The headline, “Patients’ Costs Skyrocket, Specialists’ Incomes Soar,” aptly encapsulates the theme of a recent article in The New York Times,¹ part of a series entitled, “Paying Till It Hurts.”

“Oncologists benefit from the ability to mark up (and profit from) each dose of chemotherapy they administer in private offices,” according to the article, which also pointed out rising incomes for oncologists, gastroenterologists, and dermatologists over the past several years. But particular scrutiny was leveled at dermatologists’ use of Mohs micrographic surgery for treating skin cancers.

“Use of the surgery has skyrocketed in the United States—over 400 percent in a little over a decade—to the point that last summer Medicare put it at the top of its ‘potentially misvalued’ list of overused or overpriced procedures, the Times article declared.

‘A Wonderful Tool’

Brett M. Coldiron, MD, Clinical Associate Professor of Dermatology at the University of Cincinnati, was quoted extensively in the Times article, asserting that dermatologists were “very cost-efficient” and that Mohs surgery is “a wonderful tool” that is “not generally overvalued.” He expanded on the appropriate use of Mohs surgery in response to follow-up questions from The ASCO Post.

“Mohs surgery has been intensely and repeatedly evaluated by the American Medical Association’s Relative Value Scale Update Committee and the Centers for Medicare & Medicaid Services (CMS), as recently as 3 months ago, and its valuation has decreased considerably in the past 15 years. It is not an overvalued service. It has been removed from the CMS list of potentially overvalued services,” Dr. Coldiron stated.

“Mohs has a success rate approaching 99% for difficult-to-treat basal and squamous cell cancers and is a very cost-effective treatment option for nonmelanoma skin cancer,” Dr. Coldiron continued. “Another benefit of Mohs surgery is that the entire margin of the tumor is examined for remaining cancer, essentially resulting in an extremely low rate of cancer recurrence.”

During Mohs micrographic surgery, cancerous tissue is removed one layer at a time and examined under a microscope until the skin cancer has been completely removed. This means that “the surgeon removes only the tissue that contains cancer. So the patient keeps as much healthy tissue as possible,” Dr. Coldiron added. “This is especially important when the skin cancer develops in sensitive areas, such as the face, an ear, a finger or toe, or the genitals, but the procedure is not limited to just treating sensitive areas.”

Most Procedures in Office

The Times narrative focused on a woman whose positive skin biopsy “was a prelude to a daylong medical odyssey” billed at more than $25,000 and involving a dermatologist who performed Mohs surgery, an anesthesiologist, and an ophthalmologist who practices plastic surgery to close the wound. That is not the case with the majority of Mohs surgeries, which are completed by a dermatologist in an office setting, without hospital charges, according to Dr. Coldiron.

“About 90% are either allowed to heal by second intention or closed the same day by the dermatologist in the office setting,” he said. “This is decided by the patient, in consultation with the physician, and is based on the size and depth of the wound as well as its location. In some circumstances, the Mohs surgeon may refer the patient to another specialist for reconstruction, and in some cases, patients are referred by other specialists for Mohs surgery prior to their reconstruction by the referring surgeon.”

This view was corroborated by one of several letters to the editor from dermatologists and others prompted by the Times article. “You seem to imply that dermatologists have driven medical expenses up sharply by citing a few extreme examples. To the contrary, most dermatologists keep treatment costs low by diagnosing, treating and curing the vast majority of lesions in an office setting. This is often accomplished efficiently without incurring expensive hospital charges and consulting fees,” wrote Douglas Altchek, MD, Clinical Professor of Dermatology at the Icahn School of Medicine at Mount Sinai in New York.²

Determining Factors

Determining factors for Mohs surgery include the type, size, and location of the skin cancer, as well as the patient’s overall health. “For example, Mohs surgery would be appropriate in a healthy or immunocompromised patient with an aggressive, nodular, or superficial basal cell carcinoma greater than 0.5 cm in the ‘mask areas’ of the face (central face, eyelids, eyebrows, nose, lips, chin, ear, and periauricular skin/sulci, temple), genitalia (including perineal and perianal), hands, feet, nail units, ankles, and nipples/areola,” Dr. Coldiron explained.

“It is also useful for cancers greater than 1 cm in size on the rest of the head and neck, or trunk and extremities. It is the most effective way to eradicate recurrent tumors and some rare aggressive tumors,” according to Dr. Coldiron. “It is usually not needed for superficial basal cell carcinomas on the trunk and extremities, and not in the treatment of actinic keratoses.”

Mohs surgery may also be used for melanoma in situ on the face, as it “may result in a smaller wound when treating melanoma in situ,” Dr. Coldiron remarked. He added that some melanomas may require additional treatment with chemotherapy or radiation therapy.

