Mohs surgery is vilified, physicians again fail to respond effectively

An article published in the New York Times last weekend has been circulating widely on the Internet, and I feel that more than ever, physician voices are needed to reach the public and counter certain misconceptions put forth by the media.

The article, “Patients’ Costs Skyrocket; Specialists’ Incomes Soar,” charts the growth of specialist incomes in the past decade, using the case of a patient from Arkansas who had a $25,000 medical bill for Mohs surgery to demonstrate the prevalence of unnecessary and costly procedures.

It isn’t all bad — one big pro of this article written by internist Dr. Elisabeth Rosenthal is opening the line of communication between physician and patient regarding transparency of cost and necessity of certain procedures. That’s a great thing, and for doctors out there who are taking advantage of the system, perhaps this article can make them change their ways. That being said, I think the article was at times unfair and depicted a distorted view of dermatology and other subspecialty fields. There are a few important points to address here in response to the article, and a few things I would have liked to see as a response from the physician community.

First, the article simultaneously vilified and minimized the role of Mohs surgery in treating skin cancer. The Mohs technique, invented in 1938 by general surgeon Dr. Mohs while he was still a medical student at University of Wisconsin-Madison, is a process where thin layers of cancerous tissue are sliced off and immediately studied under the microscope. The surgery stops when the tissues are completely free of cancer at all borders. This process helps to ensure that the cancer is absolutely removed while taking the minimal amount of skin necessary to do so.

Mohs has been proven in certain cancers such as recurrent basal cell carcinoma to be  more effective than excision, and there is no doubt that it has saved countless lives while preserving tissue for reconstruction. The AAD put out guidelines in 2012 to classify which lesions require Mohs surgery to remove — certain types of tumors in certain types of patient populations, tumors that are very deep, in sensitive areas on the face or ear, or ones that are very large.

The article instead characterizes Mohs instead as a “go to procedure,” a sort of money making machine. It does not go into the details that many Mohs procedures take several hours to complete, as you go through and take stage after stage of tissue. It does not go into the fact that this procedure can be lifesaving. Most of all, this article implies that Mohs is unnecessary, which can have hugely dangerous implications for patients out there with early stage skin cancer.

Not all patients are like Ms. Little either. The patient in the article had a small basal cell carcinoma which was excised via Mohs surgery, and then she was sent to an oculoplastic surgeon for the repair. Her bill was over $25,000 because she was treated by a Mohs surgeon, an oculoplastic surgeon, and an anesthesiologist. She was billed $1,833 for the Mohs, $14,407 for the plastic surgeon, $1000 for the anesthesia, and $8774 in hospital costs. She later got the costs down to $1400 for the Mohs procedure, $1,375 for the plastic surgeon, $765 for the anesthesia, and $1050 in hospital costs.

Take a second and think about these numbers. The plastic surgeon cost was able to be reduced by 90% … ? Why exactly is this article targeting the Mohs surgeon again?  Aside from that fact, there are many patients who receive Mohs who do not have to get a repair from a plastic surgeon with an anesthesiologist. In fact, the norm is for Mohs surgeons to do the repair themselves. They are trained in it, and that is their job — they only refer out if they cannot handle the repair alone. I can’t speak for Ms. Little’s Mohs surgeon (and apparently, he can’t either, as he did not comment in the article), but most Mohs surgery clinics are a one-stop shop for excision and repair.

The article also lumps all payments together as if what you’re billed for is what the doctor pockets. That cannot be further from the truth. The article cites examples of a $915.46 bill for a mole removal in Oregon or a $500 wart freezing treatment at NYU Medical Center. I spoke to two dermatologists from Stanford who laughed and said they would never see payments like that in their practices at an academic center. That money goes into paying for nurses, hospital administrators, dermatologists, medical assistants, medical record handling, and much more.

What needs fixing in this system isn’t the physician salaries, but rather, more transparency of cost. If patients can get a more truthful breakdown of costs, they would realize that the physician is not the greedy money-hungry one in this scenario.  It takes a lot more to run a medical center than meets the eye.

To be honest, I have been disappointed in the response from the physician community thus far. Dr. Dirk Elston, president of the American Academy of Dermatology, wrote a letter to the editor that appeared in the Times.

Dr. Fosko of the American College of Mohs Surgery also wrote a letter to the editor on the same page.  The responses are well written and full of information, and are great for other physicians to read.

However, I don’t think it is the best way to reach the public. If I’ve learned anything at NBC, it is that you have to tell a patient story.

Find a patient, one who has had his life saved and his world changed by Mohs surgery. It can’t be hard to find one; there are stories like this around the country. Interview him. Interview his family and his physician. Interview many Mohs surgeons. Put statistics in the piece but they can’t be the focus; numbers are fleeting but a patient story makes an impression.  And really show the world how much good Mohs surgery can do. I know it, dermatologists and other physicians know it, but now it’s up to us to convince the rest of the world that it is a worthwhile and lifesaving procedure.

Joyce Ho is a medical student who blogs at Tea with MD.  She can be reached on Twitter @TeawithMD.

