Can we open our own derm clinics?

Nilf said:

I routinely receive biopsies taken by RNs and PAs. If you are a dermpath fellow, you probably know how to take shaves, punches, and make small elliptical excisions.

The clinicians are treading upon our turf by in-sourcing pathology. IMO, pathology is tougher to master than the clinical work. Why can't we in-source clinical work?

What is stopping a dermatopathologist from opening a small clinic and start biopsing skin? What do Stark laws say about this setup?

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I actually went to a lecture by a primary path boarded dermatopathologist (dont remember where) who said he did exactly that.

sohsie said:

I actually went to a lecture by a primary path boarded dermatopathologist (dont remember where) who said he did exactly that.

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Most patients would get their biopsies taken by their dermatologist or primary care physician. I don't know how you could get patients to come to you, a pathologist, unless you false advertise.

Do primary care physicians hire dermatopaths to read their biopsies like dermatologists do?

If I were going into primary care I would refer to you. It would only be for patients I highly suspected that would need biopsy. I would be highly suspicious to send you hair or rash issues. I would like to think a derm has enough clinical experience to differentiate these issues and be the preferred referral. However, moles, from my understanding almost always get biopsied. I know there are busy enough pcp's out there who won't do any procedures because they take too much time so they refer them all out. That means no laceration repairs, no skin tag removals, no biopsies, etc. Derms also have notorious wait times.

If you took the time to actually feed their office, and arrange a meeting YOURSELF with the pcp, informed them in 15 minutes what it is you will do exactly, I bet you'd get referrals. Especially, if you focused on suspicious nevi and fast appointment time for your patients. Time is one of your biggest selling points. Fast appointments for your patients. Same or next day? AND immediate turn around time on prep/reading of biopsy. Focus on how fast you can get an answer for your patients. You could even advertise for skin/mole screening exams, so get handy with the digital camera to follow people long term.

You could also sell yourself based on lower system errors. In otherwords, because your biopsy samples will be handled by less people, you will have a statsitical lower probability of mislabeling and losing them. You can bring back the personal touch of pathology where the Physician's name means something, backed up patient word of mouth regarding, "That smart friendly physician diagnosed my melanoma so fast! S/he saved my life!"

As long as you acurately stated your credentials and are licensed there is nothing wrong with this. A physician still has the ability to read their own blood smears. From my understanding a GP can take a biopsy, prepare it, and read it themselves. This is all encompassed in the scope of practice of a medical license, so I don't see a problem with you reading your own biopsies.

I suspect you will have a hard time getting paid by insurance for your time doing the biopsies and seeing the patients. But you should get paid for doing the path. But since you are so fast to get your patients in, you will charge them $25? $50? cash up front for the office visit/procedure.

Just my opinion.

Nilf said:

I would not advertise falsely. I would give all of my credentials, (dermpath, AP/CP). I would not advertise as a dermatologist. I would stick to the niche of melanocytic lesions, SCC, BCC, and inflammatory. Outpatient only, no Mohs unless I train in it. Anything regarding excision larger than 1 inch gets referred.

Last time I checked, the waiting line to see a dermatologist in the area I'm at was 3 months. I think there are people out there who would be fed up with this.

Admittedly, I don't know the legal aspect of such practice model.

To answer your question, all primary care docs that I know send out their biopsies. In fact, overwhelming majority of dermatologists do, too.

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Im surprised most primary care docs and dermatologists send out their biopsies. I guess there are some decent ppl out there.

If it was legal I'm sure you can get a lot of business due to the long waitlists for dermatologists. If it was me, I would see an derm not a dermatopathologist. I think that is an obstacle in getting patients to come to you. I don't even think the lay population even knows what a dermatopathologist is.

How about prescribing meds? I think that's something a dermatologist would know...not a dermatopathologist.

Another idea if you are artistic and a hard core scientist is to pursue the arts. I'd like to think you guys are pretty smart. Imagine doing research on novel tattoo compounds. Who better to eloquently describe the superiority of your pigments over lay tattoo parlors? Plus, you are a physician so you represent sterility and a sure thing for professionalism and the highest quality. If a plastic surgeon can put a teenage girl under with general anesthesia you could do tattoos.

