Wednesday, July 30, 2008

Will the last medical dermatologist please turn off the lights? Access issues for dermatology patients

The trend of Dermatologists becoming more and more unavailable for actually treating dermatological conditions is in the news again in the front page of the New York Times. The article, "As Doctors Cater to Looks, Skin Patients Wait" discusses the discrepancy in how patients are catered to for cosmetic versus medical dermatologic conditions. I blogged about this same issue last September in "How Botox affects your access to a Dermatologist"

There's a few dermatologists quoted who really come off poorly in the language they use justifying their practice choices. You can bet they'd like a mulligan about now in their 'on the record' interview.

Peppered in the comments section to the article are the predictable griping like,

  • "Doctors should not get rich off their patients. Period. End of story. Society has greatly subsidized every doctor's education. If a doctor wants to supplement his or her income with cosmetic procedures, this should be strictly evenings and weekends."

  • "Why on earth should a 10-minute botox injection be worth $500?"

  • "...clinics will not take patients without referrals, and unless a matter is urgent, it can take 4 - 5 months to get an appointment (which they keep as short as possible). However, if a patient wants a cosmetic procedure, it takes only 1 - 2 weeks for an appointment. The dermatology profession needs to examine its ethics, or the lack thereof."

  • "The rest of the medical system will follow. Once health care becomes a one-payer system, there will be a second tier for the moneyed. This is how medicine works in Europe."

  • "This is a perfect example of market forces at work, and proof the market works perfectly. Money talks. In this case, however, market forces pervert the delivery of good health care. The solution is to reimburse doctors for actually taking care of patients, not doing procedures or ordering expensive tests. With a regime change in Washington on the horizon, we will hopefully have a complete overhaul of our decrepit and wasteful health care-industrial complex."

  • "Disgusting example of the growing scummy side of medicine. A terrific example of how the wrong people gain admission to medical school, sociopath sales persons, "I've always wanted to help people, blah, blah blah..." while only interested in the cash. We need a new health care system with salaried physicians"

  • "These comments are scary. Most are uniformed, ignorant and miss the point. Physicans can't meet their overhead and are responding to "managed care" in the only way they can. It is the root cause of most of the ills we see today. We will never able to administer quality healthcare in this type of system. How is it possible for a small practice to negotiate equitable reimbursements from a market giant such as Cigna?"

  • "The idea that patients with potential skin cancer have to literally beg to be seen by a doctor is absolutely horrifying. This is one area where civil suits can be an effective weapon. Drs. who refuse to deal with a skin cancer should be sued out of practice. And/or heavily regulated by the government or their own "Professional" organization (the AMA). Does this behavior actually conform to the AMA's code of conduct?"

  • "Any doctor who will not see a patient who suspects a mole cancerous, or has a chronic skin disease, for longer than 72 hours, should be sued and forced to explain his negligence in a court of law. "

  • Reading the comment sections of articles in "the nation's newspaper" is always really illustrative to me. There's alot of frustration and hostility about healthcare in the public which gets (mis)directed at physicians. (Don't forget poor Dr. Zenn who was sniped by the breast implant nutters in June.) It's really a systemic issue, but it's easier to blame "greedy" doctors then actually recognize the costs of administering and delivering healthcare is affecting this. Commenter's also usually fail to understand that this issue with dermatologists is actually going to get worse rather then better with whatever "universal healthcare" system we end up with. Unless you pay physicians market wages for their services, they're going to look for opportunities to realize it elsewhere.

    Reading this article I also kept thinking, why the hell would you feel like you absolutely have to go to a dermatologist (or Plastic Surgeon) to have a skin lesion or rash looked at? While I appreciate patient's opinion of our skills, evaluation and biopsy of lesions/rashes is simple enough that it logically should be largely the province of primary care providers or the nurse practitioners and physician assistants that affiliate with them in practice IMO. A lot of wound care clinics have such a set up, and I think wound care is much trickier then skin lesions!



Jeffrey Frentzen said...

The Times story sensationalized one angle of this story and didn't bother to explain why this two-tier approach is happening -- Just as consumers can pay extra to fly First Class as opposed to Coach, derms are offering a high-end service that one must pay extra for. It's a practice that is old as the hills, and also reflects the need of plastic surgeons, dermatologists, and all practitioners (really) to respond to the economic times in which we live.

Jeff Frentzen
Editor, PSP magazine

ray seballos, md said...

As a solo practicing plastic surgeon, I absolutely have to do cosmetic procedures. It is these very procedures that allow me to take care of my deserving reconstructive patients. If I were only doing procedures reimbursed by insurance companies, I would be out of business in less than a year as the cost of running the office will be higher than the amount that the insurance companies "feel" that my reconstructive work is worth... (about 33% of what it was worth 30 years ago without even adjusting for inflation or cost of living). I do my best though to strike a balance because both sets of patients a equally important to me and is a privilege to have them put their trust in me. But make no mistake about it, without the cosmetic part of my practice, I would be out or practice.

Plastic Surgeons Secrets said...

Yeah I agree, who needs a plastic surgeon to administer a botox injection – gosh is that all they can do after 7 years of studying and 4 years of specializing – so sad! This is why they need to charge such exorbitant fees! So that we as consumers can pay for their so called lavish lifestyles, yeah right! I must admit I would get incredibly bored having to administer those injections after having studied for years. I am sure anybody could do it within a months worth of training !

Dr. Rob Oliver said...

PS Secrets,

Actually, BOTOX is more complicated then "point & shoot" to get good results. I'm uncomfortable delgating this to someone not intimately fluent in anatomy. Also, the profit margins on BOTOX are actually small & it's not rare to take loses on uninjected vials. As the price of the product is approaching $600/vial, $300 for an area is a bargin for an effective cosmetic treatment that lasts 4-6 months on average