Derm being wrongly targeted by NYTimes

[Tamahawk]

For those of you who haven't already seen this, it is certainly worth a read. Another fine example of someone who doesn't know what they are talking about making Dermatologists out to be villains.

Patients’ Costs Skyrocket; Specialists’ Incomes Soar

http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html


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[Mad Jack]

For those of you who haven't already seen this, it is certainly worth a read. Another fine example of someone who doesn't know what they are talking about making Dermatologists out to be villains.

Patients’ Costs Skyrocket; Specialists’ Incomes Soar

http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html


Sent from my iPhone 5S

To the New York Times, anyone that makes a decent income but is not a celebrity is a villain. Welcome to the club. You can have seat next to the bankers and CEOs.

 

[catzzz88]

Yeah, they took this way to far.

"Each patient is like an ATM machine."

I'm sorry...what? I expect better reporting from the New York Times!

 

[asmallchild]

For those of you who haven't already seen this, it is certainly worth a read. Another fine example of someone who doesn't know what they are talking about making Dermatologists out to be villains.

Patients’ Costs Skyrocket; Specialists’ Incomes Soar

http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html


Sent from my iPhone 5S

Dating back to the time I was a med student, I can remember the NY times taking potshots at dermatology

They are the kings of interviewing the oddball that fits their angle

I am glad the AAD president was there to defend the specialty

 

[happygilmore]

For those of you who haven't already seen this, it is certainly worth a read. Another fine example of someone who doesn't know what they are talking about making Dermatologists out to be villains.

Patients’ Costs Skyrocket; Specialists’ Incomes Soar

http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html


Sent from my iPhone 5S

Plus or minus.

I think the article is more fair than unfair. How can we explain how little primary care doctors we have while paying them 1/4 of what some specialists earn.

Dermatology is among the most profitable fields in medicine. It is a for profit enterprise. It's hard to earn 400-600k annual without a focus to maximize profit. It's not an accident.

I'm not saying profit is wrong but it's clearly a driving motive.

 

[HeyyDoc]

Where is the AAD president's response??

 

[asmallchild]

Where is the AAD president's response??

It's Dr. Coldiron's response within the article

 

[happygilmore]

I think one of the many shocking things in the article are things like this:

With such practices, even minor dermatology procedures can lead to big bills. When Ashley Lanning, 28, of Oregon was seen by a nurse practitioner for a mole removal, the tab came to $915.46 — “way more than I’d anticipated,” she said. The growth was scraped off with a scalpel and no stitches were required. In New York last year, Kyle Snow Schwartz, 26, went to a dermatologist at New York University Medical Center to have a wart removed from his foot. The visit took five minutes, including a chat about his plans to teach English in Vietnam and a squirt of liquid nitrogen on the growth. The invoice from the billing office: $500.

Both patients have insurance with high deductibles, so they faced large out-of-pocket payments.

In contrast, in Germany where private doctors’ allowable charges are set by the government, dermatologists are paid $30 for a whole body skin check, $40 for a standard biopsy and $20 for a pathology exam, said Dr. Matthias Augustin, who studies the practice of dermatology at the University Medical Center of Hamburg-Eppendorf. There is far less use of Mohs surgery in Germany than in the United States, he said. Most patients with a possible skin cancer get a biopsy and come back a few days later for full removal if it is positive.

Everyone knows that fee for service causes more service. American doctors do more because they get paid much more to do so. A mole removal by a NP shouldn't cost $915.

I know people in my class talking about going into derm path and how much money can be made there. This whole operation has become more about profit than medicine. It's not the doctors fault. Adminstrators, hospital CEOs, and big corporations share the blame. Yet, many doctors are doing very well in this environment. A half million dollar salary is very good, especially when primary care is earning < 200k.

15 min botox injections = $500. cha-ching. No one can honestly say that those appointments are about helping people or medicine, it's about how much can we profit off this person's desire to look younger.

Again, I don't think it's immoral or anything. It's what any business does. Let's call it what it is though.

Edit: Also can we acknowledge the main point of the article, it's ridiculous to charge a woman $25,000 for a Mohs procedure. Fortunately she was able to argue down the prices, but there are very few people in the world that can afford to pay $25,000 for a few hours of services. Is it the MDs fault? Like I said earlier, it's shared - and probably more admistrators/CEOs - but some of this is private practice and those individuals are following suit for the most part.

