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A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
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08 Research
12 Legal Issues
18 Practice Management
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in this issue
from the editor
VOL. 25 NO. 1 | JANUARY 2015
Happy New Year!
opefully you each had a restful holiday. Was it a struggle to return
to work? Was the problem a result of the culture in your office?
Are you happy with the way your office functions? Are there
improvements that you never quite have the time to implement?
Not sure how to move the needle on this front? Well, since January is
the month of new beginnings, this seems like the month to implement
some changes. Setting up a successful tone in the office takes work upfront, but the dividends that it pays down the line are immeasurable.
Jeff Dover, MD, who we interview this month, presents some great
ideas on how to set up a warm and effective office culture. He tells us how, right from the
first day of everyone’s employment, the mission of the practice is taught and the standards
are emphasized. I especially liked the ones that remind us that our primary focus is the
care of patients. He also reminds us of the importance of mentors for “newbies” at all levels
within the office. I won’t spoil the rest of the piece by rattling on any further. I think that this
is an important piece to read — especially if you think that you don’t have the time to address
office concerns. I’ve watched one of my colleagues at Penn set this tone in the residency
program. He demands much from our residents each year; they in turn eagerly and happily
fulfill the expectations. These approaches can work in groups of every stripe.
ZPIC audits were new to me and I trust the same is true for many of you. We all need to
add this to our vocabulary. Alex Miller, MD, explains that being chosen for a ZPIC audit is not
good. He gives us guidance on what they are about and how to handle it if we receive word
of an impending site visit. His piece this month tells us many things, including which ZPIC
zone we are assigned to, what auditors may be looking for in a visit, and, most importantly,
how to avoid being chosen.
Another piece that I especially want everyone to take a look at is our feature on ICD-10.
This is a government mandate that is actually going to come. No amount of wishing is going
to stop its implementation. Sort of like hoping for snow days when you are in school even
when the January temps are above freezing…hard to accept, but we all have learned that it is
best to spend the energy doing your homework. And so it is with ICD-10. Our story lays out
how to get this implementation moving forward. You must educate all providers, the people
who handle your claims, your software — they all will have a role in this transition. Don’t
leave this ‘til next fall or you will regret it.
I’ll end my column talking a bit about our feature on “presenteeism”…the need to be in
the office when patients are scheduled even if we are sick. Years ago I once had an elderly patient catch the flu from me and wind up in the hospital; I felt so terrible. I learned two things
from that experience: the importance of getting a flu shot and the need to stay home when I
am ill. It’s a struggle to fight our “doctor culture,” but it’s important not to infect everyone in
the office including our patients. Hope you ride through January with nary a sniffle!
Enjoy your reading.
Brett Coldiron, MD
Elaine Weiss, JD
Lara Lowery
Katie Domanowski
Richard Nelson, MS
Victoria Houghton, MPA
Ed Wantuch
Theresa Oloier
Nicole Torling
Joe Miller
Brian Searles
Abby Van Voorhees, MD
Barbara Mathes, MD
Jan Bowers
Ruth Carol
Sarah Imhoff, JD
Alexander Miller, MD
Victoria Pasko
Rob Portman, JD
Susan Treece
Scott Weinberg
Lakshi Aldredge, MSN, ANP-BC
Annie Chiu, MD
Jeffrey Dover, MD
Rosalie Elenitsas, MD
John Harris, MD, PhD
Chad Hivnor, MD
Sylvia Hsu, MD
Risa Jampel, MD
Michel McDonald, MD
Christen Mowad, MD
Robert Sidbury, MD
Oliver Wisco, DO
Carrie Parratt
Printed in U.S.A. Copyright © 2015 by the
American Academy of Dermatology Association
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regulatory issues, and incorporating clinical and
research developments into patient care.
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DERMATOLOGY WORLD //January 2015 1
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
Picked for a ZPIC audit?
“This is a
situation that
we should be
prepared to 22
manage, or it
will manage
Experts offer guidance on a seamless
us in return.”
ICD-10 transition
Changing health care landscape prompts
reappraisal of general dermatology
Breaking the cycle of going to work sick
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Mention, Association/
Non-profit video
2 DERMATOLOGY WORLD // January 2015
A look ahead at 2015 in
state legislatures.
Making informed consent
more meaningful.
Dealing with patient
Movies: Lessons in
Managing staff
relationships and
cultivating a culture of
growth in your practice.
Call for comments, more.
Meaningful use
attestation on the rise.
ACZONE® (dapsone) Gel 5%
ACZONE® Gel, 5%, is indicated for the topical treatment of acne vulgaris.
For topical use only. Not for oral, ophthalmic, or intravaginal use. After the
skin is gently washed and patted dry, apply approximately a pea-sized
amount of ACZONE® Gel, 5%, in a thin layer to the acne affected areas
twice daily. Rub in ACZONE® Gel, 5%, gently and completely. ACZONE®
Gel, 5%, is gritty with visible drug substance particles. Wash hands after
application of ACZONE® Gel, 5%.
If there is no improvement after 12 weeks, treatment with ACZONE® Gel,
5%, should be reassessed.
Hematological Effects
Oral dapsone treatment has produced dose-related hemolysis and
hemolytic anemia. Individuals with glucose-6-phosphate dehydrogenase
(G6PD) deficiency are more prone to hemolysis with the use of certain
drugs. G6PD deficiency is most prevalent in populations of African, South
Asian, Middle Eastern, and Mediterranean ancestry.
There was no evidence of clinically relevant hemolysis or anemia in
patients treated with ACZONE® Gel, 5%, including patients who were
G6PD deficient. Some subjects with G6PD deficiency using ACZONE®
Gel developed laboratory changes suggestive of mild hemolysis.
If signs and symptoms suggestive of hemolytic anemia occur, ACZONE®
Gel, 5% should be discontinued. ACZONE® Gel, 5% should not be
used in patients who are taking oral dapsone or antimalarial medications
because of the potential for hemolytic reactions. Combination of
ACZONE® Gel, 5%, with trimethoprim/sulfamethoxazole (TMP/SMX) may
increase the likelihood of hemolysis in patients with G6PD deficiency.
Peripheral Neuropathy
Peripheral neuropathy (motor loss and muscle weakness) has been
reported with oral dapsone treatment. No events of peripheral neuropathy
were observed in clinical trials with topical ACZONE® Gel, 5% treatment.
Skin reactions (toxic epidermal necrolysis, erythema multiforme, morbilliform and scarlatiniform reactions, bullous and exfoliative dermatitis,
erythema nodosum, and urticaria) have been reported with oral dapsone
treatment. These types of skin reactions were not observed in clinical
trials with topical ACZONE® Gel, 5% treatment.
Clinical Studies Experience
Because clinical trials are conducted under prescribed conditions,
adverse reaction rates observed in the clinical trials of a drug cannot be
directly compared to rates in the clinical trials of another drug and may
not reflect the rates observed in practice.
Serious adverse reactions reported in patients treated with ACZONE®
Gel, 5%, during clinical trials included but were not limited to
the following:
• Nervous system/Psychiatric – Suicide attempt, tonic clonic movements.
• Gastrointestinal – Abdominal pain, severe vomiting, pancreatitis.
• Other – Severe pharyngitis.
In the clinical trials, a total of 12 out of 4032 patients were reported to
have depression (3 of 1660 treated with vehicle and 9 of 2372 treated with
ACZONE® Gel, 5%). Psychosis was reported in 2 of 2372 patients treated
with ACZONE® Gel, 5%, and in 0 of 1660 patients treated with vehicle.
Combined contact sensitization/irritation studies with ACZONE®
Gel, 5%, in 253 healthy subjects resulted in at least 3 subjects with
moderate erythema. ACZONE® Gel, 5%, did not induce phototoxicity or
photoallergy in human dermal safety studies.
ACZONE® Gel, 5%, was evaluated for 12 weeks in four controlled studies
for local cutaneous events in 1819 patients. The most common events
reported from these studies include oiliness/peeling, dryness, and erythema.
One patient treated with ACZONE® Gel in the clinical trials had facial
swelling which led to discontinuation of medication.
In addition, 486 patients were evaluated in a 12 month safety study. The
adverse event profile in this study was consistent with that observed in the
vehicle-controlled studies.
Experience with Oral Use of Dapsone
Although not observed in the clinical trials with ACZONE® Gel (topical
dapsone) serious adverse reactions have been reported with oral use of
dapsone, including agranulocytosis, hemolytic anemia, peripheral neuropathy
(motor loss and muscle weakness), and skin reactions (toxic epidermal
necrolysis, erythema multiforme, morbilliform and scarlatiniform reactions,
bullous and exfoliative dermatitis, erythema nodosum, and urticaria).
A drug-drug interaction study evaluated the effect of the use of ACZONE®
Gel, 5%, in combination with double strength (160 mg/800 mg)
trimethoprim-sulfamethoxazole (TMP/SMX). During co-administration,
systemic levels of TMP and SMX were essentially unchanged. However,
levels of dapsone and its metabolites increased in the presence of TMP/
SMX. Systemic exposure (AUC0-12) of dapsone and N-acetyl-dapsone
(NAD) were increased by about 40% and 20% respectively in the
presence of TMP/SMX. Notably, systemic exposure (AUC0-12) of dapsone
hydroxylamine (DHA) was more than doubled in the presence of TMP/
SMX. Exposure from the proposed topical dose is about 1% of that from
the 100 mg oral dose, even when co-administered with TMP/SMX.
Topical Benzoyl Peroxide
Topical application of ACZONE® Gel followed by benzoyl peroxide in
subjects with acne vulgaris resulted in a temporary local yellow or orange
discoloration of the skin and facial hair (reported by 7 out of 95 subjects
in a clinical study) with resolution in 4 to 57 days.
Drug Interactions with Oral Dapsone
Certain concomitant medications (such as rifampin, anticonvulsants,
St. John’s wort) may increase the formation of dapsone hydroxylamine,
a metabolite of dapsone associated with hemolysis. With oral dapsone
treatment, folic acid antagonists such as pyrimethamine have been noted
to possibly increase the likelihood of hematologic reactions.
Teratogenic Effects: Pregnancy Category C
There are no adequate and well controlled studies in pregnant women.
Dapsone has been shown to have an embryocidal effect in rats and rabbits
when administered orally in doses of 75 mg/kg/day and 150 mg/kg/day
(approximately 800 and 500 times the systemic exposure observed in
human females as a result of use of the maximum recommended topical
dose, based on AUC comparisons), respectively. These effects were
probably secondary to maternal toxicity. ACZONE® Gel, 5%, should be
used during pregnancy only if the potential benefit justifies the potential
risk to the fetus.
Nursing Mothers
Although systemic absorption of dapsone following topical application of
ACZONE® Gel, 5%, is minimal relative to oral dapsone administration, it is
known that dapsone is excreted in human milk. Because of the potential for
oral dapsone to cause adverse reactions in nursing infants, a decision should
be made whether to discontinue nursing or to discontinue ACZONE® Gel,
5%, taking into account the importance of the drug to the mother.
Pediatric Use
Safety and efficacy was evaluated in 1169 children aged 12-17 years
old treated with ACZONE® Gel, 5%, in the clinical studies. The adverse
event rate for ACZONE® Gel, 5%, was similar to the vehicle control group.
Safety and efficacy was not studied in pediatric patients less than 12 years
of age, therefore ACZONE® Gel, 5%, is not recommended for use in this
age group.
Geriatric Use
Clinical studies of ACZONE® Gel, 5%, did not include sufficient number of
patients aged 65 and over to determine whether they respond differently
from younger patients.
G6PD Deficiency
ACZONE® Gel, 5% and vehicle were evaluated in a randomized,
double-blind, cross-over design clinical study of 64 patients with G6PD
deficiency and acne vulgaris. Subjects were Black (88%), Asian (6%),
Hispanic (2%) or of other racial origin (5%). Blood samples were taken
at Baseline, Week 2, and Week 12 during both vehicle and ACZONE®
Gel, 5% treatment periods. There were 56 out of 64 subjects who had a
Week 2 blood draw and applied at least 50% of treatment applications.
ACZONE® Gel was associated with a 0.32 g/dL drop in hemoglobin
after two weeks of treatment, but hemoglobin levels generally returned
to baseline levels at Week 12.
There were no changes from baseline in haptoglobin or lactate dehydrogenase during ACZONE® or vehicle treatment at either the 2-week or
12-week time point.
The proportion of subjects who experienced decreases in hemoglobin
≥1 g/dL was similar between ACZONE® Gel, 5% and vehicle treatment (8
of 58 subjects had such decreases during ACZONE® treatment compared
to 7 of 56 subjects during vehicle treatment among subjects with at
least one on-treatment hemoglobin assessment). Subgroups based on
gender, race, or G6PD enzyme activity did not display any differences in
laboratory results from the overall study group. There was no evidence of
clinically significant hemolytic anemia in this study. Some of these subjects
developed laboratory changes suggestive of mild hemolysis.
ACZONE® Gel, 5%, is not for oral use. If oral ingestion occurs,
medical advice should be sought.
© 2014 Allergan, Inc.
Irvine, CA 92612, U.S.A.
marks owned by Allergan, Inc.
Patented. See
Based on 72205US13
144098 APC14LG14
cracking the code
coding tips
Picked for
a ZPIC audit?
ALEXANDER MILLER, MD, addresses important coding and documentation questions
each month in Cracking the Code. Dr. Miller, who is in private practice in Yorba Linda,
California, represents the American Academy of Dermatology on the AMA-CPT®
Advisory Committee.
You receive a notice of an impending on-site visit by your Zone Program Integrity Contractor (ZPIC). What is this? How is it that you have reached visit status? What do you do?
The seed for creating ZPICs was germinated by the Health Insurance Portability
and Accountability Act (HIPAA) of 1996, and subsequently grown to generate ZPICs by
the Medicare Modernization Act (MMA) in 2003. Although the MMA may at times feel
like it, it does not stand for “mixed martial arts.” Seven ZPIC zones, each covering one
or more Medicare Administrative Contractor (MAC) jurisdictions, were created. The
table on the next page designates the ZPICs assigned for individual states.
ZPICs were created to investigate potential fraud, waste, and abuse in the Medicare
system. In the practice setting Medicare fraud can be construed as any of the following
when done knowingly:
• Submitting false statements in order to obtain payment.
• Soliciting, paying, and/or accepting payments as inducements or rewards for referrals that result in billings to Medicare.
• Billing for services that were not done.
• Billing for services at a higher level of complexity than was done or documented.
Medicare abuse can include the following:
• Billing for not medically necessary services.
• Excess charges for services or supplies.
• Upcoding or unbundling of CPT codes.
What can one cull from the above that could be pertinent to an array of dermatologic
practices? Repeated upcoding of E/M visit levels, when knowingly done, and when
unsupported by chart data, can be construed as fraud. Frequent use of modifiers 25 and
24 to indicate separately identifiable E/M billed services when documentation does not
support a separate E/M service may also lead to suspicion of fraud. To further drive the
above points in, Medicare, in an August 2014 Medicare Learning Network article (www.
downloads/Fraud_and_Abuse.pdf ), gives a specific example of a false claim as being
one where a physician knowingly submits Medicare claims for a higher level of services
than the patient record supports. Under the False Claims Act such consistent physician/
provider actions can lead to civil penalties, including fines of $5,500 - $11,000 per false
claim and recoupment of up to triple the
damages calculated as overpayments.
