Recently, an interview titled “Dermatology a bellwether of health inequities during COVID-19,” was published by the AMA. In my opinion, the interview was largely accurate, but I took issue with the following statement in the article: “Dermatology is a lucrative specialty, and many dermatologists do not accept Medicaid.”
Dr. Brett M. Coldiron
To me, this implies that physicians are to blame for poor health care access, which drives me insane. Dermatology is not a particularly lucrative specialty; it ranked 13th in a recent survey from the professional medical network Doximity. Furthermore, if payment for practice expense is removed, dermatology drops much further down, close to primary care.
There is a fundamental misunderstanding by the public and legislators about physician incomes. The reimbursements that are reported by Medicare for example, include the practice expense cost, which for dermatology is about 60% of the total remitted to the doctor, as I wrote in a 2015 column.
That is, the cost of providing the facility, supplies, staff, rent, and utilities are included in “reimbursement,” though this is money that goes out the door to pay the bills as quickly as it comes in. This is for overhead, nothing here for the practitioner’s time and work.
Even when dermatologists perform hospital consults, they usually bring their own supply kit from their office for skin biopsies, or other procedures since these are impossible to find in a hospital.
I also pointed out in my earlier column that most other specialties do not provide the majority of their procedures in the office, but instead, use the hospital, which provides supplies and staff for procedures. These other specialists are to be lauded for providing their services at charity rates, or for no pay at all, but at least they do not have to pay for the building, equipment, supplies, and staff out of pocket. Dermatologists do, since in a sense, they run their own “hospitals” as almost all of their procedures are based out of their offices.
The economics of a patient visit
I do not dispute that it is more difficult for a Medicaid patient to get an appointment with a dermatologist than it is for a patient with private insurance, but this is because Medicaid often pays less than the cost of supplies to see them. It is also easier to get an appointment for a cosmetic procedure than a rash because reimbursements in general are artificially suppressed, even for Medicare (which is also the benchmark for private insurers) by the federal government. Medicare reimbursements have not kept pace with inflation and are about 53% less than they were in 1992.
Let’s look at a skin biopsy. The supplies and equipment to perform a skin biopsy cost over $50. In Ohio, Medicare pays $96.19 for a skin biopsy. Medicaid pays $47.20. That’s correct: less than the cost of supplies and overhead. So, a private practitioner not only provides the service for free, but loses money on every visit that involves a skin biopsy. When I talk to legislators, I liken this to my standing in front of my office and handing out $5 bills. In Ohio, Medicare pays $105.04 for a level 3 office visit. Medicaid pays $57.76. Medicare overhead on a level 3 office visit is again about 50%, so the office visit is about a break-even proposition, if you donate your time.
Academic medical centers can charge additional facility fees, and some receive subsidies from the city and county to treat indigent patients, and are often obligated to see all. Most hospitals with high Medicaid and indigent patient loads pay their surgical specialists to take call at their emergency rooms and often subsidize their emergency room doctors as well.
I agree that dermatology is an important specialty to have access to in the COVID-19 pandemic. I agree that patients of color may be disproportionately impacted because they may be covered by Medicaid more often, or have no insurance at all. The finger of blame, however, should be squarely pointed at politicians who have woefully underfunded Medicaid reimbursement rates, as well as payments for physicians under the Affordable Care Act, while thumping their chests and boasting how they have provided health care to millions. I think this was eloquently demonstrated when as part of the “deal” Congress made with the AMA to get the ACA passed, Congress agreed to pay primary care physicians (but only primary care) Medicare rates for Medicaid patients for 2 years.
Some states have continued to pay enhanced Medicaid rates and have fewer Medicaid patient access issues.
Most convincing, perhaps, are the states that pay Medicare rates or better for their Medicaid enrollees, for example Alaska and Montana. In these states, you will not have access to care issues beyond the actual human shortage of physicians in remote areas.
So, in conclusion, I maintain that dermatology is not a particularly lucrative specialty, once the overhead expense payments are removed, and further argue, that even if it were, why does that obligate us to provide care to insurance plans at a loss? Medicaid access to dermatologists is a government economic issue, not a physician ethical one. Most Americans get to pick the charities they choose to donate to.
The federal government would love to force all physicians into a plan where you must see patients at their chosen rates or see no patients at all. Look no further than our Canadian neighbors, where long wait times to see specialists are legendary. It has been reported that there are only six to seven hundred dermatologists in all of Canada to serve 30 million people.
So, when the topic of poor patient access to care for the Medicaid enrollee or indigent comes up, stand tall and point your finger to your state capital. That is where the blame lies.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.