01.2015 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care www.aad.org THE BIG SWITCH EXPERTS OFFER GUIDANCE ON A SEAMLESS ICD-10 TRANSITION ICD-9 ICD-9 ICD-10 ICD-10 + 05 Coding 08 Research 12 Legal Issues 18 Practice Management 42 Academy News Ranked #1 Dermatology Ambulatory EMR by Black Book Rankings 2014 Survey Black Book Rankings annually evaluates leading healthcare/medical software and service providers across 18 operational excellence key performance indicators completely from the perspective of the client experience. We are pleased to announce Modernizing Medicine has been awarded the Top Overall Ambulatory EMR Vendor Honor for Dermatology. Download your complimentary copy of the full report at www.modmed.com/blackbook, valued at $495. www.modmed.com I 561.880.2998 in this issue from the editor DEAR READERS, VOL. 25 NO. 1 | JANUARY 2015 Happy New Year! H 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. PRESIDENT Brett Coldiron, MD EXECUTIVE DIRECTOR Elaine Weiss, JD PUBLISHER Lara Lowery EDITOR Katie Domanowski MANAGING EDITOR Richard Nelson, MS ASSISTANT MANAGING EDITOR Victoria Houghton, MPA DESIGN MANAGER Ed Wantuch EDITORIAL DESIGNER Theresa Oloier DESIGN TEAM Nicole Torling Joe Miller ADVERTISING MANAGER Brian Searles ADVERTISING SPECIALIST PHYSICIAN EDITOR Abby Van Voorhees, MD PHYSICIAN REVIEWER Barbara Mathes, MD CONTRIBUTING WRITERS Jan Bowers Ruth Carol Sarah Imhoff, JD Alexander Miller, MD Victoria Pasko Rob Portman, JD Susan Treece Scott Weinberg EDITORIAL ADVISORS 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 930 E. Woodfield Rd. Schaumburg, IL 60173-4729 Phone: (847) 330-0230 Fax: (847) 330-0050 MISSION STATEMENT: Dermatology World is published monthly by the American Academy of Dermatology Association. Through insightful analysis of the trends that affect them, it provides members with a trusted, inside source for balanced news and information about managing their practice, understanding legislative and regulatory issues, and incorporating clinical and research developments into patient care. Dermatology World® (ISSN 10602445) is published monthly by the American Academy of Dermatology and AAD Association, 930 E. Woodfield Rd., Schaumburg, IL 60173-4729. Subscription price $48.00 per year included in AAD membership dues. Non-member annual subscription price $108.00 US or $120.00 international. Periodicals Postage Paid at Schaumburg, IL and additional mailing offices. POSTMASTER: Send address changes to Dermatology World®, American Academy of Dermatology Association, P.O. Box 4014, Schaumburg, IL 60168-4014. ADVERTISING: For display advertising information contact Bridget Blaney at (773) 259-2825 or [email protected]. ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR DERMATOLOGY WORLD //January 2015 1 01.2015 A Publication of the American Academy of Dermatology Association Navigating Practice, Policy, and Patient Care features www.aad.org depts 01 FROM THE EDITOR 05 CRACKING THE CODE Picked for a ZPIC audit? “This is a situation that we should be prepared to 22 manage, or it will manage THE BIG SWITCH Experts offer guidance on a seamless us in return.” ICD-10 transition COVER STORY BY VICTORIA HOUGHTON 28 BLAZING A NEW TRAIL? Changing health care landscape prompts reappraisal of general dermatology BY JAN BOWERS 34 PHYSICIAN, HEAL THYSELF Breaking the cycle of going to work sick BY RUTH CAROL 2014 AM&P Excel Bronze Award, Design Excellence 2013 HOW InHOWse Design Award – Cover/Feature Design 2011, 2012, 2013, and 2014 Graphic Design USA Award – Cover/Feature Design. 2014 Graphic Design USA American Web Design Award 2011 Ozzie Silver Award, Best Redesign: Association/Non-profit. 2014 Eddie Honorable Mention, Association/ Non-profit video 2 DERMATOLOGY WORLD // January 2015 07 ROUNDS A look ahead at 2015 in state legislatures. 08 ACTA ERUDITORUM Making informed consent more meaningful. 12 LEGALLY SPEAKING Dealing with patient images. 18 BALANCE IN PRACTICE Movies: Lessons in dermatology. 20 ANSWERS IN PRACTICE Managing staff relationships and cultivating a culture of growth in your practice. 