1) You can patent the new tattoo compounds.
2) Publish literature on how awesome they are.
3) Open your own tattoo parlor and advertise as a high class artistic studio. You don't do tattoos, you do ART!
4) Use your medical license to do conscious sedation similar to a gastroenterologist for your clients.
5) Do electronic integration into human dermis (put a chip in the skin)...Its coming in the future.
6) Perfect the perfect nipple tattoo for mastectomy patients. Make a name for yourself
7) Maintain your medical roots. You can also provide some vicodin for post-op pain.
8) You can also provide antiobiotics for any infections secondary to piercings, since you will also be doing those. Only gemstones, precious metal, and artisit piercing pieces though. No simples studs or bar bells. You don't do piercings, you do ART!
9) Make it fancy and upscale. Old school wood paneling. Art up on the walls, tapestry, wear suits, etc.
10) The new bling special. Diamond tattoos. Everyone wants a large clear diamond for their neck bling, or gold for their 'grills'. Imagine if you were rich enough to show off to your 'home boyz' that have a tattoo from brown diamond pigment. Debeers would love you for wanting to buy them off their hands!
11) Perhaps there are polymers that are perfectly synergistic with wound healing that it would increase wound strength. From my surgery rotation days I remember hearing how wounds are like 70% as strong as normal dermis? Imagine if you could tatoo in the obese abdomen of a patient a special compound that actually improved upon the wound tensile strength? Could be appropriate for high risk obese patients prone for dehiscense. Mesh on the underside, tattoo particulates on the surface!

12) Right now there is Twilight fever. Imagine how many people want full tattoos in order to sparkle like Edward? LOL!! But don't forget to have these patients evaluated first by my future specialty!

Nilf said:

Lots of interesting ideas. Niche for melanocytic lesions, fast turnaround time, mole/melanoma full body screening. Market potential there, with melanoma rates on the rise.

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Exactly! The melanocytic clinic! Melanocytic specialists! Darn good market potential especially with your guys doom and gloom attitude about your job prospects.

You could also send a PA into the nursing homes to root out your screenings. I saw some pretty suspicious looking moles on some of the people in Alzheimers units...

One catch though is you'll want to take every insurance including medicare/medicaid. When you go knocking on PCP's doors (unless they are concierge) they hate it when people are selective with insurance. Derms are already selective. So if a PCP is going to refer, is your turn around going to be enough to want to send to you and your selective insurance panel over a normal derm and their selective insurance panel? Maybe? Maybe not? The tricky thing is, if you are accepting medicare/medicaid I believe you can't charge cash for something that does have a billable code. You will have to submit to them the traditional codes for derm consult and biopsy. I suspect they'll deny it. So, for all the medicare/medicaid patients you will lose out on the up front cash. You might still be able to charge the up front cash to normal insured patients. I'm not an expert on the billing stuff though, so take it with a grain of salt.

So here is a question for you. Could a practice like this, limited by how fast/how many biopsies you can do in a day, provide you with enough dermpath slides to read and still be profitable to run a practice? You own your the practice so no one is taking a cut from the readings. No guarantee you'll get paid for the biopsy time, but the path slides are yours. Is it still doable?

More efficient to hire a few PAs to feed you the biopsies, I have heard of at least one group doing this (imo any physician should feel comfortable with shave/punch biopsies and a well trained PA would do just fine).

I have am finishing my d-path fellowship and have signed a group that has a close relationship with a group of 9 dermatologists who send them their cases, and they are very busy doing 20/dermatologist or so biopsies each day they work. They co-own their histo lab with them on their cases, plus they let them charge for porfoessional. They also have 6 color flow cytometry so I will do only skin biopsies and bone marrows, blood and lymphoma. The starting salary is more than I ever expected and I expect it to double or triple when I make partner.

Hematodermatopathology is the way to go.

So you give them a diagnosis and send them along their way?

Being actually boarded in Dermatology seems to be overrated, at least where I am. One the busiest, if not the busiest "dermatologists" is nothing more than IM boarded D.O.

So yeah, I dont think it would be hard for DP boarded pathologist to open a clinic, but that is ALOT of work. Would need to have a good biz head on your shoulders to make it pan out.

Nilf said:

I routinely receive biopsies taken by RNs and PAs. If you are a dermpath fellow, you probably know how to take shaves, punches, and make small elliptical excisions.

The clinicians are treading upon our turf by in-sourcing pathology. IMO, pathology is tougher to master than the clinical work. Why can't we in-source clinical work?

What is stopping a dermatopathologist from opening a small clinic and start biopsing skin? What do Stark laws say about this setup?

Click to expand...

I think it's a great idea..... neoplasms only.... let's get a winnebago, convert it to a couple of patient rooms, histo lab, signout room with FS set up... hell let's get a Mohs surgeon on board too. Set up in Boca and we'd be made. PM me!