Furthermore, criminal prosecution can
For those thrilled by the latest
Medicare “crime and punishment”
news, log on to This website
provides an impressive, current
account of ongoing and successful
enforcement actions.
Where do ZPIC audits fit into the
fraud and abuse scenario? Unlike audits
done by the Medicare Administrative
Contractor (MAC) and Comprehensive Error Rate Testing (CERT) audits
designed to measure error rates in claim
adjudication by the MAC, ZPIC audits
arise when the potential of fraud is
discovered. Clearly, this is not good! ZPIC
audits are not random, data-generating
audits. They happen because either fraud
is suspected or data mining analysis has
revealed outlier billing patterns that may
lead to a determination of fraud.
In the process of their investigation
ZPICs can do the following to you:
• Request medical records for review.
• Interview you and your staff as well as
your patients.
• Visit your office for an on-site inspection of charts.
• Institute prepayment audits and/or
automatic denial edits for some or all
• Suspend payments.
• Bring in law reinforcements, including from the Office of Inspector General (OIG) and Department of Justice
Potential final consequences of a
ZPIC audit include:
• Provider education (the best result, as
no sanctions would be forthcoming).
• Overpayments are determined, and
are collected by the MAC.
DERMATOLOGY WORLD //January 2015 5
cracking the code continued
• Referral to law enforcement entities for
civil litigation and/or criminal prosecution.
A ZPIC audit should not be taken
lightly. It is the result of one’s being in the
crosshairs. It is not random. It is focused
— on you. All requested information
should be submitted promptly, completely,
and with appropriate signature attestations.
Legal counsel should be sought, as the
ZPIC is not a minor annoyance that can
be swatted away. It is one that can bite you,
hurtfully, and with chronic consequences.
Prevention is the best way to deal with
potential audits. Prevention can be exercised in the form of:
• Auditing one’s own billing practices.
• Auditing one’s own charting for completeness and support of the billing
• Ensuring that how and what you think
you are billing is actually what is submitted to Medicare.
• Following Medicare policies and procedures, including Local Coverage Determinations. (For more discussion of
these, see last month’s column at www.
• Objectively examining causes for repeated payment denials and/or appeals,
determining whether they are caused
by your billing patterns, and appropriately modifying your habits.
• Basic honesty.
Example 1: Your office receives a request
for chart documentation from your ZPIC
auditor. As your office has successfully
dealt with CERT audits before, you have
your staff copy charts and send them out.
Answer: Incorrect. A ZPIC audit is a serious
event that can lead to catastrophic consequences. It is incumbent upon the physician to
ensure that all appropriate data is submitted
6 DERMATOLOGY WORLD // January 2015
coding tips
Safeguard Services (SGS)
California, Hawaii, Nevada, American Samoa,
Guam, Mariana Islands
Washington, Oregon, Idaho, Utah, Arizona,
Wyoming, Montana, North Dakota, South Dakota,
Nebraska, Kansas, Iowa, Missouri, Alaska
Minnesota, Wisconsin, Illinois, Indiana, Michigan,
Ohio, Kentucky
Health Integrity
Colorado, New Mexico, Texas, Oklahoma
Arkansas, Louisiana, Mississippi, Tennessee,
Alabama, Georgia, North Carolina, South Carolina,
Virginia, West Virginia
Under Protest; Safeguard
Services (SGS) is the current contractor
Pennsylvania, New York, Delaware, Maryland,
D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Maine, Rhode Island, Connecticut
Safeguard Services (SGS)
Florida, Puerto Rico, Virgin Islands
along with proper and legible signature attestations.
Example 2: You are delighted, as your electronic health records program has enabled
you to gather sufficient data to consistently
bill for one level higher E/M services than
you had previously felt justified in billing.
You are confident that your documentation
reliably supports the higher level of E/M billings. Your income is up, and you are happy.
Answer: Incorrect. It is the reasoning that is
incorrect. The data may be collected, but only
that data that is pertinent to the presenting patient complaints is counted toward
determining an E/M level of service. Irrelevant
history and physical findings and cloned data
from prior visits will not be counted by your
MAC toward determining the appropriate
level of E/M billing. However, a sudden and
durable upward shift in billing patterns may
attract the attention of your data-culling
ses. Your office sends the requested material. The CERT contractor determines that
documentation did not support a diagnosis
of inflamed seborrheic keratoses in three
of the five cases, and refers the bills to your
MAC for an overpayment collection, as
destruction of asymptomatic, non-inflamed
seborrheic keratoses is a non-covered
You promptly refund the MAC and
institute a careful review of your documentation and billing patterns.
Answer: Correct. The CERT audit has revealed a trend of billing unsupported by chart
documentation. Such billing for presumed
non-covered services could be interpreted as a
pattern of abuse of Medicare, and could lead
to a ZPIC audit. It is imperative to objectively
evaluate and promptly correct charting and
billing discrepancies. dw
Example 3: You receive a CERT request
for copies of five separate charts relating
to billings for CPT 17110, destruction of
benign lesions, inflamed seborrheic
news in brief
State legislatures back in
business with a full docket
of issues
pring 2015 is expected to bring about even more legislation that
could affect dermatologists and their patients. Many states will build
off of the momentum in 2014 on indoor tanning legislation. Several
states are also expected to take up never-before-seen legislation and
regulations addressing network adequacy, and many states will see legislation addressing caps on out-of-pocket costs for prescriptions.
The AADA expects to see legislation prohibiting minors from using indoor tanning beds in a number of states in 2015, with under-18
bills expected in Colorado, Florida, Kentucky, Maryland, Michigan, Mississippi, North Carolina, Oklahoma, Virginia, and Arizona. Iowa’s
legislation, which originally prohibited minors under 18 from indoor tanning, may be amended down to a lower age threshold, and Massachusetts is expected to continue pursuing its under-16 bill.
After a final hearing on proposed provider network adequacy standards, the Nevada Division of Insurance made only a few of the changes
suggested by the AADA, and as a result, the AADA and numerous medical specialties will likely advocate for legislation in Nevada to fill
in the gaps. Additionally, the AADA joined the American Medical Association in sending a letter to the National Association of Insurance
Commissioners (NAIC) urging it to adopt model legislation that would include provisions requiring network accuracy and adequacy to
ensure that patients have access to the care and physicians they need. Additionally, the groups called on the NAIC to require transparency
on provider selection standards, as well as fair and timely appeals processes for removed providers. Model legislation may be released in
March 2015.
Legislation that allows for the substitution of biosimilars passed in 2013 in Virginia and Oregon. Both bills contain provisions which require pharmacists to notify the prescribing physician of substitutions. However these provisions in Virginia will sunset July 1, 2015, and in
Oregon on Jan. 1, 2016, even though there may only be one biosimilar on the market at this time. The AADA will be looking for opportunities to ensure patient safety by advocating for permanent physician notification in these bills and active legislation in other states.
Legislation to expand the scope of practice of advanced practice registered nurses (APRN), naturopaths, and optometrists is expected to
be considered in the majority of states. A bill in Nebraska that would allow for APRN independent practice was vetoed in 2014, but is
expected to be reintroduced.
A handful of states already have or are forming coalitions to advocate for legislation that would place caps on the out-of-pocket costs of prescription drugs. These states include Oregon, Washington, Kansas, Illinois, Kentucky, Michigan, Georgia, New Jersey, and Massachusetts.
Nevada, Colorado, and Washington are addressing the issue by implementing an education strategy with their insurance commissioners.
The AADA is considering joining a new national coalition to monitor these bills.
Finally, legislation to eliminate the in-office exception to the self-referral prohibition for anatomic pathology services was defeated in
California in 2014, but is expected back in full force in 2015. To learn more about the resources available for state advocacy, visit www.aad.
org/members/practice-and-advocacy-resource-center/patient-health-advocacy/state-affairs. – VICTORIA PASKO
DERMATOLOGY WORLD //January 2015 7
acta eruditorum
Making informed
consent more
Physician Editor Abby S. Van Voorhees, MD, talks with Dr.
Benjamin Stoff about his recent Journal of the American
Academy of Dermatology article, “Reframing risk part I:
Legal and ethical standards for medical risk disclosure.”
DR. VAN VOORHEES: Why did you choose to write
about this topic?
DR. STOFF: My interest in risk communication
derives from a larger interest in informed
consent. Health care providers are obligated to
engage in informed consent discussions about
treatment with patients to conform to ethical,
legal, and medical standards of practice. In
bioethics, informed consent is often discussed
in the context of the professional duty of health
care providers to respect patient autonomy, which
reflects an ideal of self-directed care. Failure of
adequate informed consent is also a frequently
cited cause for medical malpractice claims made
against dermatologists, underscoring the legal
importance of this topic.
Despite all of the reasons to carry out
informed consent, these discussions often
seem ineffectual and perfunctory to health care
providers and patients. Discussion of risk is
especially difficult. In the flow of a busy practice,
it is often hard to know which risks to discuss and
how to discuss them effectively. The dermatology
clinic is an ideal venue to consider risk
communication because we see high volumes of
patients, who often have strong preferences about
treatment. Also, the treatment decisions we face
often have a range of acceptable options. What
aligns with the values of one patient may not with
another. Therefore, effective informed consent
and risk communication are crucial.
DR. VAN VOORHEES: Let’s discuss the requisite
elements of informed consent. While we all
“know” about informed consent, I’m not sure that
we are all certain of the various parts. Can you
review them for us?
DR. STOFF: Although we often think of informed
consent as a single construct (e.g. “consent”),
it really represents two related but distinct
processes. The first is the disclosure of certain
kinds of information (“informing”), including
the nature, purpose, risks, expected benefits, and
alternatives of a proposed treatment. Some have
suggested that other aspects of treatment, such as
cost, should also be disclosed, although this is not
widely accepted yet.
The other element of informed consent
reflects shared decision making (“consenting”).
8 DERMATOLOGY WORLD // January 2015
research in practice
Because this aspect of informed consent
has evolved from simply obtaining
a patient’s permission to undertake
treatment into patient-centered decisionmaking, some have proposed that the term
“informed consent” be abandoned in favor
of “informed choice.” In any case, shared
decision-making refers to the responsibility
of the health care provider to ensure that
the patient has sufficient understanding of
the proposed treatment options and that the
patient can make a decision free of undue
influence by others.
DR. VAN VOORHEES: Is there a specific part
of most of our informed consent discussions
with patients that could use the most
DR. STOFF: It’s difficult to say because
there are very limited data on informed
consent practices in dermatology. In
the broader medical literature, evidence
strongly supports that patients comprehend
and retain frighteningly little about the
informed consent discussions they have
with health care providers. Patients and
providers seem to have particular difficulty
with understanding probabilities related to
risks and benefits.
DR. VAN VOORHEES: How can we be
sure that we are adequately discussing
the appropriate risks with our patients?
Please tell us about the variation that
occurs depending on what state we practice
dermatology in. What are the advantages and
disadvantages of each type?
DR. STOFF: One of the challenges in
determining how to discuss risk appropriately
with patients is that legal standards for
informed consent, including risk disclosure,
vary depending upon the state in which you
practice. Even within a given state, it can
be difficult to determine precisely what the
law requires because standards may reflect
relevant common law (derived from court
rulings) as well as statutory law (derived from
legislative bodies).
In general, there are three legal
standards for disclosure of information,
including risk, in the process of informed
consent for treatment. [A map of the
states in which each standard is in effect
Provider must discuss what another reasonable provider in same field would discuss
in similar clinical context
Provider must discuss what reasonable patient in similar clinical context would want
to know to make decision
Provider must discuss what individual patient wants to know to make decision
*Data from King and Moulton (Am J Law Med 2006;32:429-501.) Consult state law
for most current information.
appears above.] The two most common
standards are the professional standard
and reasonable patient standard. In
the professional standard, a health care
provider must discuss what a reasonable
health care provider in a similar clinical
scenario would discuss with a similar
patient. The content of this disclosure
would be that which is generally accepted
within the profession as standard. In
the context of a legal dispute, an expert
witness would determine if the professional
standard has been satisfied. The
professional standard has the advantage of
being more limited and clear-cut in what is
demanded of health care providers, in that
they must simply conform to the practice
of other, similar professionals. It is less
desirable for individual patients, who may
value highly some aspects of a proposed
treatment that are not standardly disclosed.
That brings us to the reasonable patient
standard. According to this legal standard, a
health care provider is expected to disclose
what a reasonable patient in a similar
clinical scenario would want to know in
order to make an informed decision about
treatment. It is more patient-centered than
the professional standard but also more
challenging for clinicians because of the
difficulty in establishing the informational
preferences of a nebulous reasonable
patient. In the case of a dispute, compliance
with this standard is established by
members of the lay public.
Finally, there is the subjective patient
standard, effective in only a few states.
To satisfy this standard, a health care
professional must discuss what the specific
patient in question finds important in
making a medical decision. Bioethicists
often favor this standard because the focus
DERMATOLOGY WORLD //January 2015 9
research in practice
2015 Coding and
Documentation Manual
for Dermatology
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coding and reimbursement.
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Special Price*: $115
AAD Member Price: $135
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10 DERMATOLOGY WORLD // January 2015
is on the values of the individual patient, rather
than a generic reasonable patient or colleague.
However, legally, it can be difficult to establish
adherence to the subjective patient standard in
the case of a conflict because only the patient can
determine if the disclosure was sufficient.
DR. VAN VOORHEES: What information about
informed consent do we want the practicing
dermatologist to take away from your paper?
DR. STOFF: Ideally, informed consent is a
process between the health care provider and
patient which establishes adequate exchange
of information and shared decision-making
rather than a single, discrete event in which
patients simply give permission for a medical
intervention. As the legal requirements for
disclosure of information vary, dermatologists
should be aware of the standard in effect in the
state in which they practice.
One strategy to satisfy the various elements
of informed consent that we at Emory and others
in the dermatology community have found
helpful involves creating patient materials, like
short videos or simple reading handouts, that
include standardized information that providers
and patients often find important in making
medical decisions about a given intervention.
[For example, patients who may need longterm treatment with steroids watch the video
at] In order to be most effective, these
materials should be constructed in a manner that
is understandable to patients by using simple
language and whole numbers, particularly when
depicting risks. Given how busy a dermatology
clinic can be, these materials need not necessarily
be reviewed within the visit. After a patient
digests the general information, providers
should supplement it with a short discussion of
treatment options that focuses on the values of
the individual patient in order to come to a final
decision. Dermatologists are well positioned to
carry this out, given the long-term relationships
we develop with patients. dw
DR. STOFF is an assistant professor of dermatology and
pathology at Emory University School of Medicine. He is also
a fellow at the Emory Center for Ethics and a student in the
Masters of Arts in Bioethics program at Emory University.