Articles like this, combined with the sinking of the American healthcare system is really going to screw up things for our profession. The golden age of medicine is gone. In the next decade we're going to see a LOT of changes. To many hands in our patients pockets.

Kyle Snow Schwartz was billed $500 for the five-minute removal of a wart at New York University Medical Center.

Honestly. Can anyone justify something like this? Should this cost this much?

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

In derm's defense, it's all of medicine - there's no reason to single out derm.
Launch media viewer
Kyle Snow Schwartz was billed $500 for the five-minute removal of a wart at New York University Medical Center.
Launch media viewer
Kyle Snow Schwartz was billed $500 for the five-minute removal of a wart at New York University Medical Center.

 

[MOHS_01]

Plus or minus.

I think the article is more fair than unfair. How can we explain how little primary care doctors we have while paying them 1/4 of what some specialists earn.

Dermatology is among the most profitable fields in medicine. It is a for profit enterprise. It's hard to earn 400-600k annual without a focus to maximize profit. It's not an accident.

I'm not saying profit is wrong but it's clearly a driving motive.

*head on desk*

 

[MOHS_01]

I think one of the many shocking things in the article are things like this:



Everyone knows that fee for service causes more service. American doctors do more because they get paid much more to do so. A mole removal by a NP shouldn't cost $915.

I know people in my class talking about going into derm path and how much money can be made there. This whole operation has become more about profit than medicine. It's not the doctors fault. Adminstrators, hospital CEOs, and big corporations share the blame. Yet, many doctors are doing very well in this environment. A half million dollar salary is very good, especially when primary care is earning < 200k.

15 min botox injections = $500. cha-ching. No one can honestly say that those appointments are about helping people or medicine, it's about how much can we profit off this person's desire to look younger.

Again, I don't think it's immoral or anything. It's what any business does. Let's call it what it is though.

Edit: Also can we acknowledge the main point of the article, it's ridiculous to charge a woman $25,000 for a Mohs procedure. Fortunately she was able to argue down the prices, but there are very few people in the world that can afford to pay $25,000 for a few hours of services. Is it the MDs fault? Like I said earlier, it's shared - and probably more admistrators/CEOs - but some of this is private practice and those individuals are following suit for the most part.

Articles like this, combined with the sinking of the American healthcare system is really going to screw up things for our profession. The golden age of medicine is gone. In the next decade we're going to see a LOT of changes. To many hands in our patients pockets.



Honestly. Can anyone justify something like this? Should this cost this much?



In derm's defense, it's all of medicine - there's no reason to single out derm.
Launch media viewer
Kyle Snow Schwartz was billed $500 for the five-minute removal of a wart at New York University Medical Center.
Launch media viewer
Kyle Snow Schwartz was billed $500 for the five-minute removal of a wart at New York University Medical Center.

Trying really hard to not come out of the gate with a game of kick the __________.

Try reading the article again. There was no $25,0000 Mohs procedure. She was billed $1833 for the Mohs procedure; the doc's office was probably paid +/- $700 for the procedure.

The article was pure ****.

 

[happygilmore]

Trying really hard to not come out of the gate with a game of kick the __________.

Try reading the article again. There was no $25,0000 Mohs procedure. She was billed $1833 for the Mohs procedure; the doc's office was probably paid +/- $700 for the procedure.

The article was pure ****.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

See the quote above.

I think I understand your play here. The dermatologist only got paid $1400 for the $25,000 that was billed to this woman, hence it's not the dermatologist fault. Unfortunately, that's not how the patient sees it. They see a cumulative bill.

The standard response is, "oh, well the doctor doesn't get paid that much." Fair enough. But it's hard to deny that when you're doing things like this that the model isn't for profit. Maybe your practice is different but these things are happening. And since when is getting skin having a Mohs procedure done for 5k seen as chump change?

I'm curious, if the article is pure **** then answer these questions that I posed:

1. Is the mean salary for a Mohs surgeon priced at $516,000 appropriate compared to a pediatrician's $166,000?
2. Is it fair for an NP to remove a wart and have the office bill $915?
3. Should a 5 min mole removal bill for $500?

No, it's not the dermatologist who gets all that money and some payers will negotiate the prices down. The fact remains that many derm doctors are getting rich. The Mohs surgeons definitely are getting all of their half mil.