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  • southerndoc1

    “I spoke to two dermatologists from Stanford who laughed and said they would never see payments like that in their practices at an academic center. That money goes into paying for nurses, hospital administrators, dermatologists, medical assistants, medical record handling, and much more”

    And please tell us why they think it so amusing that all those parasites were collecting their shake-down fees on these simple procedures (I’m not talking about anyone involved in actual patient care)?

    • Dr. Drake Ramoray

      Because they are academics and have no sense of business or any concept of the current assault on medicine. All is well in the shiny white towers. Usually is when you see patients a few times (if that often) a week and spend most of your time writing research grants.

  • buzzkillersmith

    Pay this budding obfuscator no mind.

    On average, derms earn $100 or so per hour of work and PCPs earn about $60 per hour. Ergo, dermatologists are vastly overpaid, whether they are Mohsing or fooling with pimples or reading Field and Stream.

    Details multiply, fundamental structure abides.

    Next case.

    • FEDUP MD

      My dad is a lawyer, charges $150 an hour, has almost no overhead and pockets most of it. He is on the low end compared with many. My husband with a masters in engineering pockets $70 per hour on average.

      If you think those amounts for derm are too large you need to compare not to the guy flipping burgers but to other educated professionals.

      • buzzkillersmith

        I’m kindasorta educated as well and don’t get paid close to that. We might be able to get some more fairness in medicine. The outside is a different thing entirely.

        • FEDUP MD

          I have years more training than dermatologists yet make about the same as a PCP. I don’t begrudge them their pay. Unlike many, I don’t see it as a zero sum game. There is no reason why their making X amount should take Y amount away from me. It is this divide and conquer approach which is allowing those from outside the profession to set us on each other rather than coming together as advocates.

    • PoliticallyIncorrectMD

      Physicians in general are overpaid compared to many other professionals, should their income be curbed?

      If Dermatologists were paid less, would it make PCP’s get paid more?

      • buzzkillersmith

        I wouldn’t mind having some money re-distribution within medicine, now that you ask.

    • Allie

      Or fixing the problems PCPs cause with lotrisone . . .

  • Markus

    I do think that I have seen some overuse of Mohs surgery. One was for a lesion in the hair bearing area of the scalp and another was for an upper arm lesion. A simple excision with a scalpel under local in a primary care office would have sufficed and would have been much cheaper. On the other hand, I have seen neglected or recurrent (due to previous inadequate procedures) lesions where Mohs gave excellent results. Nothing is better than the right procedure done the right way on the right patient. However, I do have a bit of suspicion since dermatologists often work in their own offices and act as their own pathologist that a little more supervision would be useful. I have seen actinic lesions and pigmented lesions treated by dermatologists for invasive cancers that on subsequent pathology review were deemed not so serious. Our reimbursement model is based on coding by the physician that builds in incentives to updiagnose and uptreat. These temptations are resisted the vast majority of the time, but doctors are human beings.

    • Dr. Drake Ramoray

      I do have a bit of suspicion since dermatologists often work in their own offices and act as their own pathologist that a little more supervision would be useful……….. Our reimbursement model is based on coding by the physician that builds in incentives to updiagnose and uptreat.

      =================================

      What business model would you suggest to replace what we have. I concede the supervision/pathology part of your argument as I am not well versed I the daily lives of dermatologists. However, I’m not certain how doing their work in their own offices has anything to do with the cost of care. If nothing else it costs less to perform them in the office because there are no facility fees.

      http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

      And secondly if you mean they should work for hospitals because then there will be less fraud or upcoding I give you the current Governor of Florida and former CEO of HCA ( a very large hospital conglomerate).

      http://www.examiner.com/article/florida-elects-rick-scott-who-admitted-to-14-counts-of-medicare-fraud
      The only way to eliminate upcoding for services would be to salary all physicians at the same level for all patient’s regardless of complexity. This of course won’t work either, because then doctors will just collect as many healthy patients as they can because you get paid more to see 3-4 healthy easy patients it he time it takes to see one sick patient.

      • Markus

        I sure don’t have an answer. Our current RBRVS system is a strange mix of price setting by insiders, the AMA’s RUC, which is turned into policy by the government in the form of the CMS. Sometimes I think we have a combination of the worst aspects of socialist economic planning with the worst features of oligopolist heartless capitalism. Also, I certainly agree that alternative systems can be gamed as well. At the same time, independent medical practice is declining rapidly as hospital systems increasingly employ everything from primary care docs to tertiary subspecialists.
        Luckily for me, I retired 7 months ago.

  • southerndoc1

    “it (Mohs) has saved countless lives”

    You’re kidding, aren’t you?

  • PoliticallyIncorrectMD

    Good point!

  • Dr. Cap

    It’s more about an example to demonstrate the point. However, before I euthanized my own dog, I would lay down at least $200 every visit–payment due at the time of rendered services. Thank you have a nice day. I’m wondering why vets are not judged so harshly similarly to their people-doc counterparts.

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