Dermatology — prices that get under your skin

Elisabeth Rosenthal reported “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” in the New York Times today 1/19/19.  She particularly targets one of the most popular specialties for US trained physicians, dermatology.  Good hours, great pay, and compared to other specialties, easy to learn.

A highly trained thoracic surgeon can only do 2 bypass surgeries per day but a dermatologist can to 20 lesion removals per day and make almost as much money.   Patients choose to go to a dermatologist when most primary care doctors can just as easily solve the problem at a fraction of the cost (like benign skin lesions, sun related pre-cancers, and acne).  And, when infection sets in on the weekend the dermatologist’s answering machine says to  go to the emergency room ($300 co-pay).

She describes a situation where a woman had a facial skin cancer removed at a cost of $26,014.   The astounding cost was the result of a dermatologist removing a lesion and then being unable or unwilling to close the wound — but still billing for the procedure.  And, the patient also received bills from the doctors that actually fixed the problem (perhaps they should have billed the dermatologist).  Sadly, a bad system is more profitable than a good system.

It is easy to see why the patient and Ms. Rosenthal believe there is a problem with US healthcare.   Because, THERE IS A PROBLEM!

Rather than complain about the problem, what is the solution?  It is not rocket science.  The dermatologist, surgeon, operating room personnel and anesthesologist all need to be employed by an accountable care organization (ACO)– that way there is just one predetermined fee for taking care of the whole patient for a year.  If the system does the work correctly they make some money, if they goof-it-up (as in this case) they lose money.   The incentive should be to do good and efficient work.  Not to make money by making mistakes.

This solution is extremely easy yet extremely unpopular with hospitals, surgeons, anesthesiologists, pathologists, radiologists, ophthalmologists and dermatologists.  The reasons are obvious — they make less money and must follow quality guidelines.  Given the low quality and extreme  high cost of US healthcare is that really a problem?  A few more articles by Ms. Rosenthal and a few thousand letters to congress might help.  Sadly, one industry lobbyist equals one journalist in this battle.

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By the way, the lesion at the top is a benign seborrheic keratosis — harmless, but gladly removed by dermatologists ($250).