40 FROM THE PRESIDENT 42 ACADEMY UPDATE Call for comments, more. 48 FACTS AT YOUR FINGERTIPS Meaningful use attestation on the rise. www.aad.org/dw ACZONE® (dapsone) Gel 5% BRIEF SUMMARY—PLEASE SEE THE ACZONE® PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION. INDICATIONS AND USAGE ACZONE® Gel, 5%, is indicated for the topical treatment of acne vulgaris. DOSAGE AND ADMINISTRATION 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. CONTRAINDICATIONS None. WARNINGS AND PRECAUTIONS 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 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. ADVERSE REACTIONS 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). DRUG INTERACTIONS Trimethoprim-Sulfamethoxazole 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. USE IN SPECIFIC POPULATIONS Pregnancy 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. OVERDOSAGE ACZONE® Gel, 5%, is not for oral use. If oral ingestion occurs, medical advice should be sought. Rx ONLY © 2014 Allergan, Inc. Irvine, CA 92612, U.S.A. ® marks owned by Allergan, Inc. Patented. See www.allergan.com/products/patent_notices Based on 72205US13 144098 APC14LG14 cracking the code coding tips BY ALEXANDER MILLER, MD Picked for a ZPIC audit? TAKE IT SERIOUSLY. 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. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ 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 result. For those thrilled by the latest Medicare “crime and punishment” news, log on to www.stopmedicarefraud.gov/newsroom/. 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 claims. • Suspend payments. • Bring in law reinforcements, including from the Office of Inspector General (OIG) and Department of Justice (DOJ). 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 levels. • 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. aad.org/dw/monthly/2014/december/ local-coverage-determinations-whatare-they-good-for.) • 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 ZPICS ACROSS THE COUNTRY ZPIC ZONE STATES IN THE ZONE Safeguard Services (SGS) 1 California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands AdvanceMed 2 Washington, Oregon, Idaho, Utah, Arizona, Wyoming, Montana, North Dakota, South Dakota, Nebraska, Kansas, Iowa, Missouri, Alaska Cahaba 3 Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky Health Integrity 4 Colorado, New Mexico, Texas, Oklahoma AdvanceMed 5 Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, North Carolina, South Carolina, Virginia, West Virginia Under Protest; Safeguard Services (SGS) is the current contractor 6 Pennsylvania, New York, Delaware, Maryland, D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Maine, Rhode Island, Connecticut Safeguard Services (SGS) 7 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 ZPIC. 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 service. 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 keratowww.aad.org/dw rounds news in brief State legislatures back in business with a full docket of issues STATE NEWS ROUNDUP S 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. INDOOR TANNING 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. NARROWING NETWORKS 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. BIOSIMILARS 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. SCOPE OF PRACTICE 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. PATIENT ACCESS TO PRESCRIPTION MEDICATIONS 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 Q&A Making informed consent more meaningful IN THIS MONTH’S ACTA ERUDITORUM COLUMN, 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 www.aad.org/dw 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 improvement? 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 LEGAL STANDARDS FOR RISK DISCLOSURE PROFESSIONAL STANDARD Provider must discuss what another reasonable provider in same field would discuss in similar clinical context REASONABLE PATIENT Provider must discuss what reasonable patient in similar clinical context would want to know to make decision SUBJECTIVE PATIENT 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 Order TODAY and Save! Stay up-to-date with the latest in coding and reimbursement. While supplies last! Special Price*: $115 AAD Member Price: $135 *Save $20 when you mention promo code DWCODE15. Visit www.aad.org/store or call the MRC at (866) 503-SKIN (7546). Copyright © 2015 American Academy of Dermatology. All rights reserved. 14-1079-MKT 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 https://www.youtube.com/watch?v=_qS7CqyAts.] 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 2013;69:634-6.doi: http://dx.doi.org/10.1016/j.jaad.2013.02.028. www.aad.org/dw legally speaking BY ROBERT M. PORTMAN, JD, MPP, AND SARAH IMHOFF, JD, MHSA Dealing with patient images EVERY MONTH, DERMATOLOGY 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 C 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. TELEDERMATOLOGY WITH AN ESTABLISHED PATIENT 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 circumstances? 