His article appeared in the October 2013 issue of the Journal
of the American Academy of Dermatology. J Am Acad Dermatol
legally speaking
Dealing with
patient images
WORLD covers legal issues in
Legally Speaking. This month’s
authors, Robert M. Portman, JD,
MPP, and Sarah Imhoff, JD, MHSA,
are health care attorneys with
Powers Pyles Sutter & Verville PC
in Washington, D.C. Portman is also
outside general counsel for the AAD
and AADA.
12 DERMATOLOGY WORLD // January 2015
ontinued advances in the quality of video and photographic images allow the medical profession to make
beneficial use of such images for diagnosis, research,
and educational purposes. Telemedicine has become
an increasingly common part of the practice of dermatology, perhaps even more so than for other specialties that
do not lend themselves as well to the diagnosis of medical
conditions using high-quality images. Advancements in
picture quality have enhanced the desire and ability to
share photos in image libraries, databases, and medical
journals for research and educational purposes. However,
the increased use of images also raises concerns about
professional liability and health information privacy and security risks. The following vignettes and related questions
and answers address those legal risks and provide guidance
on how to share patient images in a manner that reduces
legal exposure.
Dr. Katherine Jones, a dermatologist at an academic medical
center in a mid-size urban area, checks her work email after
a long day at the clinic. She views a message from a current
patient, Cynthia, who she has seen in person several times,
but lives and works 30 miles from Dr. Jones’s office. Cynthia
asks for Dr. Jones’s opinion on whether the mole on her neck
appears abnormal. Cynthia writes that she is extremely busy
and does not have time to come in for an appointment before
she leaves for a lengthy trip to Europe. But, Cynthia wants to
make sure the mole is not cancerous before she departs. She attaches a photo of the mole to her email. The photo displays the
bottom of her chin, her entire neck, and the top of her shirt.
Should Dr. Jones be concerned about advising this
patient based solely on the photo? What are the liability
risks of making a diagnosis to an existing patient in these
The first question Dr. Jones must answer is whether
making a diagnosis for an existing patient based solely
on a photo is within the standard of care. While not
purporting to establish a definitive standard of care, the
American Academy of Dermatology (AAD) has issued a
position statement on teledermatology that should inform
Dr. Jones’s decision. The AAD statement advises all dermatologists to provide teledermatology services directly to
patients only under the following circumstances:
1. There is an existing physician-patient relationship
(through seeing the patient in person); or
2. A physician-patient relationship is created through
use of a live-interactive face-to-face consultation
before the image was sent over email; or
3. The physician is part of an integrated health system
where the patient already receives care, and the dermatologist has access to existing medical records and can
coordinate follow-up care.
legal issues
As Dr. Jones has an existing physicianpatient relationship with Cynthia, and
Dr. Jones is in a position to provide this
patient with follow-up care, she meets the
statement’s criteria for directly providing
teledermatology services. Dr. Jones would
also be well-advised to ensure that making
a diagnosis in these circumstances is consistent with her medical center’s guidelines
and any local standards of care.
Even if treatment in these circumstances
is generally consistent with the applicable
standard of care, there are a number of other
issues that should be considered to ensure
proper treatment and reduce liability risk.
First, since Cynthia is an existing patient,
Dr. Jones has a physician-patient relationship with her and must respond to the email
and either provide a diagnosis or schedule
follow-up with Cynthia. Ignoring the email is
not an option.
Second, Dr. Jones must make a judgment
on whether the image is of sufficient quality
to make an accurate diagnosis. The big risk
here is missing a cancerous or pre-cancerous
mole. If the image is not of sufficient quality
to make even a preliminary diagnosis, Dr.
Jones should advise the patient to schedule
an in-person appointment or send a higher
quality photo. The AAD recommends that
all images used in teledermatology have a
minimum of 800 x 600 pixel (480,000)
resolution. If Dr. Jones makes an incorrect
diagnosis that the mole is not precancerous
based on a poor quality image, she may be
held responsible for not obtaining a better
quality photo or seeing the patient in person.
Third, the image may not be of sufficient
scope for Dr. Jones to make an accurate
diagnosis. While the photo is of a mole on
the patient’s neck, a full-body screening for
other moles on the patient’s body may be
necessary to provide a complete evaluation.
To provide a more comprehensive view,
Dr. Jones may want to suggest videoconferencing with Cynthia, which would allow
Dr. Jones to view other moles on Cynthia’s
body. Quality concerns may also arise with
videoconferencing. The patient must have a
high resolution camera and Dr. Jones must
have a monitor with a resolution matched to
the patient’s camera resolution. In addition,
the AAD statement recommends that the
1 The use of images in dermatology carries liability and privacy risks.
2 Dermatologists should generally exercise caution in treating new patients
via teledermatology without a prior in-person visit unless they are doing so
as part of a consultation requested by the patient’s treating physician.
3 For research and educational purposes, dermatologists should ensure
that they are sharing images in compliance with HIPAA and any relevant
state privacy laws. When in doubt, obtaining patient authorization or
de-identifying the image is the best way to avoid a privacy violation.
connection speed should be above 384 kbps
in order to have a sufficiently clear picture.
While Dr. Jones’s medical center may have
the requisite equipment, Cynthia may not.
Fourth, Dr. Jones needs to ensure she
obtains an accurate and complete medical
history from the patient before diagnosis,
which can be difficult to do via electronic
communication. However, since Cynthia
is a current patient, Dr. Jones only needs to
gather information on Cynthia’s medical
status since her last visit.
Fifth, for HIPAA purposes, the images
and information submitted must be secure.
IP transmission must have a minimum
of 128-bit encryption and password-level
Finally, a dermatologist who provides
direct care via teledermatology, as opposed to
only providing consultations to other physicians, has full responsibility for the patient’s
care, including any follow-up treatment and
coordination of care with other specialists. So,
depending on her diagnosis, Dr. Jones must
ensure that Cynthia schedules appropriate
follow-up visits and that Dr. Jones’s staff contacts Cynthia if they do not hear from her in a
timely way. This might be complicated in this
case by Cynthia’s impending travel to Europe,
but the timing of the follow-up visit should be
dictated by the urgency of the patient’s condition, not her travel schedule.
Dr. Jones receives another email from a 75-yearold man, George, who is not an existing patient.
George asks for her medical advice concerning
a rash on his hand. George lives in a rural area
about 100 miles from Dr. Jones’s medical center
and says there are no dermatologists anywhere
near his town and he cannot drive himself to see
Dr. Jones. He says his daughter found Dr. Jones’s
bio and contact information on the medical center
website and helped him draft this email. George attached a photo of the rash on his hand to his email.
Should Dr. Jones be concerned about
treating George? What are the liability risks
in providing teledermatology services to
a new patient without any prior in-person
Dr. Jones should proceed with caution
when answering a request for medical
advice from a potential new patient. George’s
email does not establish a physician-patient
relationship. A physician-patient relationship
would only be created if Dr. Jones agrees to
treat George, whether via electronic communication or in person. Therefore, since
George is not a patient, Dr. Jones has no legal
obligation to respond to his email. However,
from a professional and ethical perspective, she should respond and at least try to
refer George to a primary care physician or
another dermatologist if she can’t help.
By contrast, if Dr. Jones does try to diagnose George in these circumstances, she
would create a physician-patient relationship
and would have full responsibility for the
treatment of George’s rash. That said, she
would be out of step with the AAD’s position
statement if she treats him solely based on
his photo since she has never seen George in
person; has not had a live, interactive face-toface consultation with him; and has not had
a request for a consultation from another
physician treating George.
If Dr. Jones does give advice to George,
she would have to consider all the factors
discussed in Cynthia’s case, including the
quality and scope of the photo. In addition, it
is important to remember that Dr. Jones does
not have a pre-existing physician-patient relaDERMATOLOGY WORLD //January 2015 13
legally speaking continued
tionship with George and does not have his
full medical history. It would be relatively risky
from a legal perspective to treat George in
these circumstances. Instead, Dr. Jones would
be well-advised to schedule an in-person appointment with George or a live, interactive
videoconference. Arranging an in-person visit
may be difficult given George’s distant location. Setting up a videoconference would again
depend on whether George has access to the
necessary equipment. If not, Dr. Jones’s best
bet may be to speak to George’s primary care
physician (PCP) and try to arrange a videoconference through him or her. Working on a
consultant basis with George’s PCP would be a
much safer way to approach this case since Dr.
Jones has no prior relationship with George
and the referring provider would ultimately
be responsible for the patient’s treatment. Dr.
Jones would still be responsible for the advice
she provides, but would not be responsible for
the patient’s follow-up care.
Dr. Jones determined that Cynthia’s mole looked
abnormal from the picture she sent and has
Cynthia come into the office for an in-person examination. Dr. Jones discovers that Cynthia’s mole
is cancerous and treats the patient appropriately.
Based on the unique characteristics of the mole, Dr.
Jones decides to write a case report that includes
the patient’s images. She submits the report to the
Journal of the American Academy of Dermatology Case Reports (JAADCR). She also shares the
patient’s images with other dermatologists for their
opinions, with medical residents in her department
for education purposes, and with the patient’s
insurance company for reimbursement purposes.
Does Dr. Jones have to worry about complying with HIPAA in submitting the photos
of Cynthia’s mole to JAADCR? Does she
need Cynthia’s authorization to do so?
HIPAA establishes rules concerning the
privacy and security of protected health
information (PHI). PHI is health information that identifies or can be used to identify
a patient and consists of a variety of different
formats, ranging from paper to images to
videotapes. The HIPAA rules preclude the
use or disclosure of PHI by physicians and
other covered entities without patient authorization unless an exception applies, such
as for treatment or payment purposes. The
14 DERMATOLOGY WORLD // January 2015
legal issues
rules state that full face photographic images
and comparable images are PHI. Although
there is no comprehensive list of when an
image constitutes PHI, if a photo contains
any features that would make it possible to
identify the individual in an image, the photo
would likely constitute PHI. Possible identifiers include tattoos, facial features, unique
jewelry, or other distinctive characteristics.
If an image does not contain identifiable
information, the photo does not constitute PHI
and patient authorization is not required to
share the image with third parties. In Cynthia’s
case, the photo only displays her chin, neck,
and top of her shirt. It did not show any tattoos,
unusual jewelry, or other identifiable information. As such, Dr. Jones should not need Cynthia’s written permission to submit her photo
to JAADCR. Nonetheless, it is always better to
obtain a patient’s authorization/consent before
sharing an image with a journal or other entity
that is going to publicly display the image to
avoid disputes with the patient after the photo
is published. For instance, Cynthia might
disagree with Dr. Jones that her photo contains
no identifiable features. She might also claim
that she has intellectual property rights in her
photo and threaten to bring legal action against
Dr. Jones for improper disclosure of her image.
In addition, some state laws may have stricter
rules than HIPAA for when patient consent is
required for publication of patient photos. Dr.
Jones should check state law before submitting
photos to JAADCR without Cynthia’s consent.
What if Cynthia’s photo contained a
unique tattoo or other identifiable feature?
Would Dr. Jones need her authorization to
submit the image to JAADCR?
If an image contains a unique tattoo or
other identifiable characteristics, patient authorization may be required to share the photo
with third parties, depending on the purpose
of the disclosure. Dr. Jones’s submission to
JAADCR for research and public education
purposes would likely require an authorization from Cynthia. The patient authorization
must disclose the exact purposes for which
any potential images may be used. It must also
be revocable by the patient at any time. And,
treatment generally cannot be conditioned on
the patient signing the authorization.
If Dr. Jones wishes to use images that
contain PHI, but cannot obtain patient
authorization and no exception applies, she
must de-identify the images. Images can be
de-identified by removing all of the characteristics from the image that make it identifiable. For example, if the photo of a Cynthia’s
mole also shows a unique tattoo, Dr. Jones
could crop or alter the image to only display
the mole and then share the image with
JAADCR. Even then, Dr. Jones should check
state law to make sure it does not require
patient consent even for photos that are deidentified pursuant to HIPAA standards.
Can Dr. Jones’s office submit Cynthia’s photo
with its claim for reimbursement from Cynthia’s insurer? What about sharing the photo
with residents or other dermatologists at Dr.
Jones’s medical center?
Images containing PHI can be used and
disclosed for treatment, payment, and health
care operations purposes without patient
authorization under HIPAA. Dr. Jones’s
office can therefore include Cynthia’s photo
with documentation supporting its claim
for reimbursement for treating Cynthia. Dr.
Jones could also use the photo in teaching
residents, since education of residents would
be part of the medical center’s health care operations. Likewise, sharing the photos with
other physicians at the medical center for
referral and/or consultation purposes would
be part of the treatment process and exempt
from the HIPAA authorization requirement.
To the extent that PHI is shared for payment or health care operations purposes, Dr.
Jones would need to make sure the photo
included only the minimum necessary PHI.
For instance, the photo that Cynthia sent may
include identifiable features or private body
parts that are not germane to diagnosing her
mole. Those features should be cropped from
the photo before sharing it with residents or
third-party payers. The minimum necessary
standard does not apply to the sharing of
PHI for treatment purposes. Again, Dr. Jones
should check state law to ensure that it does
not require patient consent for the purposes
described in this question.
This article is provided solely for educational and
informational purposes. It is not intended to provide
legal advice and should not be treated as such. dw
Clean Laundry
& Gentle on Skin
Dr. Nussbaum specializes in general and
cosmetic dermatology. She is also a Clinical
Instructor of Dermatology at Weill Cornell Medical
Center. Among her numerous awards are the
Outstanding House Staff Award and the Women
in Science Award. Dr. Nussbaum is a member
of the American Academy of Dermatology, the American Society
of Dermatologic Surgery and the Women’s Dermatologic Society.
Dr. Nussbaum was compensated by Procter & Gamble for her
consultation on this advertorial.
Researchers have found that nearly 45 percent of people report having “sensitive” or “very sensitive” skin.1 Many dermatologists recommend
sensitive-skin patients use a dye- and perfume-free laundry detergent because
dyes and fragrances are considered to be one of the most common causes of
detergent skin allergies.
Each one of us approaches our laundry with the same goal: to clean it.
However, to those with sensitive skin, achieving “clean” has not always been
a straightforward task. “A lot of my patients feel they are sacrificing cleaning
power when using some dye-free and perfume-free laundry products,” said
Dr. Marnie Nussbaum. “As a result, many of my patients compensate by
using scented stain removers or even abandon dye-free and perfume-free
products in order to get their clothes truly clean.” In fact, surveys of patients
with sensitive skin show:
• 80 percent say they are dissatisfied with their current fragrance-free
laundry products and believe they must sacrifice cleaning power for a
detergent that is non-irritating.
• More than four out of five use a pre-treatment to compensate for a lack of
cleaning power.2
More and more dermatologists are now recommending Tide Free & Gentle. New data shows it provides a better clean while being mild on sensitive skin in multiple
dermatologist supervised studies or tests.
How Does Tide Free & Gentle Clean Better?
In tests, Tide Free & Gentle removes more residue from
stains than the leading free detergent. In fact, Tide Pods
Free & Gentle outperform the leading free detergent
on 10 different stains, including blood, coffee and grass
stains, and is mild on sensitive skin.
