Growing impediments to the delivery of dermatologic care

Government regulations have a broad and deep impact on the delivery of dermatologic health services. It is incumbent on dermatologists to be involved in the development and discussions of these issues and to educate government officials about the effects of existing and proposed regulations on the delivery of dermatologic health care.     

Issues in dermatologic health care delivery in minority populations

It is well known that African Americans are at low risk for one of the most serious diagnoses in dermatology--skin cancer. A consequence of this lower cancer risk has been an undervaluing of the importance of appropriate dermatologic care in this population. In fact, there are many other skin diseases and disorders that not only cause significant morbidity among this population but also emotional and psychological sequelae. This article examines barriers and challenges to providing dermatologic care among African Americans and provides recommendations and suggestions for improving care delivery in this population.     

The role of dermatologists in the delivery of occupational dermatologic care

This article reviews the role of dermatologists in occupational dermatologic care by reviewing the types of skin diseases that may be work-related, the diagnostic testing, and evidence of quality of care delivery and outcomes provided by dermatologists.     

The emerging role of physician assistants in the delivery of dermatologic health care

The NAMCS provides a wealth of information on use of PAs in all practices, including dermatology. Two important points regarding the NAMCS and SDPA data are addressed here: the number of visits to PAs for dermatologic symptoms and the expected growth of PA use in dermatologists' offices. Dermatologic symptoms were evaluated frequently by PAs, accounting for 14% of PA visits. These statistics do not address the number of referrals those PAs made to dermatologists. Perhaps PAs as a group should be targeted for increased dermatologic education, particularly stressing the need for appropriate referral to a dermatologist. PAs could increase the number of dermatology referrals from primary care offices with improved understanding of the importance of the dermatologist in the management of patients' overall skin health. At projected growth rates, the number of PAs employed by dermatologists should exceed 500 by the end of 2000. Most of this growth has been in private practices and rarely in HMOs or in large multispecialty clinics. There are a number of reasons for this growth, as follows: A PA may help reduce the patient load on the dermatologist, especially with sameday appointments and drop-ins. Some dermatologists are moving away from clinical dermatology into cosmetics, which not only leaves a vacuum in clinical dermatology, but also creates job opportunities for PAs in cosmetic dermatology. Regarding managed care growth, PAs can have a positive impact on the problem of having to see more patients for less money. PAs are cost-effective. In the 1998 SDPA survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:1. Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. PAs can cover satellite offices, allowing for practice expansion. Effective with the new Medicare laws of January 1, 1998, PAs can now see new Medicare patients or Medicare patients with new conditions without the physician being on site, opening up the possibility for satellite offices in remote areas. Just as dermatologists may move toward specialization in surgery, cosmetics, or medical dermatology, PAs may do the same, filling a niche in a particular practice. As in other specialties, patient acceptance of seeing dermatology PAs has not been a significant problem. Continued access to the dermatologist remains unfettered, but, over time, many patients become willing to see either. Are PAs likely to become future competitors of dermatologists? Genuinely concerned dermatologists worry that a dermatology-trained PA will become part of a gatekeeper system that impedes patient access to dermatologists. This is not happening and is not at all likely to become a trend, for a number of reasons. First, primary care cannot compete with dermatology practices in remuneration for PAs. Just as financial benefits in high-production specialty practices entice physicians, the same benefits entice PAs as well. Second, according to member surveys of the SDPA, virtually 100% of fellow members work with dermatologists. Although PAs can work in any type of practice and evaluate dermatologic symptoms just as a general practitioner would, PAs who specialize in dermatology primarily practice with dermatologists, a collegial association most PAs seek out. PAs have steadfastly maintained their dependent, noncompetitive relationship with physicians and would not have it any other way. Although PAs see a good number of patients (2.8 million) with dermatologic symptoms, the NAMCS data indicate that most (72%) of these patients are also seen by a physician. Third, physicians are ultimately responsible for the actions of their PA employee. A general practitioner not trained to perform excisions or manage certain dermatologic conditions should not allow a PA to perform such duties. Similar to much of medicine, the PA profession continues to evolve, with many members moving awa     

Issues in the delivery of dermatologic surgery for skin cancer

Significant financial resources need to be dedicated to treating the large numbers of skin cancers in the United States. The goal of the surgical treatment of skin cancer is to provide a high cure rate in a manner that is minimally morbid, convenient, and inherently of high value. Cost-effective delivery of this skin cancer care is critical given the prevalence of cutaneous neoplasia. Dermatologists are the best-trained physicians in the identification and management of melanoma and NMSCs. They are the most highly skilled judges of when intervention is indicated, of which lesions warrant biopsy, and of which treatment techniques are applicable for each individual tumor. These skills take years to develop and are necessary to provide the highest standard of medical and surgical management of skin cancer. As dermatologic surgery continues to evolve and dermatologists in residency receive even more surgical training, the dermatologist will prove to be the surgical skin cancer specialist well into the new millennium.     