 

[Drdrdr1115]

Another issue the article brings up is the lack of a real discussion between provider and patient in regards to diagnosis and treatment options.
The patient is told she needs Mohs..there is no talk of other options or what the diagnosis means. Even as a medical student, I've seen this type of paternalistic medicine all too often.

Additionally, there is lack of transparency in regards to the cost of procedure. A patient has a wart and the doctor says, this is a quick fix, I'll do it right now. They never mention the cost. This is a problem. We always ask the mechanic how much it'll cost to fix the car before letting them do it...why should us as doctors treat patients differently?

 

[Dral]

The NP probably sent the mole (as she should) to a pathologist to verify it was benign. So other than the time and supplies in the office for the biopsy, a courier needs to transport the specimen. Someone needs to receive it. Someone needs to process, section, mount, and stain it. Supplies are necessary to do that. The pathologist needs to sign it out, possibly getting more sections and special stains to r/o melanoma. The NP then takes more time to log the sample and contact the patient.

The article addresses none of that. It gives a biased image to uninformed public. Off the commentary page, news reporting should be unbiased. That is why the article...well...sucks.

 

[Dral]

We always ask the mechanic how much it'll cost to fix the car before letting them do it...why should us as doctors treat patients differently?

Nor do we expect someone to change our tires for free...yet when a patient is told that insurance doesn't cover the cost of their benign skin tag removal, they get all pissed and start ranting to their Dermatologist. Do we just perform the procedure for free? Nope.

It doesn't condone not discussing options and costs with patients. I actually discuss these things all the time. If my patient doesn't have insurance, I ask them if they can afford the cost of pathology services. If they can't afford it, I offer them the services of my health system's sliding scale program.

However, the metaphor you put forth goes both ways. It's frustrating to deal with patients who do not understand how these things work...and get angry even when you clearly explain it to them.

 

[happygilmore]

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[DermApp13]

The real problem is not that dermatologist make a high income but why are pediatricians make so little taking into account studying/training they undergo and the loans they have.

Why aren't there articles in NYT complaining about relatively low income of pediatricians in comparison to nurse anesthetists with incomes of $120K ?

 

[doctalaughs]

Ha. The pathology fees aren't that much - stain/mount/mail/etc - those are done by high volume facilities and shipping a sample isn't expensive (who is to say it isn't done in house with even more profit for the shop?). What portion of the $500 fee are you saying goes to path/processing? Regardless of your percentage, is the remaining fee appropriate for a 5 min appointment? Let's multiple that by 12, the hourly rate for that service would be approximately what? $6,000 / hr minus your percentage for processing. In all reality, it's probably less than 25% that goes to path/processing. That's $4500 an hour.

What about the NP removing the Wart for $915 dollars! No pathology report for that.



Exactly, most doctors just say what needs to be done - treatment options or things like, "how much will I be charged by the end after seeing this derm, anes, ophtho, facility fee, etc.?" Oh, $25,000. That's a lot. Too many hands in the patients pockets.

Still I would enjoy to hear the answers to the questions posed above:

1. Is the mean salary for a Mohs surgeon priced at $516,000 appropriate compared to a pediatrician's $166,000?
2. Is it fair for an NP to remove a wart and have the office bill $915?
3. Should a 5 min mole removal bill for $500?

I will answer your questions only because I feel your understanding of how thinks work is preventing you from understanding how sensational and wrong that article is.

Is the mean salary for a Mohs surgeon priced at $516,000 appropriate compared to a pediatrician's $166,000?

I don't know if it "fair" or "appropriate" but like most things in life, medicine and business are not based on fairness. In addition, most mohs surgeons don't get paid 516k. In fact, I wonder if they pulled numbers from different surveys because they said they used MGMA and everyone knows MGMA is inflated. In fact, the pediatrics numbers in the more recent mgma surveys list >200k for peds which is hard to believe. I would have no problem with paying pediatricians more, but it does not help to say look, the oncologist, or GI physician or orthopedics docs are getting paid "too much."

Is it fair for an NP to remove a wart and have the office bill $915? Should a 5 min mole removal bill for $500?