Appropriate Use Criteria

The American Academy of Dermatology (AAD), in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery, reviewed, categorized, and rated the appropriateness of Mohs surgery for 270 scenarios for which Mohs surgery is often considered. The results were used to develop appropriate use criteria to guide clinical decision-making.³

“This is a resource for all dermatologists and other physicians who encounter skin cancer in their practices,” commented Dr. Coldiron, who was a member of the task force that developed the appropriate use criteria and is President-Elect of the AAD. “We analyzed all the available evidence on the use of Mohs surgery and followed the RAND/UCLA appropriateness method [a process originated in the 1980s to measure overuse and underuse of medical and surgical interventions by determining relative risks and harms] that has been well-established for development of appropriate use criteria in other specialties. This means that the appropriate indications were determined by a majority of dermatologists who do not perform Mohs surgery,” he added.

“To clarify, the Mohs appropriate use criteria do not say that Mohs should be used for certain skin cancers, rather, that in some instances Mohs can be an appropriate choice, and in others it is not. For example, surgical excision with margin control is also appropriate for most skin cancers but may result in a larger hole and a slightly lower cure rate,” Dr. Coldiron stated.

“Mohs surgery is beneficial for the removal of many skin cancers, and there are a number of studies that demonstrate this efficacy in addition to the vast clinical experience with this surgery,” he said. Other studies have found Mohs surgery to be safe and cost-effective.^4-6 Dr. Coldiron has served as an author for several of those studies.

“The Mohs appropriate use criteria highlighted several areas where additional research would be helpful, and ideally this would also include comparative effectiveness research. There are few blinded comparative studies on the surgical treatment of most cancers,” Dr. Coldiron stated.

Unfairly Targeted?

In the New York Times article, Dr. Coldiron was quoted as saying that the specialty of dermatology “was being unfairly targeted by insurers because of general frustration with medical prices.” He stands by that, but added, “Many specialists have been targeted in the past few years. Physician’s fees are a small part of the problem—about 17% of the cost of health care. Dermatologists fall in the middle of specialists in terms of reimbursements,” he noted.

“Dermatologists have at least 4 years of residency, and Mohs surgeons have an additional year of fellowship, and so the treatments are highly specialized,” he continued. “Consideration in reimbursement should be given to specialists who receive this additional training and have expertise in their field. One of the fears is that new physicians coming into medical practice will choose not to specialize, and long waits could develop.”

According to Dr. Coldiron, “The actual reimbursement to perform Mohs surgery and repair the wound has gone down by over 20% in the past 15 years. An increase in Mohs utilization may be justified on the basis of the skin cancer epidemic.⁷ The procedure offers the highest cure rate for difficult-to-treat basal and squamous cell cancers. Furthermore, the number of skin cancers treated with Mohs surgery has leveled off in recent years to about the same rate as the increase in skin cancer incidence,” he said.

“Additionally, there is an increase in the number of dermatologist providers who have been trained to perform Mohs micrographic surgery as practice gaps have been filled in around the United States,” he noted.

For dermatologists, the increased incidence of skin cancers in recent years has caused a shift in practice patterns since skin cancers are so potentially serious they go to the head of the line to be treated, Dr. Coldiron observed. Basal cell carcinoma and squamous cell carcinoma “are the two most common forms of skin cancer but are easily treated if detected early.” ■

Disclosure: Dr. Coldiron reported no potential conflicts of interest.

References

1. Rosenthal E: Patients’ costs skyrocket; specialists’ incomes soar. New York Times, January 18, 2004.

2. Altchek D: The costs of a trip to the doctor. Letters. New York Times, January 21, 2014.

3. Connolly SM, Baker DR, Coldiron BM, et al: AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: A report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol 67:531-550, 2012, and Dermatol Surg 38:1582-1603, 2012.

4. Merritt BG, Lee NY, Brodland DG, et al: The safety of Mohs surgery: A prospective multicenter cohort study. J Am Acad Dermatol 67:1302-1309, 2012.

5. Rogers HW, Coldiron BM: A relative value unit-based cost comparison of treatment modalities for nonmelanoma skin cancer: Effect of the loss of the Mohs multiple surgery reduction exemption. J Am Acad Dermatol 61:96-103, 2009.

6. Ravitskiy L, Brodland DG, Zitelli JA: Cost analysis: Mohs micrographic surgery. Dermatol Surg 38:585-594, 2012.

7. Donaldson MR, Coldiron BM: No end in sight: The skin cancer epidemic continues. Semin Cutan Med Surg 30:3-5, 2011.