Tide Free & Gentle’s unique “Lift and Block” technology removes stains and soils to keep clothes clean while
being gentle to skin.
Step 1: Lift
• Deep Clean System: Enzymes break up hard-toremove stains and surfactants lift out stains, dirt and
odor particles down to the fiber level [figure 1].
Step 2: Block
• Anti-Redeposition Technology: Concentrated polymers sweep in to trap the dirt in the wash water, to
prevent it from reattaching to the fabric fibers.
Figure 1: The fabric washed in Tide Free & Gentle is clean
down to the fiber level, demonstrating superior clean ability;
not only removing or lifting stains, dirt and odor particles,
but preventing them from reattaching or redepositing to the
fabrics, wash after wash.
Original image in B&W. Soil has been colorized to show
Misery, L., Sibaud, V., Merial-Kieny, C., & Taieb, C. Sensitive skin in the American population: Prevalence, clinical data, and role of the
dermatologist. Int J Dermatol. 2011;50:961-967.
2010 Habits, Practices and Attitudes conducted by P&G.
Our bodies produce up to 50 grams of body soil
per day, including mucus, dead skin, sweat, sebum and
bacteria. Clothing may look clean, but in a given laundry
load, all that soil combines in the water to create a very
dirty environment. This is important because even if a
stain appears to have been removed from clothing the first
trip through the washing machine, dirt attracts dirt, so any
soil residues left on clothing fibers will cause dirt in the
wash water to redeposit on clothes over time [figure 2]. Dirt
redeposition is a primary reason why whites tend to appear
dingy after numerous washings – not just dye transfer as
is commonly believed.
to be free of dyes and perfumes. Eighty-seven percent of
those who use free detergent use scented fabric softeners or dryer sheets [figure 3]. For this reason, it is critical
to remind patients that caring for sensitive skin doesn’t
stop with detergent; the entire laundry regimen needs to
be dye-free and perfume-free. In fact, fabric softeners that
do not contain dyes or fragrance, such as Downy Free &
Gentle, may have sensitive skin benefits, such as reducing friction between clothes and skin and, therefore, skin
Figure 2: Soil residues left on fibers attract dirt from the
wash water.
As larger high efficiency washers continue to become
the norm in American households, this issue becomes
more pronounced. High efficiency washers use three
times less water so soil is more concentrated in the wash
water, increasing the likelihood of redeposition of dirt on
clothing. However, Tide Free & Gentle’s unique “Lift and
Block” technology provides a superior clean from wash to
wash. Patients benefit from the gentleness of a dye- and
perfume-free detergent without having to sacrifice superior cleaning power.
The Importance of Patient Compliance in a
Laundry Regimen
“I recommend Tide Free & Gentle to my patients because
it drives compliance since it is not only gentle, but provides
a better clean,” says Dr. Nussbaum.
But it’s also very important to remind patients with
sensitive skin issues that the entire laundry regimen needs
who use a
fabric softeners/
dryer sheets
Figure 3: 87 percent of those who use free detergent use
scented fabric softeners or dryer sheets.
Dermatologists Play an Important Role
Dermatologists can help patients ensure they are achieving
the best results for their laundry and their skin. Talk with
your patients, particularly those with sensitive skin, about
their current laundry detergent choices and help them
understand the benefits of following a Free & Gentle regimen. Be sure to recommend products that complement
your patient’s skin health needs while also helping them
achieve the optimal result of clean laundry.
Sponsored by
balance in practice
Movies: Lessons
in dermatology
tackles highlights the special interest or hobby
of a dermatologist. This month DW talked to
Vail Reese, MD, about how he balances his
career in dermatology with his passion for
cinema. Want to be featured, or know someone
who should be? Email
“There was this new thing
called ‘The Internet.’
I looked at this medium
and thought that by
using images and photos
of actors and movies,
this might be the way to
get the word out about
skin conditions.”
18 DERMATOLOGY WORLD // January 2015
ike most dermatologists, Vail Reese,
MD, has been a visual person his
whole life. Dr. Reese — who practices in San Francisco and serves as
assistant clinical professor at the University of California San Francisco — has
always enjoyed movies and conducted
film projects in high school and in college. However, when Dr. Reese was in
the midst of his dermatology residency at
Brown University he started to see movies differently.
“The entertainment that I was
watching all my life was suddenly being
filtered through the perspective of a budding dermatologist,” Dr. Reese said. “I
recognized that filmmakers were using
skin conditions as part of the storytelling.” By the mid ’90s, Dr. Reese encountered a novel outlet to fuse his passion
for cinema with his chosen profession.
“There was this new thing called ‘The
Internet’,” Dr. Reese remembers. “I
looked at this medium and thought that
by using images and photos of actors
and movies, this might be the way to get
the word out about skin conditions.” In
1996, was born.
On his website, Dr. Reese files film
actors and characters under three main
categories — all of which offer critical
lessons for patients, the public, and
dermatologists alike.
Category 1: Actors with skin conditions
By highlighting actors with moles, acne,
skin imperfections and skin conditions,
Dr. Reese hopes that physicians will be
better equipped to show patients that
they are not alone in dealing with their
conditions. Actor Richard Gere has a
Becker’s nevus on his back. “If a patient
comes in at age 14 and suddenly has this
management insights
dark spot on the chest, I explain that a Hollywood actor
— who has this same type of mark — has had romantic
leads in many movies.”
In The Da Vinci Code, the antagonist had albinism.
Dr. Reese worked with the National Organization for
Albinism and Hypopigmentation on a media campaign that attempted to dispel some of the myths about
Category 3: Protagonists with skin conditions
Dr. Reese also highlights sympathetic movie characters
with skin conditions (such as The Man Without a Face)
on because he believes that these movies
can remind the public and physicians of the emotional
toll that skin conditions have on their patients. “These
movies are rare, but when they do come out, I find them
Dr. Reese earned the ‘Best Website’ award at the AMA
International Medical Film competition in 1996 for www.
Category 2: Evil characters with skin conditions
Dr. Reese has found that for decades, skin conditions
and imperfections have been utilized by filmmakers to
subconsciously persuade their audience to believe that
the character is evil. “That’s one of the things that I try to
dispel on my website: people with scars, psoriasis, and
skin conditions aren’t evil. I use the website to describe
the nature of the skin condition.”
Dr. Reese worked with actor John Cleese on a BBC miniseries documentary titled The Human Face in 2000,
which analyzed the science behind facial beauty.
Dr. Reese meets with former Surgeon General C. Everett
Koop at the International Medical Film competition dinner
in 1996.
Throughout the almost 20 years since Dr. Reese started, he has done all of the writing, coding,
and Web design himself. He does not advertise on the
site and doesn’t track data related to the site’s traffic. “It
really has been a labor of love and a personal project
rather than a corporate thing.” Dr. Reese earned the
AMA media award for in 1997 and
has also been featured in several documentaries. For
more on Dr. Reese and his website, including more
examples from each of his three categories, visit www. dw
DERMATOLOGY WORLD //January 2015 19
answers in practice
Managing staff
relationships and
cultivating a
culture of growth
in your practice
Dermatology World talks with Jeffrey Dover, MD, about
how SkinCare Physicians manages staff relationships
and cultivates a culture of growth among staff
you describe the culture/environment
in your office?
DR. DOVER: SkinCare Physicians was founded
14 years ago with a goal of creating a state-ofthe-art dermatology practice that provides the
highest quality dermatologic care possible. The
original mission statement of SkinCare Physicians was “to deliver unparalleled personalized
service along with ethical, skilled, and comprehensive dermatologic care.” While this vision
and mission have not changed over the years,
we have found shorter mantras that are easier
for all of us to remember and that we use on a
daily basis. These include:
• Put the patient first.
• Figure out a way to say yes to patient
• Don’t just meet expectations, exceed them.
• Do ordinary things, extraordinarily well.
• Create a warm and welcoming environment.
• Treat staff with respect.
• Commit ourselves to excellence in all
Meticulous attention to the quality of
patient care, the work environment, and the
quality of life and work at SCP has resulted in
the long-term retention and good will of our
employees in a cooperative and warm office.
Most of our original staff from the time the office was established 14 years ago remain loyal
and happy colleagues.
How do you encourage and cultivate
good staff relations among SCP’s 14
DR. DOVER: One of the driving principles that
helps us succeed as a large group is that we
build consensus and make unanimous decisions that are good for all those in the practice.
Our brand identity is that we deliver outstanding care in all aspects of dermatology, not just
aesthetic or surgical dermatology. We pride
ourselves on being able to offer state-of-theart care in medical-pediatric, adult, geriatric,
procedural, and aesthetic dermatology, and we
20 DERMATOLOGY WORLD // January 2015
management insights
teach fellows and students and carry out
clinical research. We have monthly board
meetings with all nine partners and the
chief operating officer where we discuss
all financial, strategic, and operating matters of the practice, including our mission.
We make sure all of our decisions, which
are made in consensus, fit into our practice mission and culture.
How many non-physicians/
administrative staff members do
you employ, and how do you ensure that
the physicians and other staff are
effectively communicating?
DR. DOVER: We employ 73 people excluding physicians and fellows. In total, the
organization employs 90 people. With
this many staff, it is essential to have open
lines of communication. We have monthly
Operations Committee meetings which
are attended by the physician staff and all
management. From information acquired
in that meeting, each manager can ensure
that their teams are updated and informed. We also have an open-door policy
in which any employee can stop in and see
any physician or management office with
any question, concern, or just to say “hi” at
any time. We also try to have fun activities
for everyone in the office on a regular basis throughout the year to create an open,
warm, and friendly environment for staff.
Do you have an incentive
compensation bonus program
and/or annual reviews of support staff?
DR. DOVER: We have a performance
management program that includes annual reviews, merit increases, and a bonus
program. These incentives are constantly
being reviewed and updated as needed,
depending upon the local market and the
overall goals the organization sets for the
year. Investing in staff performance is one
of the most important aspects that drive a
productive work environment.
What practice management
training and education do you
provide your administrative staff on a
regular basis?
DR. DOVER: Training in practice management is essential in our organization.
It ensures improvement in employee
performance, satisfaction, increased
productivity, and enhanced quality of
service; it also reduces costs. We have
created a well-organized training and
development program at SkinCare
Physicians for our practice management system and our EHR software,
providing staff with constant knowledge
and experience. The program’s fundamentals begin during our orientation process, where staff acquires the
practice management skills required for
specific tasks. Training and education
start from the moment an employee is
hired, by assigning them a team leader
as a mentor, and it continues through
their three-month introductory period.
Consistency is vital when it comes to
an organization’s practice management
training. Daily operational and practice
management procedures are outlined in
our training manuals for staff reference,
and hands-on training is provided daily
by team leaders/management. Meetings
and educational in-service gatherings
are also provided to staff.
Our billing staff also has access to
the AAD Derm Coding Consult, Dermatology World’s Cracking the Code
column, CMS (Medicare) news, and
the Medicare Learning Network for hot
topics and reimbursement issues. The
Dermatology Reimbursement & Business
Journal is also a reference to keep staff
current. Staff also attend network and
hospital health plan orientations for
individual carriers, and review new
trends including denials, changing
reimbursements, and authorizations on
a daily basis.
SCP offers a wide range of services
and procedures. What kind of
education and training do you provide
your staff on these procedures?
DR. DOVER: Staff is sent to regional and
national medical meetings but perhaps
more importantly, we have monthly inservice sessions presented by our medical
staff for our entire clinical staff during
which a host of topics on patient care —
and new and modified procedures — are
presented, demonstrated, and discussed.
Administrative staff who schedule appointments and work with patients also
have regular in-service gatherings as well
as customer service training sessions.
Beyond CME, what type of
training, education, seminars, and
conferences are physicians on staff
encouraged to participate in and why?
DR. DOVER: We encourage our medical
staff to attend regular meetings such as
those of the Massachusetts Academy of
Dermatology, the Massachusetts Medical
Society, and the New England Dermatologic Society. Staff also attends national
meetings for the American Academy
of Dermatology, American Society for
Lasers in Surgery and Medicine, and
American Society for Dermatologic
Surgery, as well as smaller specialty meetings such as Controversies and Conversations in Laser and Cosmetic Surgery and
the Dermatology Foundation Clinical
Meeting. A variety of international meetings are also attended. dw
JEFFREY DOVER, MD, is associate clinical
professor of dermatology at Yale University School
of Medicine, clinical professor of surgery at
Dartmouth, Geisel School of Medicine, and adjunct
associate professor of dermatology at Brown
Medical School. Dr. Dover practices in Boston as
co-director of SkinCare Physicians and serves on
the Academy’s AgingSkinNet Workgroup and as an
editorial advisor to Dermatology World.
DERMATOLOGY WORLD //January 2015 21
22 DERMATOLOGY WORLD // January 2015
or 30 years, physicians have been using the same language when classifying diagnoses. In ICD-9, acne diagnoses have always been classified as 706.1. However, that language will change completely with the
implementation of the new ICD-10 diagnosis classification system this fall. For
an acne diagnosis, physicians will now have to choose from eight codes. “Something like folliculitis, which has one code in ICD-9, now has almost 25 codes in
ICD-10,” said Michael Sherling, MD, co-founder and chief medical officer at
Modernizing Medicine — creator of EMA, a specialty-specific electronic health
record system. “An insect bite, which has one code in ICD-9, has 180 possibilities in ICD-10. Benign nevi — which have maybe nine codes in ICD-9 — now have
more than 20 in ICD-10.” Indeed, while ICD-9 has 13,000 codes, ICD-10 will have
more than 68,000.
Moreover, ICD-10 is a complete restructuring of the diagnosis coding system
and will include more alpha-numeric codes to allow for greater specificity of
diagnoses. “One of the more difficult parts of this transition is that there is
absolutely no relationship at all between ICD-9 and ICD-10,” explained Mark
Kaufmann, MD, a member of the Academy’s ICD-10 task force. “So we will all
have to forget everything we ever knew about ICD-9.” It’s not just dermatology,
however, that will be affected by the big switch. On Oct. 1, 2015, all HIPAA-covered entities will be required to implement the ICD-10 diagnosis classification
system, or they will not get paid. >>
DERMATOLOGY WORLD // January 2015 23
Unfortunately, according to an August 2014 poll of 514 health
care organizations and providers conducted by the Workgroup
for Electronic Data Interchange (WEDI) — a nonprofit
health information technology coalition that advises the U.S.
Department of Health and Human Services (HHS) — only about
50 percent of provider groups have conducted an assessment
of how the ICD-10 switch will impact their practice, and only
one-third of providers have started external testing of the ICD-10
software, even after two postponements of the implementation
deadline. In a letter to HHS, WEDI Chairman Jim Daley said,
“While the delay provides more time for the transition to ICD10, many organizations are not taking full advantage of this
additional time. Unless all industry segments make a dedicated
effort to continue to move forward with their implementation
efforts, there will be significant disruption on Oct. 1, 2015.”
Despite the urgency of the impending ICD-10 switch, experts
suggest that the key to a seamless ICD-10 transition is
preparation, boiled down to bite-sized, manageable portions.
