake.
Speaking only for myself.
Dave
-Yes, the world changes, David, and the expedient hurry up to perceive the direction and move ahead of the herd. Medicine has changed rapidly over the last twenty years. But what is that direction, when we determine what there is to “catch up to” and lead the pack? Who decides?
-How much better has medicine gotten over the last twenty years? Why have the general protests from the patients about our new & improved healthcare, only become louder and more angry? They insist that that we have made is ineffective and ruinous. Have they not realized which way the wind is blowing? I see medicine with much more inefficiency and poor care – am I an Oldthink practitioner?
-The trend is towards national pharmaceutical chains “offering independent practice clinics” within their sales floor, so that prescribers can see the patient, and then scurry to another window to pick up their drugs. Is this a conflict of interest, or who cares anyhow? Wal-Mart wants to be the leader by 2020 with the most in-building “independent practice clinics.” Are people be selfish or whiny when they question this trend?
-The general strategy of administering medical practice in the United States has been decided and fixed in stone, and not by you or I. Are we to be like the Reich citizens, whispering to their ‘underclass’ friends: “I really don’t go along with all this rot, and we’re both trying to keep our heads above water, aren’t we?” Or is that just something to blame on the Enemy?
-Who cares? Anyone?
Dave, what are you going to do when it becomes legal for an LPN and a computer full of protocols to be allowed to do what you currently perform? She will be increasing access, be more cost-efficient, and with a weekend course or two, will be the embodiment of the argument you keep advancing. Let me know how it feels, will ya?
I foresee the de-labeling of many pharmaceuticals under the rubric of “consumer freedom of choice.” Much of the cost of medical care comes from the “professional obstacle.” Patients seem to feel that the doctor’s appointment is a tedious scam that adds one more step to getting the medicines that they want. That way, direct-to-consumer advertising will truly be direct to consumer, from the pharmaceutical companies.
-But the “professional obstacle” exists to deliver the service of expertise to the patient. Since many are ready to jettison the need for professional advice, what do we need PA’s for, or LPN’s? Just go to the drugstore and pick up your Viagra, just like they do in Mexico!
-The Third World direct-to-consumer model dumps all the liability on the patient. YOU decided to do this or that, your fault. We’ll be dispensing with about half of the ‘labeled’ pharmaceuticals – hopefully not the DEA controlled ones – to buy over-the-counter, not on any “insurance policy.”
-This is the direction that SOMEBODY has chosen for us, and we’ll see by 2020. Like it?
As a physician who refuses to employ extenders, and a board certified dermatologist, I couldn’t agree with Dr Coldiron more. Extenders will eventually consume the field.
If physicians who refer or request consults refuse to send those patients to an office with extenders, it would help curb this abuse. Locally, most primary docs are in multi specialty groups and it’s a rarity for them to send any patient outside their group. They are rewarded financially for keeping patients within their group–it’s built into their salary formula, the more the collective group makes, the more they personally make each year.
“They are rewarded financially for keeping patients within their group–it’s built into their salary formula, the more the collective group makes, the more they personally make each year.”
That sounds marginally unethical. Is the presumption that the most qualified physician must by default be the one in the group? This smacks of a conflict of interest.
We constantly hear that the general population wants easy access to well-trained physicians; however, this same populace constantly uses their politicians to choose the cut-rate option. LELT’s are the opportunistic infection invited by the philosophical immunosuppression of a populace that demands what they will not pay for.