Current dermatologic laser applications in patient care.

Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. Current clinical applications of lasers are changing the practice of dermatology. Research and the changing practice significantly impact dermatologic nursing practice.     

The gatekeeper model is inefficient for the delivery of dermatologic services

BACKGROUND: Gatekeeper-paradigm managed care systems may discourage the use of dermatologists in the management of skin conditions by limiting direct access. This may limit the quality of care patients with skin disorders receive and may be an inefficient use of medical resources. OBJECTIVE: The purpose of this study was to determine the likelihood that patients with dermatologic conditions who see a primary care provider will be referred to a dermatologist. METHODS: Data on the disposition of outpatient visits to primary care physicians for one and only one dermatologic diagnosis were obtained from the 1990-1994 National Ambulatory Medical Care Survey. These data were used in an econometric model to estimate the likelihood of referral to a dermatologist for an episode of care. RESULTS: Of all visits for a single dermatologic diagnosis, 39% were to primary care physicians. The disposition of referral was more common for these dermatology-related visits than for all office visits to primary care physicians (5.8% vs 4.5%, P < .001). The most frequent diagnoses associated with referral were common dermatologic problems, not rare disorders. The number of visits per episode of care was highly dependent on the assumptions of the analysis, resulting in estimate ranges for referral rates per episode between 6.8% and 18.5% for pediatricians, 8.2% and 23% for family and general practitioners, and 16.6% and 46.5% for internists. CONCLUSION: The relative difficulty for primary care providers of managing skin problems is reflected by their frequent need to refer patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical conditions. The high rates of referral per episode of care supports the cost-effectiveness of direct access to dermatologists.     

The work experience of a district dermatologist in the dispensary care of dermatology patients

The author reviews her experience gained in follow-up of 143 patients, divided into 5 groups, carried out at a dermatology room of a central district hospital in a rural region from 1980 through 1986. Favorable results were achieved in 4/5 of these patients; temporary invalidity was essentially reduced and the index of cure was increased from 10 to 48%.     

Dermatologists and office-based care of dermatologic disease in the 21st century

Most professional care of skin diseases is provided in physicians' offices. In the past 25 y, medical practice has changed substantially. Since 1973, the National Ambulatory Medical Care Survey has provided data about patients seen in physicians' offices. Using 1974, 1980, and 1989 data, we have previously analyzed these data as they pertain to skin diseases. To provide a more current assessment of dermatologists' practices and the care of skin diseases in office-based practice, we analyzed National Ambulatory Medical Care Survey data for 1999 to 2000. We used statistical methods for survey data to estimate the number and characteristics of visits to dermatologists and others for skin diseases. We compared the characteristics of dermatologists' office-based practices with those of other physicians. In 1999 to 2000, there were approximately 35 million visits annually to office-based dermatologists, double the number for 1974. Eight diagnostic groups account for 65% of all visits to dermatologists. Acne is still the most frequent primary diagnosis at visits to dermatologists, but since 1974 the proportion of all visits that were for acne has decreased by half. Compared to other office-based physicians, dermatologists are significantly more likely to own their practices (OR, 2.78; 95% CI, 1.52-5.02) and much less likely to see capitated patients (OR, 0.30; 95% CI, 0.17-0.53). Over 26 y, utilization of dermatologists' services has grown in proportion to the increase in the number of office-based dermatologists. The organization of their practices has changed little. Dermatologists dominate the care of many of the same diagnoses as they did 20 y ago.     

Introduction: US dermatologic health care needs assessment

The health care needs assessment (HCNA) addressed in this issue of Dermatologic Clinics is designed to aid practitioners and policy makers by providing current, evidence-based research that can be used to guide United States' dermatologic care. The topics covered in this skin disease HCNA include those that are considered common dermatology care needs in society and those severe enough to create a burden on the medical system. Disease discussions address epidemiology, costs to society and patients, prevention, treatment, gaps in management, and future recommendations.