“Don’t panic,” said George Hruza, MD, who practices in
Chesterfield, Missouri, is president of the American Society for
Dermatologic Surgery, and serves on the Academy’s Board of
Directors. “It’s not the end of the world. Just become informed
and don’t bury your head in the sand.”
Taking stock
Like any big change in a physician’s practice — whether hiring
another physician or building out the office space — the process
by which physicians transition to ICD-10 will require a close look
at where the practice stands operationally and financially.
Physicians should begin by evaluating the current system
used for recording their diagnoses. For physicians using an EHR
system, it will be important to work with their vendor to ensure
that the system is up to par. Some experts contend that it will
be extremely difficult for physicians to manage ICD-10 without
an EHR system. “I think that is going to be very challenging.
If you don’t have an EHR system, you will probably need to
hire someone who is very well-versed as a coder,” said Arturo
Saavedra, MD, clinical medical director of the dermatology
department at Massachusetts General Hospital. With so many
codes, experts agree: it will be difficult to memorize even the
most common dermatologic codes. “Learning all of the ICD10 codes — even just the ones commonly used in dermatology
— would be an impossible feat,” Dr. Kaufmann said. “A good
place to start would be a crosswalk available from the AAD. This
four-sided laminated piece contains the most commonly used
dermatology codes.” (Learn more about available resources in the
sidebar on p. 26.)
However, according to Jeffrey Queen, president of Integrated
Dermatology Group (IDG) — a company that operates
dermatology practices throughout the continental U.S. — allpaper practices will manage to get by. IDG has many dermatology
practices that are sticking with paper because of where the
physicians are in their careers. As a result, using information that
they have collected from their practices, IDG created an ICD-10
superbill that only shows the most common dermatologic codes,
broken down by body location. “We find that the majority of our
dermatologists use the same 80 percent of the codes during their
regular day. About 40 percent of the new codes represent body
location,” Queen said. “So we’re making the superbill easy, and
each practitioner can customize it.”
In addition to documentation needs, physicians will need to
consider the capacity of their staff, and how much of a burden
the transition will be on everyone — physicians included. “The
transition is going to be very challenging and that’s where staff
education will come in,” Dr. Hruza said. “The staff in your office
needs to get comfortable and familiar with this. Otherwise it’s
going to be a big mess. Have meetings with the staff, mainly so
that they’re not so worried.”
If possible, it may be helpful to appoint a willing staff
member to lead the ICD-10 transition so the physician’s time is
While the transition to ICD-10 will affect specialties across the board, the switch will
also affect various practice settings regardless of their size, scope and configuration.
DW asked two large health systems how they are handling ICD-10 implementation.
The Mayo Clinic started planning for the ICD-10 classification system in 2009.
With both its outpatient and inpatient areas, Mayo worked backwards and had its
physicians and their support staff choose diagnoses in ICD-10 terminology. Behind
the scenes the terms map to an ICD-9 code and an ICD-10 code. For now the ICD10 mapping is not being used, but will be turned on, and the ICD-9 code turned off,
on the final effective date of implementation. Mayo asked physicians to begin documenting and recording their diagnoses with
the specificity required for ICD-10, which familiarized them with the new language before the actual required switch. “In the
outpatient area, we developed a list of terms that doctors normally use and then linked them to the correct billing codes behind
the scenes. We used diagnoses that we currently used and expanded to right, left, bilateral, initial, and subsequent,” explained
Jeffrey Thompson, MD. “Our philosophy at Mayo is we don’t want our doctors to be coders,” explained Janice Graner, Mayo’s ICD10 system-wide conversion administrator. “We try to use terms they are familiar with and learned in medical school rather than
24 DERMATOLOGY WORLD // January 2015
not diverted from patients. However, choose your ICD-10
project manager wisely. According to Dr. Saavedra, the ICD10 administrative burden could create a morale issue. “There
are already a lot of onerous requirements on physicians
in terms of documenting and billing. There has been so
much change that what tends to happen is that people get
overwhelmed.” Consequently, physicians should evaluate
whether they, or their staff, have the time and are willing
to lead the ICD-10 transition plans, and if not, whether the
practice can afford to hire additional staff to do so.
Developing a strategy and timeline
Once the physician has assessed the practice’s capital and
its needs, Dr. Hruza recommends creating a strategy to get
ready for the Oct. 1 deadline. Also, “build a timeline of steps
to get there,” Dr. Hruza said.
David Henriksen, CEO of Nextech — a specialtyspecific EHR provider — advises physicians to talk to
their peers when building their own strategies. “Talk to
another practice or provider, your fellow AAD members,
residency partners, and people in your local communities,”
Henriksen said. “Engage with someone who has gone
through the process — the upgrade, the test transmission,
the communications and transition — and you will get
comfortable with moving forward.”
According to Dr. Saavedra, Massachusetts General
started its transition strategy with an assessment of all of
the specialty groups to determine the departments that
would be most affected. Dermatology was one of them
so they developed a transition plan and timeline that
incorporated more direct planning and training. “Our
hope is to do this in three stages. We set up strategic
plans for each division, which included programs to help
clinicians train on ICD-10 issues,” Dr. Saavedra said.
In April, the department will hold face-to-face meetings
with the heavily impacted divisions to ensure that the
transition plans are running smoothly. “Around August
and September we will reconvene with faculty for a review
session and ask them what have they learned and what
steps remain.”
Evaluating your vendor
For the majority of physicians, the linchpin in ICD-10
preparation is ensuring that their EHR software is ICD-10
compliant and that the vendor has a defined rollout plan.
“Then you need to keep up with the vendor to make sure
they are updated and prepared,” Dr. Hruza advises. “They
have to put all of those codes into the system. Then they have
to have some easy way to look up the codes such as a robust
search engine. The mapping of the codes is very important.”
According to Henriksen, physicians should start the
conversation with their EHR software vendors about ICD10 preparedness if they have not been contacted already.
“The sooner, the better,” Henriksen said. “If you wait to
upgrade and you wait to get trained until the last minute, the
transition is going to be harder than if you’re thinking about
it now.” First and foremost, physicians should ask if the costs
of the ICD-10 software upgrade will be included in their
annual support and maintenance contracts. If not, it may be
time to review other software vendors and find out what they
have to offer. “Physicians need to be educated on whether or
not the vendor solution is simply putting the burden back on
the doctor,” Dr. Sherling said. “Everyone needs to ask their
vendor: ‘Do you have an ICD-10 solution for me? Do I have to
pay for it? How much time is it going to take me?’”
Additionally, communication and training are key. Is
the vendor in constant contact with you? Does the vendor
offer literature, webinars, and other training opportunities
for its customers? When can you test the system with the
clearinghouse? “The ideal scenario would be for your vendor
to let you use the system before Oct. 1 so you can test drive
it and actually see if it works as advertised,” Dr. Hruza said.
coding language. We worked with each of our clinical departments to choose the terms that they were most comfortable with and
that matched the specificity needed for ICD-10.”
Like Mayo, after a comprehensive two-year review, Kaiser Permanente’s (KP) diagnostic terminology was also overhauled to
help clinicians get accustomed to using the new terminology required under the ICD-10 language. According to KP, more than
60 percent of its physicians have been trained on the new terminology and are already using it comfortably. “The learning curve
was rapid, and in spite of anxiety about the new code set, the response has been largely positive,” said Bryan Matsuura, executive
director of the ICD-10 Program at KP.
With more than 17,000 clinicians practicing in hospitals and multi-specialty medical offices across the country, KP established
work groups to assist each different clinician group with the transition. “Kaiser Permanente is in the unique position of
experiencing the impacts of ICD-10 in our physician organization, our hospitals, other care delivery settings, and our health plan
operations,” Matsuura said. “We have a comprehensive ICD-10 implementation plan to ensure readiness in all areas, including
information technology remediation, changes to our KP HealthConnect® Electronic Health Record and Convergent Medical
Terminology (CMT), updating reporting systems, policies, and workflows, and role-based training. We are firmly on track to
achieve ICD-10 compliance by Oct. 1, 2015.”
DERMATOLOGY WORLD // January 2015 25
“You don’t want to just go live on Oct. 1 without having tested it.
You want to have a process in place in the office where you can
trial-run the system.”
what the error message is that came up so that they can go back
and look at their programming.”
Scheduling dress rehearsals
As such, once the physician has a grasp on what the vendor
offers, they should incorporate testing periods into their
transition timeline. Dr. Saavedra believes that it is extremely
important to schedule time to test the software with private
payers and the Centers for Medicare and Medicaid Services
(CMS) throughout the transition process. “Do this along the way.
We’re bound to make mistakes and we’re not going to get it right
the first time, so we want to make sure that we’re adaptable.”
CMS will be offering end-to-end testing weeks March 2-6 and
June 1-5, where physicians can test and verify that their ICD-10compliant claims can be transmitted successfully through CMS.
(For more information about the CMS end-to-end testing, visit All Medicare Administrative Contractors
(MACs) will provide updates through listserv messages and
websites, so it will be important for physicians to pay attention.
“We want to make sure on our end that our EMR properly
transmits to the clearinghouse,” Dr. Hruza said. “The CMS trial
runs will be very helpful because if we send a claim all the way
through them, we know that our pathway is correct.” When
reaching out to private payers, “pick your top three payers and
make sure that they’re comfortable with what they’re doing and
if there’s anything they need you to do in terms of testing,” Dr.
Hruza said. And if, for some reason, the trial run fails it will be
up to the vendor to fix the issue. “Let the vendor know exactly
The number-one objective for physicians before Oct. 1 is to
organize their practice. However, it’s also important for the
physician to mentally prepare for the changes and challenges
that lie ahead. According to Dr. Kaufmann, one of the key
components of ICD-10 readiness is accepting that the ICD-10
switch will occur. “CMS has been gearing up for this changeover
for the last few years already, and has no plans to abandon it,”
Dr. Kaufmann said. “While Congress did delay ICD-10 last year,
there is no reason to believe that this will happen again.”
Thinking about specificity
Although the impact of the ICD-10 switch will be felt across the
board, the effects will vary depending on the type of medicine a
dermatologist practices. According to Dr. Hruza, Mohs surgeons
will be affected significantly because the ICD-10 codes require
the physician to account for laterality of procedures. However,
“it’s really your general dermatologist who is going to be affected
most because they see a broad range of diagnoses,” Dr. Hruza
said. “Now, you may have hundreds of unique diagnoses. With
ICD-10, diagnoses are going to be expanded to thousands.
However, it’s still not going to be easy for anyone.” Dr. Sherling
agreed. “For a drug rash, in ICD-9 you only need one code. Now
you need not just the fact that you have a drug rash which is a
separate code in ICD-10, but what drug caused it. If you have a
patient with an infection, and you know what bacteria caused it,
you have to put that ICD-10 code in there.” As a result, physicians
should start considering the specificity of their cases to align their
With less than a year to get ready for ICD-10, providers will need to act immediately to avoid significant financial disruptions on
Oct. 1. “I think sometimes we hope that issues will go away and that we won’t have to deal with them,” said Arturo Saavedra,
MD, clinical medical director of the dermatology department at Massachusetts General Hospital. “However, ICD-10 is not an ‘if,’
it’s a ‘when,’ and we should all be prepared.” The Academy suggests the following 10 steps to make sure your practice is fully
STEP where the practice currently stands, and where it needs to be before Oct. 1.
Depending on the size of the practice, identify an internal project leader who has the authority to assess and manage
needs to be done.
timeline, working backward from Oct. 1, that includes a monthly plan to track progress.
STEP that there is a budget to cover transition costs. This budget should include costs associated with the
purchase of upgrades to your EHR system, as well as any additional costs associated with hiring more staff.
your vendors’ plans for converting to ICD-10 — what software upgrades are necessary, what is covered
by your current software license contract(s), and what, if any, fees will be assessed.
Find out when to expect software upgrades.
26 DERMATOLOGY WORLD // January 2015
thinking with the new diagnosis requirements of the ICD-10
coding set.
Bracing for opportunity costs
For many physicians, the costs associated with the ICD10 transition will not necessarily be tangible costs, such as
paying for a new EHR system. However, physicians should
expect to endure significant opportunity costs at the front end
of the switch. “The costs are mostly indirect in terms of lost
productivity,” Dr. Hruza said. “To get all of the data entry right,
it will take more hours of time, which does cost money. You
might have to do one less case per day.” Dr. Kaufmann agrees
and adds, “Staff training is where the costs will begin. But that
cost will be much less than not adequately preparing for the
changeover. Denied claims and lost productivity will be much
more expensive.”
Anxiety is high and it is clear that it will take time to adjust to
ICD-10. However, experts reason that while headaches may
initially occur, in the long run the ICD-10 classification system
will have its perks.
Jeffrey Thompson, MD, of the Mayo Clinic — who serves as
associate professor of physical medicine and rehab and ICD 10
physician leader, and worked alongside Janice Graner, Mayo’s
ICD-10 system-wide conversion administrator, to prepare for the
transition — believes that, given the specificity required by ICD10, the new system of classification will improve the efficiency of
medical research. “The new code set will be able to describe more
accurately and differentiate the complexity [of cases] we have,” Dr.
Thompson said. He recalled reviewing a paper that evaluated the
outcomes of hip replacement on a population basis. However, the
diagnostic coding did not include laterality — indication of which
hip underwent surgery. Therefore, they could not determine
which x-ray matched up with the affected hip because it wasn’t
coded. “Having that extra information will be very valuable in
research and in clinical care.”
Dr. Saavedra agrees, and believes that ICD-10 will also
help physicians manage patient conditions over time. “It will
discriminate conditions and geographical areas that are affected
in the body, whether it’s face, arms, or legs,” Dr. Saavedra said.
“So I think it will help you clinically because it will remind you
where the problem was in a patient.”
In addition to improving research and patient care, Dr. Hruza
believes that having more specificity in diagnoses will help
physicians if faced with economic credentialing by a payer. “They
may decide you cost more than someone else even though you
may be treating sicker patients,” Dr. Hruza said. “The benefit
of having more robust coding is that the claims data has much
more granular information, so it makes it more possible to tease
out why you are more expensive — for example, do you treat a lot
of skin cancers on the tip of the nose? You can use these data to
defend yourself.”
Regardless of whether ICD-10 will prove beneficial to
physicians, or simply cause administrative nuisances, experts
agree that accepting and adapting is the best approach when
preparing for the Oct. 1 deadline. “One of the important things
to remember is that this probably won’t be the last update and it
will not be the last challenge in terms of expectations of doctors,
and it’s a good opportunity to test our abilities to be nimble,” Dr.
Saavedra said. “This is a situation that we should be prepared to
manage, or it will manage us in return.” dw
Once the software upgrades are complete, test and verify that ICD-10-compliant claims can be transmitted successfully to the practice’s clearinghouse and payers. CMS will be offering end-to-end testing weeks March 2-6
and June 1-5. Visit
when-is-the-cms-end-to-end-testing-period-for-icd-10 to learn more.