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. www.aad.org/dw 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 KEY POINTS: 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 authentication. 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. TELEDERMATOLOGY WITH A NEW PATIENT 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 consultations? 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. WRITING A CASE REPORT 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. CLAIM SUBMISSION AND EDUCATION 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 www.aad.org/dw PAID ADVERTORIAL Clean Laundry & Gentle on Skin EDUCATE PATIENTS WHO BELIEVE THEY MUST SACRIFICE CLEANING POWER FOR A DETERGENT THAT IS NON-IRRITATING MARNIE NUSSBAUM, MD, FAAD 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 contrast. 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. 1 2 2010 Habits, Practices and Attitudes conducted by P&G. PAID ADVERTORIAL 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 irritation 100 90 80 70 60 50 40 30 20 10 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 87% who use a free detergent, use SCENTED 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 BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR Movies: Lessons in dermatology THREE TIMES EACH YEAR, DERMATOLOGY WORLD 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 [email protected]. “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 L 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, www.skinema.com was born. VALUE GLEANED FROM FILM 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 www.aad.org/dw 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 albinism. Category 3: Protagonists with skin conditions Dr. Reese also highlights sympathetic movie characters with skin conditions (such as The Man Without a Face) on Skinema.com 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 helpful.” Dr. Reese earned the ‘Best Website’ award at the AMA International Medical Film competition in 1996 for www. skinema.com. 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. EXPANDING A PASSION 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 Skinema.com, 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 www.skinema.com 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. aad.org/dw. dw DERMATOLOGY WORLD //January 2015 19 answers in practice Managing staff relationships and cultivating a culture of growth in your practice IN THIS MONTH’S ANSWERS IN PRACTICE COLUMN, Dermatology World talks with Jeffrey Dover, MD, about how SkinCare Physicians manages staff relationships and cultivates a culture of growth among staff members. DERMATOLOGY WORLD: How would 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 requests. • 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 areas. 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 physicians? 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 www.aad.org/dw 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 THE BIG ICD-9 ICD-10 22 DERMATOLOGY WORLD // January 2015 www.aad.org/dw SWITCH EXPERTS OFFER GUIDANCE ON A SEAMLESS ICD-10 TRANSITION BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR F 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 THE BIG SWITCH ICD-9 ICD-9 ICD-10 ICD-10 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.” PREPARING FOR ICD-10 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 ICD-9 ICD-10: AN EQUAL-OPPORTUNITY TASK 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. ICD-10 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 www.aad.org/dw 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 THE BIG SWITCH ICD-10 ICD-10 “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 www.aad.org/members/publications/member-to-member/2014archive/september-26-2014/when-is-the-cms-end-to-end-testingperiod-for-icd-10.) 