I will answer these together as they are the same question. I guarantee no dermatologist has ever gotten $500 for a mole biopsy or $915 for a wart removal so these numbers are totally fictional. Did a patient somewhere, some time, see a piece of paper with $500 written on it after a dermatology office visit? Maybe (although probably rare). The only way this would happen is if it included some sort of facility fee (practice is part of a hospital or university), and the dermatologist would have ZERO control over what that facility fee was. In addition, the majority of this would be written off after the insurance contract reduced the fee. 99.9% of the time the "wart removal" or "mole removal" would end up generating maybe 90 bucks, 50 of which would go to the practitioner. So those numbers are truly fiction.

I have a feeling the same thing happened regarding the "25,000" dollar bill. Facility and hospital fees (which the mohs surgeon had ZERO control over) which where then written down to a few thousand dollars total, of which maybe 900 went to the mohs surgeon. Is a few thousand dollars too much to pay the mohs surgeron + ocluoplastics to do a flap + anesthesia? We know nothing about the medical facts in this case based on how sensationalized the article was. I'm guessing the basal cell carcinoma was infiltrative/morepheaform and therefore much larger than it looked clinically. Patient ended up with a large defect, better handled by oculoplastics, and therefore was appropriately sent over. Had a good result but then freaked out over a "fictional" bill (she had insurance after all) which the healthcare team had no control over. For all we know the mohs surgeron handled it great and saved her eye.

In any case, there are some practices overusing mohs (just like procedures can be overused in many areas of medicine) but the article was terrible because the numbers are purely invented, and apparently believed by not only the general public but also medical students...

 

[MOHS_01]

See the quote above.

I think I understand your play here. The dermatologist only got paid $1400 for the $25,000 that was billed to this woman, hence it's not the dermatologist fault. Unfortunately, that's not how the patient sees it. They see a cumulative bill.

The standard response is, "oh, well the doctor doesn't get paid that much." Fair enough. But it's hard to deny that when you're doing things like this that the model isn't for profit. Maybe your practice is different but these things are happening. And since when is getting skin having a Mohs procedure done for 5k seen as chump change?

I'm curious, if the article is pure **** then answer these questions that I posed:

1. Is the mean salary for a Mohs surgeon priced at $516,000 appropriate compared to a pediatrician's $166,000?
2. Is it fair for an NP to remove a wart and have the office bill $915?
3. Should a 5 min mole removal bill for $500?

No, it's not the dermatologist who gets all that money and some payers will negotiate the prices down. The fact remains that many derm doctors are getting rich. The Mohs surgeons definitely are getting all of their half mil.

How acutely aware of you of healthcare financing? Because you're not demonstrating much of an acumen here....

By and large salary does not apply. We are paid for a service; the payment for this service is largely determined via the same technocratic system that sets all payments. Physician income is then determined based upon the revenues generated by those services rendered (a function of volume and service mix) minus the costs incurred in the provision of these services. I understand that I am likely trying to explain the color blue to a blind man at this point (given your proclivity to believing in the incredibly naive labor theory of value as demonstrated by the portion you chose to bold above), but let's just consider this an honest college effort.

As for #2 and 3 on your list -- no insurance company remaining in business on earth would pay anything approaching those numbers. If a person was paying out of pocket for the procedures they should have asked up front -- although I do agree that the charges are well beyond what I would charge (or consider reasonable).

 

[MOHS_01]

See the quote above.

I think I understand your play here. The dermatologist only got paid $1400 for the $25,000 that was billed to this woman, hence it's not the dermatologist fault. Unfortunately, that's not how the patient sees it. They see a cumulative bill.

....

Heh. The patient is "wrong" in how she sees it, then. It's really simple -- Doc A billed service A, Doc B billed service B, hospital / facility billed service C. A had nothing to do with B or C's charges.... her ignorance on the matter be damned. Had doc A billed $10 and the total bill been reduced by $1823 -- to a mere $23,000 -- would the outrage magically fade? Greedy **** that he was... he should be flogged in the public square for his 7.3% of the total bill. In fact, I'd dedicate the bulk of a scathing, poorly thought out, ignorant ass article to the character assassination of those who provided the 7.3% of the bill. Bastards -- the whole lot of them.

 

[Dral]

Ha. The pathology fees aren't that much - stain/mount/mail/etc - those are done by high volume facilities and shipping a sample isn't expensive (who is to say it isn't done in house with even more profit for the shop?). What portion of the $500 fee are you saying goes to path/processing? Regardless of your percentage, is the remaining fee appropriate for a 5 min appointment? Let's multiple that by 12, the hourly rate for that service would be approximately what? $6,000 / hr minus your percentage for processing. In all reality, it's probably less than 25% that goes to path/processing. That's $4500 an hour.