If the practice submits paper claims, research and select printed reference resources to help staff prepare. The AAD
offers an ICD-9 to ICD-10 crosswalk. This four-sided laminated piece contains the most commonly used dermatology
codes, and costs about $20. The AAD’s 2015 Coding and Documentation Manual for Dermatology also includes an
alphabetical index of ICD-10 dermatology diagnosis codes, as well as an ICD-10 implementation overview with
examples of code changes. Learn more at
Once the software upgrades are complete and functioning, assess and hold training sessions for the staff who will be in charge of managing your practice’s coding through your paper or EHR systems.
Develop a comprehensive and ongoing outreach plan to all business partners — your clearinghouse, Medicare
contractors, state Medicaid agency, and private payers — to discuss requirements, changes, timing, and the effect of
ICD-10 on the processing of your claims.
The Academy has developed numerous resources to help members get their practices organized for the ICD-10 shift. Learn more
about these 10 steps to ICD-10 preparedness, and access other tools and resources, at
DERMATOLOGY WORLD // January 2015 27
Changing health care landscape prompts
reappraisal of general dermatology
28 DERMATOLOGY WORLD // January 2015
leven years ago, said Mitchel P. Goldman, MD, volunteer clinical professor
of dermatology at the University of California, San Diego School of Medicine,
his practice was a mix of skin cancer surgery, general dermatology, and cosmetic procedures. But, he reports, “insurance companies were not only decreasing
what they would reimburse, but also continuing to question what I was doing, and
demanding more documentation, to the point where it wasn’t unusual for me to be
three months in arrears on insurance companies paying me for things that I’d done.”
After absorbing a $400,000 loss on a laser procedure he developed to treat varicose
veins, Dr. Goldman, who is immediate past president of the American Society for Dermatologic Surgery, decided “enough’s enough. That’s when I went to a 100 percent
cash cosmetic practice. Finally, I could spend time with my patients, and I didn’t have
to have three billing staff for every doctor.” And he’s not alone, he maintained: “More
and more dermatologists are becoming cash cosmetic or practicing what we call
‘concierge medicine.’”
Dermatologists who don’t perform complex surgical procedures may be facing even
stiffer headwinds from insurers, as reimbursement rates for cognitive work drop and
companies resist paying for costly drugs like biologics. “While it’s become a more
challenging time for medical dermatology, in many ways it’s also a more rewarding
time, because the treatments we have are so much better than what we used to have,”
said Mark Lebwohl, MD, Sol and Clara Kest Professor and chairman of dermatology at
the Icahn School of Medicine at Mount Sinai and president-elect of the AAD. “We have
medicines that can clear almost everyone, and they work for conditions that we’ve had
difficulty treating forever. But they’re not approved for those conditions, and they’re
expensive. So we have to fight with insurers to get them. That’s why cosmetic dermatology is so appealing to some; nobody went into dermatology to write letters to insurance companies.”>>
DERMATOLOGY WORLD // January 2015 29
In addition to declining reimbursements, battles
with insurers, and high price tags for dermatologic
drugs, general dermatologists are burdened by the same
regulatory requirements that other physicians face,
and the ensuing cost of additional administrative staff.
“There’s a lot of personal time and staff time spent on
reporting for various government agencies and getting
approvals from insurers for medications and procedures,”
said Elizabeth Martin, MD, a dermatologist with a private
practice in Hoover, Alabama. “In the future, I think the
time demands will increase, and the need to include
qualified, skilled individuals as part of your team is a
critically important component of affording physicians
time to care for our patients.” Risa M. Jampel, MD, a
private practitioner in Owings Mills, Maryland, agreed
that rules around HIPAA compliance, the transition to
ICD-10 coding, and the PQRS quality measures “have
just gotten really stifling and time-consuming. And yes,
reimbursements have gotten very low. I think it’s getting
incredibly difficult.”
Are general dermatologists running for the exits? Not
yet. There’s a strong demand for dermatologists’ unique
expertise, and those who can change the way they practice
to adapt to the new environment will likely continue to
thrive, said veterans from a broad range of practice types.
In Dr. Goldman’s view, general dermatologists can only
make a profit by hiring a nurse practitioner or physician
assistant “who can spend the time with a new acne patient
or a new psoriasis patient, so the physician can do other
things at the same time. It’s not unusual for some of my
colleagues to have two or three physician extenders in
their office, so it’s almost like having six hands instead of
two. The societies representing dermatologic NPs and PAs
have grown exponentially in the last 10 years because most
of my colleagues are utilizing these extenders.”
Adding non-physician clinicians to a practice, as an
alternative to seeing more patients in a limited amount
of time, is becoming increasingly common, said Henry
W. Lim, MD, chairman and C.S. Livingood Chair of the
department of dermatology at Henry Ford Hospital.
“This is the model we’ve adopted in our department,” he
remarked, noting that the AAD’s most recent Practice
Profile Survey data shows that more than 40 percent
of dermatologists have done the same, with 50 percent
adoption likely in the near future.
Another prominent academic dermatologist
maintained that the trend toward hiring non-physician
clinicians has more to do with improving access than
boosting profits. “The demand for our services is far
outstripping access in most areas of the country,” said
Karen Edison, MD, chair of the department of dermatology
and Philip C. Anderson professor of dermatology at the
University of Missouri School of Medicine. Non-physician
clinicians, she said, “are hired to help extend expertise and
access. That’s the driver.” Expressing a more sanguine
view than many of her colleagues, Dr. Edison insisted that
As seasoned dermatologists tweak their practice patterns to stay profitable, today’s dermatology residents are
embracing general dermatology with eyes wide open, say the chairs of three dermatology departments. But the
way they plan for and launch their careers has changed with the times.
“A lot of them are fearful of the future,” said Mark Lebwohl, MD, Sol and Clara Kest Professor and chairman
of dermatology at the Icahn School of Medicine at Mount Sinai. “In the old days, a lot of residents would go out,
open their own offices, hang out a shingle, and be successful. You can’t do that anymore because now you need
a HIPAA officer, an EMR, all those things that make it difficult to be in solo private practice as a dermatologist.
Many of them are trying to increase the amount of cosmetic dermatology exposure they get because it’s more
lucrative. There is still a core that’s enthusiastic about medical dermatology, but they’re headed to academic
dermatology positions, multi-specialty practices, and single-specialty group practices.”
Another chair observed that her residents are aiming to be more versatile. “One of the changes we’re
seeing is that the young people who are interested in surgery are more likely to also be wanting to do
general dermatology along with that surgical practice,” said Karen Edison, MD, chair of the department of
dermatology and Philip C. Anderson professor of dermatology at the University of Missouri School of Medicine.
30 DERMATOLOGY WORLD // January 2015
despite a “squeeze on some of our codes, we still have the
capacity to make a very robust income in most parts of the
country. General dermatology is alive and well in the U.S.”
AAD President Brett M. Coldiron, MD, a Mohs
surgeon in private practice in Cincinnati, noted that
some NPs and PAs are setting up their own dermatology
practices, and that others are working without proper
supervision in dermatologists’ offices. “I don’t have a
problem with physician extenders if they are supervised,
but we’re seeing NPs and PAs operating without
supervision, patients are booked into the practice and
never see an MD. Frankly, it is deceptive, and perhaps it’s
consumer fraud if a patient makes an appointment to see
a dermatologist and never sees one.” Dr. Jampel noted
that there are dermatologists in her area who “have the PA
doing the majority of the medical dermatology, while they
do primarily cosmetic procedures. I had an extender at one
time; I supervised her very closely and it was a tremendous
time commitment. I don’t now, and don’t plan to replace
her. I think that puts me in the minority.”
Without going quite as far as Dr. Goldman did in moving
to a cash-only cosmetic business model, many general
dermatologists are incorporating cosmetic procedures
into their practice as a way of subsidizing their medical
dermatology. “It’s not all gloom and doom; I think
aesthetic medicine offers a way to stay competitive in
general dermatology,” Dr. Coldiron said. “I think general
dermatologists ought to look at learning some aesthetic
procedures, and I think most all of them do. If things get
bad, that’s what you can do.”
“Cosmetic dermatology is an area that we continue to
use to supplement the economic model in running the
department,” Dr. Lim said. “But that change [to more
cosmetic dermatology] occurred quite a few years ago.
Those dermatologists who did not learn the procedures in
their training, because toxins and fillers didn’t exist then,
have already learned by now. The more recent graduates
already know how to do it because it’s an integral part of
any training program. But it’s important to keep in mind
that depending on the location of the practice, there is a
finite number of patients who have the ability to pay for
those procedures.”
Dr. Martin said that while cosmetic procedures “are
nice, because it’s cash pay, I’m enjoying what I do with
medical dermatology. I haven’t felt the need to have an
entirely cosmetic practice in order to make ends meet.
Does it help supplement the income for the practice? Yes,
it does.”
Another model embraced by a select group of general
dermatologists is to accept only patients who can pay out
of pocket. “A very small percentage of dermatologists,
usually only in large cities like Los Angeles or New York,
can go to that model,” Dr. Lim said. “Few places have
enough patients who can afford this type of cash payment
to see the ‘top doctors.’” Maurice Thew, MD, a private
practitioner in Wilmington, Delaware, predicted that
“I think they’re recognizing that some of the highly specialized services we provide, such as Mohs surgery
and dermatopathology, may not always have protection of those heretofore generously reimbursed codes.
Residents are going into them, but maybe with the thought that they’ll do two days of surgery and two or three
days of general dermatology clinics. They’re more likely to want to be more broadly specialized, not limiting
themselves to just a few codes,” Dr. Edison said.
Multispecialty group practices and academic medical centers are offering more and more opportunities for
residents, said Henry W. Lim, MD, chairman and C.S. Livingood Chair of the department of dermatology at Henry
Ford Hospital. “Many of the large group practices and academic medical centers are either purchasing practices
or opening up satellite clinics because the financial pressure is such that they need to get new patients into their
system. With that comes jobs for the new residents.” Although some residents are interested in the “core mission
of the academic department, teaching and doing research, many of the positions in academic medical centers are
primarily clinical,” Dr. Lim said. Regarding the focus of their work, “the good part I see is that there is a balance
of residents wanting to pursue careers in medical, surgical, and cosmetic dermatology. Our specialty attracts
such high-quality people, and I’m very gratified to see that we have excellent physicians graduating from training
programs across the country who cover all aspects of dermatology.”
DERMATOLOGY WORLD // January 2015 31
Epiphanies in
that Changed the Course
of Careers and the
Face of Dermatology
Going to World Congress?
Join us for a unique course taking place
before the 23rd World Congress of
Dermatology in Vancouver, Canada.
Monday, June 8, 2015
Speakers will discuss a significant event
in their career that helped change the
face of dermatology.
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to register.
Copyright © 2015 American Academy of Dermatology. All rights reserved.
32 DERMATOLOGY WORLD // January 2015
due to the shortage of dermatologists in many areas,
more will gravitate to a cash-only practice: “They’ll
be beholden to nobody else, unrestricted, and in fact
you can do very well. The reality is that nobody knows
dermatological problems like dermatologists.”
Alternately, some mid-career and older
dermatologists in one- or two-physician practices are
approaching hospitals in an effort to integrate with the
larger institution, Dr. Lim said. “The large institutions
are developing into health care systems, so they have
to have more patients to make their economic model
work. At the same time, dermatologists are interested
in joining a larger institution, either full time or on a
contractual basis, in order to ease the administrative
Despite a practice environment fraught with insurance
and regulatory hurdles, seasoned dermatologists
predict a bright future for general dermatology. The
demand for dermatologists’ expertise will continue
to grow in the face of a national epidemic of skin
cancer, Dr. Coldiron said. “Dermatologists are needed.
We have a critical fund of knowledge,” he remarked.
“We’re going to push back against these insurance
companies, and I think the pendulum will swing
back our way. The current turmoil [due to health care
reform legislation] is artificial and temporary. They’re
bottling up demand. These skin cancers won’t go
away; they won’t get better on their own.”
Advances in medicine, in both general and
cosmetic dermatology, have greatly enhanced the
value of dermatologists’ expertise, Dr. Lebwohl
said. “The innovations in cosmetic medicine that
have come from dermatology have really positioned
us to be the front-line deliverers of cosmetic care,
and insurance plays no role there. So that, in some
ways, protects us from all the awful things that are
happening in medicine. Dermatologists will always
be needed; we will never be replaced by computers or
robots. The hurdles to prescribing medications, the
challenges to reimbursement, are difficulties it is our
job to overcome.”
Dr. Martin views the future of medical
dermatology as “still very bright, because no one
else has the expertise and the ability to care for these
patients in the way that we’re able to in an outpatient
clinic setting. However, for the specialty to survive,
we need to continue to participate in our medical
communities. That means being available to other
physicians for consultations, in outpatient clinics
and in the hospital, and getting involved in our local
and state medical societies. We need to have a seat at
the table in all of those arenas so that our colleagues
see that we are interested and engaged in the care of
patients.” dw
WCD2015 is presented under the auspices of the
International League of Dermatological Societies.
The ILDS has 157 national and international member
organizations including the AAD, ASDS, and SID.
clinical pearls
and tips from
around the
Late-Breaking Abstracts
open for online submission
on our website until
January 31, 2015.
heal thyself
Breaking the cycle of going to work sick
34 DERMATOLOGY WORLD // January 2015
ou wake up with a sore throat, headache, and fever. That delicious meal last night left you with food poisoning this morning.
Your bursitis is flaring. Do you go to work?
Most people probably wouldn’t. Most physicians probably would.
That’s because there is a culture within the medical profession of going
to work, no matter how sick physicians are, in order to care for their patients. But are physicians acting in their patients’ best interest when they
go to work sick?
There is a confluence of circumstances that makes presenteeism, which
refers to the phenomenon of individuals working despite being ill, more
prevalent in the medical profession than in other fields, said Joseph
“Yossi” Faber, owner and managing director of Teaneck, New Jerseybased Faber Healthcare Solutions, a medical practice management
consultancy. Physicians are a population of driven professionals who
have pushed themselves in their studies and training. They have a strong
perception that they are an essential part of the medical team, he said.
Their professional ethics and Hippocratic Oath drive them to minimize
any disruptions that stand in the way of caring for their patients.
“Doctors tend to be Type A individuals who have a very strong work
ethic,” Stephen Webster, MD, outgoing chair of the AAD’s Ethics and
Professionalism Committee, concurred. “It’s been drummed into us as
part of our ethics and professionalism that we’re here to provide an important service to our patients. We have an obligation to take care of our
patients and put their interests above all others,” he said.>>
DERMATOLOGY WORLD // January 2015 35
heal thyself
“I suspect that 80 to 90 percent of physicians tend to feel
it’s more important to take care of their patients than to take
care of themselves,” added Mary Maloney, MD, chief of the
division of dermatology at the University of Massachusetts.
Patients depend on their physicians and there is an
expectation that they will be taken care of, she said.
A sense of obligation to colleagues is another factor
for not calling in sick, Dr. Webster said. “The entire staff
is adversely affected when the physician is absent,” Faber
added. “Their workload is simply redistributed on the backs
of their colleagues. If they have heavy workloads, the burden
is even greater.”
Rescheduling patients isn’t always easy, Dr. Maloney
noted. “Your colleagues are busy, too. Sometimes it’s just
easier to see the patients today because you will feel worse
tomorrow when you have to see six extra people,” she said.