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.” PREPARING FOR PAIN POINTS 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 10 STEPS TO ICD-10 PREPAREDNESS 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 compliant: STEP STEP STEP STEP STEP STEP STEP 6 STEP 7 STEP STEP 1 TEP 2 3 1 1 2 2 3 3 4 4 5 5 STEP STEP TEP TEP ICD-9 ICD-9 6 6 7 7 Identify STEP where the practice currently stands, and where it needs to be before Oct. 1. STEP Depending on the size of the practice, identify an internal project leader who has the authority to assess and manage STEP needs to be done. STEP what 8 8 STEP 9 Create timeline, working backward from Oct. 1, that includes a monthly plan to track progress. STEP a9 STEP that there is a budget to cover transition costs. This budget should include costs associated with the Ensure STEP purchase of upgrades to your EHR system, as well as any additional costs associated with hiring more staff. 10 10 STEP Understand your vendors’ plans for converting to ICD-10 — what software upgrades are necessary, what is covered STEP 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 STEP 8 www.aad.org/dw 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.” THE MERITS OF ICD-10 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 6 TEP 1 STEP TEP TEP TEP TEP TEP TEP TEP TEP TEP TEP TEP TEP TEP TEP TEP 2 1 1 3 1 2 2 4 2 3 3 5 3 4 4 4 5 5 5 STEP 7 STEP STEP 6 6 STEP 8 STEP 6 STEP STEP 7 7 STEP 9 STEP 7 STEP STEP 8 8 STEP 10 STEP 8 STEP STEP 9 9 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 www.aad.org/members/publications/member-to-member/2014-archive/september-26-2014/ when-is-the-cms-end-to-end-testing-period-for-icd-10 to learn more. STEP 10 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 www.aad.org/store/product/default.aspx?id=9276. TEP TEP TEP TEP STEP 9 STEP STEP 10 10 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 www.aad.org/ICD10. DERMATOLOGY WORLD // January 2015 27 BLAZING A NEW TRAIL? Changing health care landscape prompts reappraisal of general dermatology 28 DERMATOLOGY WORLD // January 2015 www.aad.org/dw BY JAN BOWERS, CONTRIBUTING WRITER E 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 BLAZING A NEW TRAIL? 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. HIRING HELP 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 RESIDENTS LEAD CHANGE 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 www.aad.org/dw 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.” CHANGING THE MIX 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 complim entary registr ation Epiphanies in Dermatology OPTIMISM RULES 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. Visit www.aad.org/WC15 for more information and to register. Copyright © 2015 American Academy of Dermatology. All rights reserved. 14-1079-MKT 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 burden.” 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 www.aad.org/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. Featuring clinical pearls and tips from around the world! A TRULY UNIQUE GLOBAL DERMATOLOGY EXPERIENCE THE WORLD’S LONGESTRUNNING DERMATOLOGY CONGRESS A FRIENDLY AND STUNNINGLY BEAUTIFUL HOST CITY PHOTO COURTESY OF TOURISM VANCOUVER SO MUCH TO SEE AND DO IN VANCOUVER Late-Breaking Abstracts open for online submission on our website until January 31, 2015. www.derm2015.org Physician, heal thyself Breaking the cycle of going to work sick 34 DERMATOLOGY WORLD // January 2015 www.aad.org/dw BY RUTH CAROL, CONTRIBUTING WRITER Y 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? CULTURE OF PRESENTEEISM 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 Physician, 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.” TO GO OR NOT TO GO 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 WILL YOU BAN THE HANDSHAKE IN YOUR PRACTICE? 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 www.aad.org/dw 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 colleague. SICK LEAVE POLICY 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 THE PERFECT HANDOUTS FOR PATIENTS! 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. RESCHEDULING PATIENTS Over 60 titles! Visit www.aad.org/store or call (866) 503-SKIN (7546) to purchase today! 