What about the NP removing the Wart for $915 dollars! No pathology report for that.

Right I'm saying the pathology fees ($300 to $400 at my in house institution) were probably part of the fees in that $915 that the article conveniently left out.

Furthermore, it's not really correct to assume that someone does 12 biopsies in an hour. Um, no. It usually takes me betwen 5 or 10 minutes to do a biopsy, but then my next patient may be a complex psoriasis patient that takes 20 minutes because I have to review labs, contact another physician for some reason, etc.

Oh I forgot to mention the overhead (electricity, rent, water) to run an office, nurse/MA salaries, malpractice fees, EMR costs...

 

[MOHS_01]

Right I'm saying the pathology fees ($300 to $400 at my in house institution) were probably part of the fees in that $915 that the article conveniently left out.

Furthermore, it's not really correct to assume that someone does 12 biopsies in an hour. Um, no. It usually takes me betwen 5 or 10 minutes to do a biopsy, but then my next patient may be a complex psoriasis patient that takes 20 minutes because I have to review labs, contact another physician for some reason, etc.

Oh I forgot to mention the overhead (electricity, rent, water) to run an office, nurse/MA salaries, malpractice fees, EMR costs...

Just for giggles sometime, take your total costs per month and divide that by the hours you are seeing patients -- that's your burn rate. You'll be amazed at how high that number is. Derm is a high volume specialty; high volume specialties have large staffing and space requirements. Small changes in reimbursement in these high overhead specialties translate into disproportionately large declines in reimbursement.

SMH @the covet clowns.

 

[DoctwoB]

Still I would enjoy to hear the answers to the questions posed above:

1. Is the mean salary for a Mohs surgeon priced at $516,000 appropriate compared to a pediatrician's $166,000?
2. Is it fair for an NP to remove a wart and have the office bill $915?
3. Should a 5 min mole removal bill for $500?

1. Even if the ~500k salary is accurate, I would argue that the pediatrician's 166k is underpaid rather than the former is overpaid. You are talking about a highly paid subpsecialist who spent ~10 years (not including undergrad) learning a unique skill that benefits the public. The salary of all doctors combined is a whopping 8% of health care cost. Think of that again. 8%. You're focusing on cutting the 8% instead of the systemic 92% that causes the issue.

2. Once again, this demonstrates a lack of understanding of how health care billing works. For an insured patient, the office charges the insurance a $900 bill, and the insurance company pays maybe $100 (which considering the time/equipment/facilities/liability, is hardly extravagant). The people that get hosed are individuals without insurance or with an extremely high deductibles, who pay full price unless they can negotiate lower. This is a system wide issue and not the fault of an individual dermatologist, who could in fact be sued by an insurance company for providing services for cheaper then their contracted rates with the insurance company.

3. See #2

There are a lot of things wrong with healthcare in this country and how much it costs. Focusing on the greedy doctors is missing the problem completely. In fact, any attempts to cut physician reimbursements for specific services/procedures often have had vast unintended consequences like reducing appointment times, increased utilization of newer/more expensive technology, etc.

 

[happygilmore]

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[happygilmore]

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[DoctwoB]

1. Actually, I don't advocate only attacking the 8% - I think you're correct that there is waste all around. I've never singled out physician incomes - I'm going to be part of that piece of the pie, I'm certainly not saying it's the only place to look. It's still one place though. And it's not only 8%, plenty of enterprising physicians have figured out how to get other pieces of the pie with facility fees, laboratory fee, imaging fees, etc. These are part of that 92% and plenty of business owning physicians are having a piece of that.

2. Right, the bills are so high to screw the people without insurance or who run out. It's not a dermatology problem, it's a system wide problem. I get that and agree. Doesn't mean that dermatology isn't playing part of the game. In other words, the article is more fair if it says that everyone is guilty instead of just derm? Ok. I will go with that.

Focusing on greedy doctors isn't the whole solution, and I agree there probably aren't tons of greedy doctors. To blindly think that physicians are only 8% though is completely wrong. Facility fees, imaging, labs, equipment, robots, etc. These are all things companies earn money off and that some physicians have been enterprising enough to get into. Physicians earn much more than their salaries and the excessive drugging, procedures, and all the other results of fee for service are catching up with a broken American healthcare system only made worse by Obamacare which has done nothing to solve the systemic issues and just brought in more people to rip off.