“So you end up slogging along and seeing the patients
because there is no out.”
Shrinking revenues and growing costs may also be
driving some physicians to work while sick, especially those
in solo or small practices, said Faber, who consults primarily
with small practices. Many non-medical jobs offer paid sick
time; even staff in physician offices may receive it. But many
physicians’ salaries are based on the revenue they generate,
creating additional pressure to work through illness. “While
certain industries have embraced the concept that sick
employees can spread illness,” he said, “it’s not prevalent
in the medical office environment.” Even for salaried
physicians in large groups or those working in hospitals who
do get paid time off, Faber said, the workplace culture often
promotes taking as few sick days as possible.
There is no specific research on the rate of presenteeism
among physicians, but there is research on residents’ attitudes
toward coming to work when sick, noted James D. Hook,
MPH, director of consulting for the Fox Group, LLC, a health
care consulting group in Upland, California. “The residents’
reasons — an obligation to colleagues and patients, and not
wanting to be regarded as ‘weak’ — are probably on the minds
of physicians in other practice settings, as well,” he said.
As an intern in a hospital, Dr. Maloney recalls coming
down with the flu and the resident not allowing her to go
home. “Today, that resident would be called on the carpet for
not letting me go home,” Dr. Maloney said, “so things have
changed.” She attributes this shift in physicians’ attitudes
toward illness in the past decade, in part, to the influx of
millennials in the workforce. “I think the millennials have
a better work/life balance. They’re more willing to say they
don’t feel well, so they’re going to stay home.”
Dermatologists have to realize that working while sick is
an old habit that is not in their or their patients’ best interest,
said Jeff Queen, chief executive officer of Boca Raton,
Florida-based Integrated Dermatology Group. Working
with dermatologists to change that mindset is important to
changing the culture, he said. “We encourage a culture where
your patients will appreciate you more if you call in sick and
reschedule. Everyone knows that the doctor is human.”
Dermatologists who try to honor their professional
obligation to care for their patients when ill may actually get
them sick. So where should physicians draw the line?
“We are ethically driven to do no harm to the patient,”
Dr. Webster said. If there is any possibility of transmitting
an infectious disease to the patient, the dermatologist should
not go to work. Dr. Maloney, who is the incoming chair of
the AAD’s Ethics and Professionalism Committee, agrees.
“If you have a fever or any symptoms of a communicable
disease, it’s not right to put your patients at risk, especially
The movement to ban the handshake in health care settings to reduce the
transmission of pathogens is gaining momentum; an article encouraging a ban
appeared in the Journal of the American Medical Association last year (doi:10.1001/
jama.2014.4675). But at what cost to the physician-patient relationship?
Given that 80 percent of all infections are transmitted by hands, according to
the Centers for Disease Control and Prevention, banning this common social
practice makes practical and scientific sense. In the health care setting,
however, the handshake between physician and patient demonstrates empathy
and compassion. For dermatologists, in particular, the handshake goes beyond
building a bond with patients.
Many patients with psoriasis or eczema feel like nobody wants to touch them, said
Mary Maloney, MD, who has mixed feelings about the idea of a ban. That is why
the handshake in particular and touch in general is so important, almost therapeutic, for these patients. If there was an
epidemic, she would embrace banning the handshake wholeheartedly as a way to break it. “If you wash your hands and
use hand cleanser, it shouldn’t be that big of a deal,” Dr. Maloney said.
36 DERMATOLOGY WORLD // January 2015
immunosuppressed patients. If you think you’re contagious,
you should stay home. If you’re sick with a bad cold, you
shouldn’t really be seeing patients.”
The routine cold is “a gray zone,” said Dr. Maloney, who
has several colleagues with young children who bring all
sorts of germs home from school just as her children did
when they were young. “Physicians can’t stay home every
time they have a cold,” she said. They can wear a mask,
don gloves, and wash their hands more frequently. “Many
of us wear gloves when we’re examining patients anyway.”
Dr. Maloney suggests avoiding shaking hands at that time,
as well. Patients will appreciate you taking precautions to
prevent spreading the cold, Dr. Webster noted.
But there is contagious and then there is sick. While
a flare-up of Crohns disease, a migraine, or knee pain are
all illnesses that do not present a health threat to patients,
the symptoms may be so distracting that it’s difficult to
concentrate. “If you’re in so much distress that you’re unable
to perform at the top of your game, you should stay home,”
Dr. Maloney said.
Research suggests that people tend to go to work when
they are suffering from chronic conditions that are not
infectious, Hook said. Those individuals may experience
a decline in cognitive energy. That may compromise a
physician’s medical decision-making capabilities, although
there is no evidence that it contributes to worse outcomes
for patients, he added. “If you think your patients would start
wondering why you are still at work given how you look or
how you are acting,” Hook said, “you are probably too sick to
be there.”
Physicians need to be comfortable enough to recognize
when an illness, whether it’s contagious or not, is a problem,
Faber added. If they’re uncertain, they can speak with a
A sick leave policy also can address questionable illnesses.
The sick leave policy at Gundersen Health System, where
Dr. Webster practiced until he retired last year, spells out
when sick is too sick. “Overall, the policy is not to go to
work if you are sick with an acute communicable disease,”
he said. But the cause of the illness is as important as the
illness itself. Nausea from a new medication is not a reason
to call in sick, but nausea with a fever and muscle achiness
is. Diarrhea due to irritable bowel or food poisoning is not
a reason to stay home, but diarrhea due to the stomach flu
is. Of course, if the physician can’t provide an optimal level
of care even if not infectious, the doctor should not go in,
he added. The health system also encourages all employees
who see patients to get a flu vaccine. “If they don’t, they need
to wear a mask daily,” Dr. Webster said. “Most practitioners
don’t like doing that, so they get a vaccine.”
Hospitals are more successful at getting doctors out
when they’re sick, Dr. Maloney noted. “They can shut the
doctors down,” she said. “In private practice, it’s harder to
police that.”
Faber advises practices of all sizes to have a sick leave
policy, even though he acknowledges that it can be unwieldy
for smaller practices to implement it. It’s a good idea to have
a policy if only to address the degree of illness that should
result in a physician taking the day off. It can help make
staying home acceptable, Faber said. “A policy can help
address that gray area between a little sniffle and a full-blown
illness where the physician would likely come to work, but
would caution a patient to stay home. It’s not that physicians
wouldn’t make that call on their own, they certainly
would, but the pressures of the culture of the office or
administrative ramifications can be such that they minimize
their own concerns.” When there is no policy, people invent
Stephen Webster, MD, who continues to see patients in skin cancer screening clinics, makes it a point to use a hand sanitizer
before shaking hands with patients. “I do like to shake hands or pat the patient on the back. Personally, I feel it’s very
important to establish close contact with the patient,” he said, adding, “I don’t think it’s a good idea to ban the handshake.”
Banning the handshake will result in losing the human contact and warmth in the physician-patient relationship,
practice management consultant Yossi Faber said. Furthermore, he pointed out that a handshake ban doesn’t address
key vectors of infection such as neckties, lab coats, and scrubs as well as medical instruments.
Integrated Dermatology Group tried implementing a handshake ban in a few of their practices, said Jeffrey Queen, the
group’s CEO, but it wasn’t successful. The handshake helps create a bond between the physician and the patient. “The
physician needs to touch the patient,” he said.
Banning the handshake sounds like a good idea, consultant James Hook, MPH, said, given the research that links it to
the transmission of germs. He recommends replacing it with the fist bump or even a bow, the latter of which is common
in some cultures. “Of course, nothing replaces routine hand hygiene when moving from patient to patient,” Hook said.
“And physician neckties have also been shown to contain pathogens that can potentially move from wearer to patient.
Maybe both should be banned!”
DERMATOLOGY WORLD // January 2015 37
in their own minds what is and isn’t acceptable without a
standard to follow.
Sick leave policies are probably needed more for staff
than for physicians, Hook noted. They ensure consistent
treatment of employees and compliance with local laws or
regulations. In 2011, Connecticut became the first state to
require private sector employers to provide paid sick leave
to employees. California will be the second one when the
Healthy Workplace, Healthy Families Act of 2014 goes
into effect in July 2015. While a handful of cities have a
paid sick leave law on the books, no such federal laws exist.
Still, Hook is not convinced that sick leave policies will
necessarily decrease presenteeism among physicians.
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38 DERMATOLOGY WORLD // January 2015
When physicians do call in sick, covering for those in large
organizations is easier to do than for those in solo practices,
Hook said. Large organizations can offer patients an
appointment with another dermatologist or even in urgent
care on the day of absence or at least in the near future.
As a division chief at UMass, Dr. Maloney shuffles
patient appointments when a colleague calls in sick. She
always asks when the physician thinks he/she will have the
time to see patients, such as during “academic time” or a
day next week when he/she is not scheduled to come in.
“You can usually move half of the patients,” Dr. Maloney
said. “You can’t reach the other half or it’s unacceptable to
reschedule the appointment.” The latter patients get parsed
out among the providers at work that day. “We get into
trouble if it’s a pediatric dermatologist who is out because
so few of the surgeons feel comfortable seeing two-yearolds,” she quipped. That may require calling a dermatologist
who is off that day to come in. A nurse practitioner or
physician assistant may be asked to come in for a half day to
see non-complex patients. “Nobody complains; we just get it
done,” Dr. Maloney said. She checks in with the sick doctor
in the early afternoon to find out if he/she expects to return
to work the next day.
At Gundersen, patients are seen or rescheduled based
on priority, Dr. Webster said. Those with acute problems
are seen first.
Allowing for flexibility in the schedule may be helpful
for rescheduling patients in a small practice, Faber said. For
example, if Wednesday afternoon is set aside for paperwork,
that time could be used to schedule patients. Another
option is to schedule 15-minute appointments instead of
10-minute ones to build in time to accommodate squeezing
patients in. Physicians may consider canceling the morning
patients and letting staff know by 10 a.m. whether or not to
cancel the afternoon patients. “Sometimes you feel lousy
when you get up with a cold, but you feel better as the day
goes on,” he said.
The decision to come to work when unable to perform
at an optimal level is a very personal one, Hook concluded.
“Everyone has different levels of tolerance to pain or other
symptoms that can affect cognitive ability or even motor
skills.” There are grades of being sick and recognizing them
requires self-awareness, Dr. Maloney added. “We all need
that level of self-awareness.”dw
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Copyright © 2015 American Academy of Dermatology. All rights reserved.
from the president
academy perspective
AMA policy
on network
adequacy highlights
value of partnering
with house of
ermatology is a small specialty, but we are mighty — a powerful force working
on behalf of our patients. Especially this year, as we hear more and more that
our patients are finding it difficult to get dermatologic care because of increasingly tightened provider networks. As a result, patient access to our care has become
one of the Academy’s top priorities, one that we have labored over with great force.
We’ve been to the White House, the Centers for Medicare and Medicaid Services
(CMS), the halls of Congress, and the offices of insurance companies. At each meeting we have delivered the same message: preserve patient access to dermatologic
care, and provide accurate and timely information to patients about their provider
networks. As a specialty, I believe that we have made quite an impression with this
broad scope of policymakers.
While we’ve been hitting the pavement, our colleagues in other specialties have
been paying attention to our efforts and have decided to join our fight. In November,
at the American Medical Association (AMA) House of Delegates (HOD) interim
meeting, the AMA took a strong position on patient access and approved a new policy
that calls on insurance companies to provide patients with an accurate and comprehensive directory of participating physicians that also identifies physicians who are
not accepting new patients. Additionally, the AMA policy calls on insurance companies to only make changes to their provider networks before the open enrollment
40 DERMATOLOGY WORLD // January 2015
period begins each year, so patients are
not left without a provider after they have
already enrolled.
This policy is clearly a step in the right
direction. Additionally, the AMA’s policy
on narrowed networks is proof that we
are making a dent in our efforts to ensure
patient access to care — our colleagues
are hearing us and the house of medicine
is coming together on this critical issue.
However, if we want to have any influence
on the policies that affect the specialty
and our patients as a whole, we need to be
more involved in the AMA HOD. There
is no denying that at the end of the day,
private payers and regulatory and legislative bodies are looking to the AMA for
guidance on their policies.
The AMA is the one group in the house
of medicine where every state medical society and every specialty appoints
delegates who can vote on AMA policies.
The number of delegates a group receives
is proportionate to the number of specialists who are members and designate that
specialty as their primary organization.
The AAD has four delegates — this means
that we have four votes to support or
prevent resolutions. However, if we want to
have a bigger voice in the greater house of
medicine, we could use a few more votes. I
call on all of my fellow Academy members
to join the American Medical Association
under the AAD designation. There is no
denying that we are a strong and vocal
specialty when it comes to defending our
patients, but we are stronger when we
work together with our colleagues in other
specialties. dw
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academy update
Board statement regarding proposed membership dues increase
SUMMARY: The Board voted unanimously in favor of this increase.
Dermatology is experiencing unprecedented pressure from regulatory bodies, payers, legislators and the public. The AAD Board of
Directors believes this is a critical time for us to choose a decisive pathway that will lead to greater sustainability for our specialty. Dermatologists cannot do this individually or one step at a time — it requires the Academy to launch an ongoing, multi-pronged effort to protect
and promote the value of dermatology. To do this successfully, we need funding.
The Board recommends a three-pronged effort with expanded resources to fund and sustain programs that demonstrate the value of
dermatology to key audiences, including: 1) Creation of a dermatology-owned data platform that will collect information that demonstrates
quality of care, outcomes, and performance measures; 2) Development of practice tools that help define appropriate value for services;
and 3) Stepping up advocacy communications that impact value perceptions of our specialty with organized medicine, payers, legislators,
regulators, and the public.
The AAD board believes the key to the future of dermatology is for us to own the data that defines our specialty by showcasing our
outcomes, our fair value, and the direction of best practices. In addition, the Academy must develop practice tools to help dermatologists
define appropriate value for their services, such as a risk adjustment tool. We also need a communications platform to educate key stakeholders on these measures.
“We have the future of dermatology in our hands,” says Dr. Brett Coldiron, FAAD, President, AAD. “We are now at a juncture to help
protect fair value for the service we provide. We do not want others to own this data – it is ours and ours alone to own. Many organizations
will try to define dermatology and what we are worth. The entity that owns the data on dermatology owns the future of dermatology.”
It has been 12 years since the AAD enacted a dues increase, and to pay for these new initiatives requires an investment. Therefore, the
American Academy of Dermatology (AAD) Board of Directors is asking members to approve a one-time $50 increase for 2016, followed
by modest cost-of-living increases, based on the Consumer Price Index, for 2017 and beyond. (Note: In any given year, the Board of Directors has the ability to decline the cost-of-living increase.)
The Board concluded that data are essential to help payers understand why they need dermatologists in their networks and on their
panels. This requires a collective, specialty-wide data-gathering effort, something only the Academy can coordinate and deliver. Fortunately, a registry will also help with the quality measurement and reporting that is becoming a bigger part of the way Medicare and other
payers evaluate and reimburse each of us as individuals.