14-865-MKT 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 www.aad.org/dw INTRODUCING AAD’s 2015 WEBINAR ALL-ACCESS PASS! Provide your staff with a year’s worth of practice management training The new Webinar All-Access Pass provides the ability to participate in all seven of the 2015 live webinars, and the flexibility to train and watch these webinars “on demand” wherever and whenever is convenient. Best of all, you don’t have to spend a fortune – the Webinar All-Access Pass costs $599! To see a listing of all webinars scheduled in 2015 visit www.aad.org/webinars. Webinar All-Access Pass:$599 Individual Live Webinar: $199 each Save over $700! Visit www.aad.org/store to purchase Copyright © 2015 American Academy of Dermatology. All rights reserved. from the president academy perspective BY BRETT COLDIRON, MD AMA policy on network adequacy highlights value of partnering with house of medicine D 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 www.aad.org/dw Registration and Housing is now open! Join us in San Francisco and experience an array of dermatologic educational sessions like no other! • Sharpen your skills with over 360 sessions covering the latest in dermatology • Enjoy full access to the high-energy exhibit floor as hundreds of exhibitors showcase the latest products and services • Network with colleagues from across the globe and build valuable professional relationships • Discover new and innovative research at the electronic poster exhibits And while in San Francisco, check out: • The Golden Gate Bridge – experience the views of San Francisco’s most famous landmark • Cable Cars – take a ride on the world’s last manually operated cable car system • Pier 39 – home to more than 100 shops and restaurants, an aquarium, and the famous sea lions • Museums – from Modern Art to Walt Disney, explore all the different museums that San Francisco has to offer Discounted rate expires February 11 at 12 p.m. (CT)! Visit www.aad.org/AM15 for more information! 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 increase!” The board is asking for your yes vote for the dues increase on the 2015 election ballot. STATEMENTS ON PROPOSED DUES INCREASE DUE FEB. 18 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: Website: www.aad.org/proposedduesincrease Email: [email protected] 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 www.aad.org/dw 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 www.aad.org/AM15. 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 www.aad.org/AM15. 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 DATEBOOK WHAT’S COMING UP 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 www.aad.org/Forms/ Policies/ps.aspx. 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 agreement. 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 [email protected]. – 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, visit www.aad.org/volunteerandmentor. Copyright © 2015 American Academy of Dermatology. All rights reserved. classifieds PRACTICES FOR SALE NEW ROCHELLE, NEW YORK Well established, solo, derm practice for sale. IPL, NBUvB, Blu-U on site. Beautiful facility in historic building in downtown New Rochelle. Walk to PROFESSIONAL OPPORTUNITIES PORTERVILLE, CALIFORNIA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. train. Close to Manhattan. Owner will stay on to ease transition. Please email: [email protected]. BOULDER, COLORADO TEXAS Partnership available. Established Established medical, surgical and cos- practice. Contact Karey, (866) 488- metic practice in the Texas Hill Coun- 4100 or www.MyDermGroup.com. 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 [email protected] or call 863.293.2147 for more information. Please visit us on the web at www.centralfldermatology.com. will stay for successful transition if desired. Contact [email protected]. MONTROSE, COLORADO 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 •Retiring Please call Jeff Queen at (866) 488-4100 or e-mail [email protected] Visit www.MyDermGroup.com practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. OCALA, FLORIDA 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 [email protected]. 4100 or www.MyDermGroup.com. FOR MORE INFORMATION: TAMPA, FLORIDA Contact: Carrie Parratt Partnership available. Established Phone: (847) 240-1770 practice. Contact Karey, (866) 488- Email: [email protected] 4100 or www.MyDermGroup.com. ANN ARBOR, MICHIGAN MEDICAL DERMATOLOGY FELLOWSHIP 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, [email protected]. RENO, NEVADA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. SOUTHERN NEW JERSEY Great opportunity for BC/BE dermatologist in Medford, NJ. Beautiful SALES INFORMATION UPCOMING DEADLINES FOR 2015 ISSUES: WEST PALM BEACH, FLORIDA March*...................... January 23 Partnership available. Established April........................ February 27 practice. Contact Karey, (866) 488- May............................. March 27 4100 or www.MyDermGroup.com. June................................. May 1 July................................ May 29 August**....................... June 26 ANN ARBOR, MICHIGAN 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 [email protected]. passes all aspects of dermatology in- September...................... July 31 October...................... August 28 CHICAGO, ILLINOIS cluding Mohs surgery and cosmetic SANTA FE, NEW MEXICO *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 www.MyDermGroup.com. ship. For more information please con- 4100 or www.MyDermGroup.com. tact A. Craig Cattell, M.D. by phone (734) 996-8757, fax (734) 996-8767, or email: [email protected]. DERMATOLOGY WORLD // January 2015 45 classifieds PROFESSIONAL OPPORTUNITIES NEW YORK FT/PT BC/BE dermatologist needed to join as associate. Excellent opportunity to join busy Plastic Surgery solo practice on LI. Forward CV to PENNSYLVANIA [email protected]. Dermatology Associates of Lancaster is seeking a BC/BE HICKORY, NORTH CAROLINA dermatologist to join a thriving, Partnership available. Established highly regarded practice with 8 practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. 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 SANFORD, NORTH CAROLINA Partnership available. Established practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com. 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 MOHS SURGEON 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 [email protected]. Website www.dermlanc.com. Bountiful, UT 3-4 days/mo Contact Karey, (866) 488-4100 or www.MyDermGroup.com. WASHINGTON, DC Associate Opportunity. Contact Karey, (866) 488-4100 or www. MyDermGroup.com. ww.aad.org/dw 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 [email protected]. 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. DERMATOLOGISTS 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: http://physiciancareers.kp.org/nw/ 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 EOE www.aad.org/dw ad index AAD CAREER NETWORKING EVENT 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 FREE TO ATTEND 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, FOR DISPLAY ADVERTISING INFORMATION, CONTACT: Ascend Integrated Media, Publisher’s Representatives Bridget Blaney (Companies A-D and Q-R) Email: [email protected] Phone: (773) 259-2825 Cathleen Gorby (Companies E-L and S-T) Email: [email protected] Phone: (913) 780-6923 Maureen Mauer (Companies M-P and Tu-Z) Email: [email protected] Phone: (913) 780-6633 ADVERTISING STATEMENT: 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. 14-989-MKT THE AD INDEX IS PROVIDED AS A COURTESY TO OUR ADVERTISERS. THE PUBLISHER IS NOT LIABLE FOR OMISSIONS OR SPELLING ERRORS. DERMATOLOGY WORLD // January 2015 47 facts at your fingertips data on display MEANINGFUL USE ATTESTATION ON THE RISE I 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 www.aad.org/meaningfuluse to learn more. – RICHARD NELSON dw Dermatology EHR meaningful use attestations by vendor, 2011-2014 0($1,1*)8/86($77(67$7,216 180%(52)'(50$72/2*,676 Vendor Key Epic EMA/Modernizing Medicine Nextech eClinicalWorks Allscripts NextGen GE Centricity Encite Practice Fusion <($5 *Data collected from www.americanehr.com/ratings/ehr_ratings/MU-Attestation-Data.aspx based on data gathered from healthdata.gov. Includes complete EHR system attestations. 48 DERMATOLOGY WORLD // January 2015 www.aad.org/dw g about in th g in rd a w re t Th e m o s logist is : to a rm e d a g in e b ply) (check all that ap e rtise to mak medical expe y m g in Us e a differenc s' faces y on patient Seeing the jo ents t new treatm Learning abou t skin cancer patients abou g in at c du E about le feel better Helping peop ance their appear to pay for for patients s th on m g tin Wai e and care my expertis _ ______________ __ ____________ If waiting for patients to pay didn't make your list, CareCredit can make an immediate difference. When a patient pays with the CareCredit healthcare credit card you get paid in just 2 business days - with no responsibility if the patient delays or defaults.† This immediately helps make payment more rewarding: Reduce accounts receivable Improve cash flow Free your team from the time and stress of billing and collections Helps remove cost as a barrier – can be used for deductibles, co-pays, skin care products, and other fees not covered by insurance To get started at no cost today, call 866-247-3049 † Subject to representations and warranties in the CareCredit Acceptance Agreement for Participating Professionals. www.carecredit.com
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