“We’re playing with the future of the Academy and of our colleagues...the future of dermatology,” says Dr. Coldiron. “We are at a
time when we cannot afford to fritter away dermatology’s future over a few cents a day. So, if you want to be part of something better, if
you want to fight back against rapacious insurance companies, and intrusive government bureaucrats, if you want to be able to practice
medicine, not paperwork, you need data and the tools to put it into practice. You, and everyone you talk to, should support a modest dues
The board is asking for your yes vote for the dues increase on the 2015 election ballot.
The AAD is accepting statements on the proposed dues increase Jan. 5, through Feb. 18. The proposed dues increase will be presented to
the membership for a vote on the spring 2015 election ballot. The ballot will be accompanied by up to six statements from members who
express support for or opposition to the proposed increase (three for and three against). Any member who wishes to submit such a statement to the secretary-treasurer for consideration can do so using one of the following methods:
Mail: American Academy of Dermatology
Attn: Secretary-Treasurer
Proposed Dues Increase
930 E. Woodfield Road
Schaumburg, IL 60173-4729
Statements may not exceed the length of two typewritten, double-spaced pages. A statement may be submitted by one or more members,
but no more than three members can be designed as principal authors and identified with the statement. The deadline for receipt of statements is Wednesday, Feb. 18.
42 DERMATOLOGY WORLD // January 2015
news + events
news + events
2015 Annual Meeting registration and housing still available
REGISTER NOW at the discounted registration rates to attend the Academy’s
73rd Annual Meeting in San Francisco, being held March 20-24, 2015, by registering online at Discounted registration rates will apply
until Feb. 11, 2015, at 12 p.m. (CT). After this date and time standard registration rates will apply.
Guest rooms are being held at several major hotels in San Francisco at
AAD discounted meeting rates available only to those who book through the
AAD. For a current listing of official AAD hotels, visit
Hotel reservations must be made online in conjunction with registration for
the meeting. More information is available on the Academy website and in the
2015 Annual Meeting Advance Program.
You can add a donation as you register for the Annual Meeting. Be a part of
the Academy’s efforts to create a world without skin cancer by contributing to
SPOT Skin Cancer™, or help support a unique summer camp opportunity for
young patients by giving to Camp Discovery. – SUSAN TREECE
Board approves new Annual Meeting end time
THE BOARD OF DIRECTORS of the American Academy of Dermatology
approved ending the Annual Meeting at noon on Tuesday starting in 2016.
(Previously, the Board had voted to end the meeting on Monday starting in
2016; this decision reverses that one.)
The AADA Board approved revisions to two position statements, on CLIA
and indoor tanning. The full text of both is available at
The Board also adopted changes related to the Academy’s councils, committees, and task forces. With the Academy now involved in so many important and sensitive initiatives for which confidentiality is critical and to ensure
all discussions about these and other initiatives can be discussed effectively
within the Board and committee structure, members of these bodies will now
be required to sign a non-disclosure agreement acknowledging their “duty to
maintain the confidentiality of certain confidential or proprietary information”
encountered as part of their service. Guests at meetings of councils, committees, and task forces will be required to sign a similar guest confidentiality
Finally, the Board approved the formation of the Women’s Health Expert
Resource Group (ERG). The new ERG will facilitate communication and collaboration among experts in women’s health or other key persons within the
range of medical and surgical dermatology practices, including solo, group,
academic, military, and dermatopathology practices. To learn more or join,
contact Jenny Murase, MD, at – RICHARD NELSON
DERMATOLOGY WORLD // January 2015 43
Join the movement.
Get involved.
Demonstrate compassion. Foster goodwill.
Volunteer your time.
Be part of the inspiring effort growing among dermatologists dedicated to helping patients, communities
and the profession.
Opportunities include patient/public outreach in the United States and abroad, mentoring young
physicians, political advocacy, and academy committees.
Be sure to submit your volunteer hours through the Volunteer Recognition program. It’s quick and easy!
For more information about AAD volunteer and mentor
opportunities, and the Volunteer Recognition program,
Copyright © 2015 American Academy of Dermatology. All rights reserved.
Well established, solo, derm practice
for sale. IPL, NBUvB, Blu-U on site.
Beautiful facility in historic building
in downtown New Rochelle. Walk to
Partnership available. Established
practice. Contact Karey, (866) 4884100 or
train. Close to Manhattan. Owner
will stay on to ease transition. Please
Partnership available. Established
Established medical, surgical and cos-
practice. Contact Karey, (866) 488-
metic practice in the Texas Hill Coun-
4100 or
try of northern San Antonio. Doctor
Central Florida Dermatology and Skin Cancer Center (CFD) is seeking an ACMS fellowship trained
Mohs Surgeon and/or a BE/BC General Dermatologist. We are also looking for qualified ARNPs
who have dermatology experience. CFD is located in Winter Haven, FL. Winter Haven is the
home of Legoland and is also known as the Chain of Lakes area. Winter Haven offers the suburb
experience with quick access to Tampa, Orlando, and the beach.
Interested parties, who want to join a busy and successful practice, can submit resumes/CVs to
our Practice Manager, Dan Lackey, at or call 863.293.2147
for more information. Please visit us on the web at
will stay for successful transition if
desired. Contact
Partnership available. Established
We Buy Practices
•Why face the changes in Health
Care alone?
•Sell all or part of your practice
•Succession planning
•Lock in your value now
•Monetization of your practice
Please call Jeff Queen at
(866) 488-4100 or e-mail
practice. Contact Karey, (866) 4884100 or
Partnership available. Established
practice. Contact Karey, (866) 488-
Manchester & Wolfeboro, NH
APDerm® is a vibrant, growing practice of clinically accomplished and patient-focused dermatologists who practice in a community distinguished as among the best places to live on the east coast/
Boston area.
We are seeking a full or part-time dermatologist/Mohs surgeon to join our group of twelve
board certified dermatologists in a professionally run practice with dermatopathology lab, Mohs
surgery and medical aesthetics. This opportunity would allow a highly qualified dermatologist/
Mohs surgeon to practice with excellent support staff in a collegial practice in our Manchester and
Wolfeboro, New Hampshire offices with competitive salary, benefits and opportunity for practice
ownership. For more information, please contact: Glenn Smith, MHA, Administrator and Chief
Operating Officer, at (978) 849-7501 or email
4100 or
Contact: Carrie Parratt
Partnership available. Established
Phone: (847) 240-1770
practice. Contact Karey, (866) 488-
4100 or
1 – 2 years experience in management of complex medical dermatology patients in both private practice
and teaching clinic. Biologics,
immunsuppressants, immunomodulators, clinical trials. PGY 5/6. Send
CV & 2 LOR to: David Fivenson, MD,
Partnership available. Established
practice. Contact Karey, (866) 4884100 or
Great opportunity for BC/BE dermatologist in Medford, NJ. Beautiful
March*...................... January 23
Partnership available. Established
April........................ February 27
practice. Contact Karey, (866) 488-
May............................. March 27
4100 or
June................................. May 1
July................................ May 29
August**....................... June 26
Ann Arbor Dermatology is looking for a
career oriented, conscientious, well-
community near Philadelphia, PA and
Cherry Hill, NJ. Well-established busy
dermatology practice in a brand new
facility, with associated medical spa.
trained dermatologist/MOHS surgeon to
Opportunity for competitive salary,
join a busy, growing practice. This posi-
benefits, and practice ownership. FT/
tion offers an opportunity to build a
PT position available. Email inquiry or
comprehensive practice that encom-
CV to
passes all aspects of dermatology in-
September...................... July 31
October...................... August 28
cluding Mohs surgery and cosmetic
*Distributed at the AAD 73rd
Annual Meeting, San Francisco,
March 20-24
**Distributed at the Summer
Academy Meeting, New York,
August 19-23
Partnership available. Established
work with highly competitive salary plus
Partnership available. Established
practice. Contact Karey, (866) 488-
bonuses, full benefits and early partner-
practice. Contact Karey, (866) 488-
4100 or
ship. For more information please con-
4100 or
tact A. Craig Cattell, M.D. by phone
(734) 996-8757, fax (734) 996-8767,
or email:
DERMATOLOGY WORLD // January 2015 45
FT/PT BC/BE dermatologist needed
to join as associate. Excellent opportunity to join busy Plastic Surgery solo
practice on LI. Forward CV to
Dermatology Associates of
Lancaster is seeking a BC/BE
dermatologist to join a thriving,
Partnership available. Established
highly regarded practice with 8
practice. Contact Karey, (866) 4884100 or
other dermatologists. The practice
offers a 12,000 sq.ft. state of the
art facility with services including
Mohs, dermatopathology, phototherapy, lasers, an aesthetic center
Help Build a Gateway
for Better Health
and adult and pediatric medical
Partnership available. Established
practice. Contact Karey, (866) 4884100 or
dermatology. Our continually
growing population base offers
an already established patient
base with an excellent mix of
third party payers. Our practice
is located in an affluent, highly
picturesque, family-oriented
community with excellent schools
and a broad range of cultural
and sporting activities. Lancaster,
Multiple Part Time Opportunities
PA is located within 1 hour
Montrose, CO 1-2 days/mo
Enfield, CT
2-3 days/mo
Groton, CT
1-2 days/mo
Reno, NV
1-2 days/mo
Hickory, NC
1-2 days/mo
Sanford, NC
2-3 days/mo
of Philadelphia and Baltimore.
For inquiries please contact
Bonnie Oberholtzer, Practice
Administrator, at 717.509.5698
or email
Bountiful, UT 3-4 days/mo
Contact Karey, (866) 488-4100 or
Associate Opportunity. Contact
Karey, (866) 488-4100 or www.
Meriter-UnityPoint Health is actively recruiting a Board-Eligible or Board-Certified
Dermatologist in Madison, Wisconsin. Meriter-UnityPoint Health is an affiliate
of UnityPoint Health, the nation’s 13th largest nonprofit and fourth largest
nondenominational health system in the United States.
Employed position includes competitive compensation and full benefits, complete
malpractice insurance, including tail coverage; sign on bonus and relocation
With a metro population of over 570,000, scenic Madison is home to the University of
Wisconsin-Madison and the State Capital, and offers a wide variety of entertainment,
recreational, cultural and leisure activities usually found in much larger cities! The
area consistently ranks as one of the top places in the country to live, work, go to school,
play and raise a family.
For more information about this excellent opportunity, please contact our recruiter Susan
Shurilla at (800) 528-8286, extension 4114, or
46 DERMATOLOGY WORLD // January 2015
At Northwest Permanente, P.C., we want every patient we see
to receive the medical care they need to live long and thrive.
We also offer NWP physicians the opportunity to pursue
their personal and professional goals with equal passion
through cross-specialty collaboration and work-life balance.
We invite you to consider this opportunity with our physicianmanaged, multi-specialty group of 1,100 physicians who care
for approximately 500,000 members throughout Oregon and
Southwest Washington.
Portland, Oregon
We’re seeking BC/BE Dermatologists to join our team of 16
Dermatologists. Our Dermatologists have an active practice
with an unusual number of complex cases and opportunities,
if desired, for cosmetic procedures. Ours is a collegial and
stimulating practice in one of the most successful managed
care programs in the country.
Physicians with Northwest Permanente, P.C. receive
competitive salaries in addition to an extensive benefit
package which includes medical, dental, disability and life
insurance; generous retirement plans; vacation, sabbatical
and educational leave; and professional liability coverage.
Physicians are also eligible for Senior Physician and
Shareholder standing after approximately three years with
the group (must be Board Certified by that time).
To submit your CV and learn more about this
opportunity, please visit our website at: and click on
Physician Career Opportunities. Or call (800) 813-3762
for more information. We are an equal opportunity
employer and value diversity within our organization.
Northwest Permanente, P.C.,
Physicians and Surgeons
ad index
We gratefully acknowledge the following advertisers in this issue:
Company Product/Service
Allergan...............................................Aczone.................................................. 3-4
Care Credit...........................................Corporate............................................. IBC
Modernizing Medicine.........................EHR...................................................... IFC
Mushatts..............................................Mushatts No. 9....................................... 11
Nextech................................................EHR....................................................... BC
P&G......................................................Tide Free & Gentle.......... Cover Tip, 15-17
Vancouver World Congress.................CME........................................................ 33
Recruitment Advertising
Adult & Pediatric Dermatology, PC.................................................................... 45
Central Florida Dermatology & Skin Cancer Center......................................... 45
Meriter-UnityPoint Health................................................................................46
Northwest Permanente P.C............................................................................... 46
Make connections and explore
different practice setting
opportunities at the AAD Career
Networking Event!
Friday, March 20, 2015
5:00 – 7:00 p.m.
Golden Gate Ballroom A
Marriott Marquis San Francisco
Classified ads are welcomed from dermatologist members of the American
Academy of Dermatology, from dermatology residents of approved training
programs and institutions with which they are affiliated, as well as from
recruitment agencies or organizations that acquire and sell dermatology practices and equipment. Although the AAD assumes the statements being made
in classified advertisements are accurate, the Academy does not investigate the
statements and assumes no liability concerning them. Acceptance of classified
advertising is restricted to professional opportunities available, professional
opportunities wanted, practices for sale, office space available, and equipment
available. The Academy reserves the right to decline, withdraw, or edit advertisements at its discretion. The publisher is not liable for omissions, spelling,
clerical or printer’s errors. For more information about classified advertising,
Ascend Integrated Media, Publisher’s Representatives
Bridget Blaney (Companies A-D and Q-R)
Phone: (773) 259-2825
Cathleen Gorby (Companies E-L and S-T)
Phone: (913) 780-6923
Maureen Mauer (Companies M-P and Tu-Z)
Phone: (913) 780-6633
The American Academy of Dermatology and AAD Association does
not guarantee, warrant, or endorse any product or service advertised
in this publication, nor does it guarantee any claim made by the
manufacturer of such product or service.
DERMATOLOGY WORLD // January 2015 47
facts at your fingertips
data on display
n 2011, the first year dermatologists could attest to being meaningful users of an electronic health record (EHR) system and earn an incentive payment from Medicare for doing so, only one vendor saw more than 100 dermatologist users successfully attest to use of a complete
system. As of Dec. 8, the nine vendors with more than 100 dermatologists attesting had more than 2,900 dermatologists attest in 2014;
these figures will continue to rise through early 2015. (More than 280,000 physicians overall had attested.) The same nine vendors had only
346 dermatologists attest to meaningful use in 2011, including one company that had zero attestations that year. The chart below shows each
vendor’s meaningful use attestations by dermatologists over the last four years.
The rising number of attestations means that fewer dermatologists will face Medicare payment reductions this year. For more on how
Medicare penalties for not using EHR interact with other payment adjustments, read next month’s Answers in Practice column.
The AAD offers a variety of resources to help members with EHR implementation and meaningful use; visit
to learn more. – RICHARD NELSON dw
Dermatology EHR meaningful use attestations by vendor, 2011-2014
Vendor Key
Epic EMA/Modernizing Medicine
NextGen GE Centricity Encite
Practice Fusion
*Data collected from based on data gathered from Includes complete EHR system attestations.
48 DERMATOLOGY WORLD // January 2015
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