1. While I agree with your basic point that there is widespread waste/inefficiency, once again I think you're wrong to target physicians in what is a systemic issue. Even if doctors are including ancillary services (imaging, surgicenters, etc.) those services are generally lower cost then in-hospital procedures/imaging

2. You're right in that the un/underinsured get screwed, but once again its wrong to blame the doctors. Most would happily charge the same rate as they net on a privately insured patient, but they can't.

 

[happygilmore]

I realized that I have been in the wrong in this discussion and that I may have caused some dissension. For that I apologize.

In my personal experience with dermatologists I have been impressed with how intelligent, hard working and caring they have been. I hope you all do well.

I have erased my previous posts. Good luck to everyone.

 

[Dral]

I realized that I have been in the wrong in this discussion and that I may have caused some dissension. For that I apologize.

In my personal experience with dermatologists I have been impressed with how intelligent, hard working and caring they have been. I hope you all do well.

I have erased my previous posts. Good luck to everyone.

? No need to erase. It's nice to have a discussion on this forum that doesn't involve 4th year neuroses for a change. Heh.

 

[DermViser]

Ironically enough the author is a doctor (unlike the usual NY Times dermatology bashing author, Natasha Singer)
http://en.m.wikipedia.org/wiki/Elisabeth_Rosenthal

She's a general medicine doctor who lives in China (not kidding) and has bashed other specialties such as gastroenterology, anesthesiology, OB-Gyn, etc. in the NY Times so at least we're in good company.

 

[rockit7]

Something else missing from the article is a basic understanding of how healthcare billing works.

ALL specialties inflate their charges to some value that is way above any amount that insurance providers pay. The bill is sent to the insurance company.

The insurance company says "You have contracted with us, and therefore we offer you our patients as "in network," but that also means you can bill only the "network allowable charge."

The insurance company then pays a percentage of the "allowable charge" and the remainder is secondarily billed to the patient.

The practice of overinflating the price in order to capture the most value was initiated because Medicare pays very little, and most private insurers at least loosely tie their reimbursement (aka "allowable charge") to Medicare. It also allows for the greatest catchment--one price that's guaranteed to be above the allowable charge of any given insurance company.

So, even if the dermatologist is "charging" $25,000 himself (which we know he's not), he is only allowed to received what the insurance company allows for the charge and visit. A percentage is paid by the company (less and less these days), and the remainder billed to patient. And it is likely that the patient in the story would owe very little for the surgery itself. It is the add-ons--anesthesia, "complex repair" involving plastics, etc--that leads to extra charges that when added up she is secondarily billed for.

Take a look at the "explanation of benefits" you get after you see your doctor. Back in the day, lots of doctors never bothered to secondary bill the patient for the balance that insurance didn't pay because it was usually very little left over. Now, insurance companies offer you less coverage per dollar in premium, and doctors get blamed for trying to preserve their practices.

 

[dantt]

Sadly, patients without insurance will get billed that full price. If the service was done at a hospital or other facility where the doctor is not involved with billing, you can bet the facility will go after the patient for as much as they can (definitely more than what the patient and insurance company together would otherwise pay). It's quite sad.

Something else missing from the article is a basic understanding of how healthcare billing works.

ALL specialties inflate their charges to some value that is way above any amount that insurance providers pay. The bill is sent to the insurance company.

The insurance company says "You have contracted with us, and therefore we offer you our patients as "in network," but that also means you can bill only the "network allowable charge."

The insurance company then pays a percentage of the "allowable charge" and the remainder is secondarily billed to the patient.

The practice of overinflating the price in order to capture the most value was initiated because Medicare pays very little, and most private insurers at least loosely tie their reimbursement (aka "allowable charge") to Medicare. It also allows for the greatest catchment--one price that's guaranteed to be above the allowable charge of any given insurance company.

So, even if the dermatologist is "charging" $25,000 himself (which we know he's not), he is only allowed to received what the insurance company allows for the charge and visit. A percentage is paid by the company (less and less these days), and the remainder billed to patient. And it is likely that the patient in the story would owe very little for the surgery itself. It is the add-ons--anesthesia, "complex repair" involving plastics, etc--that leads to extra charges that when added up she is secondarily billed for.

Take a look at the "explanation of benefits" you get after you see your doctor. Back in the day, lots of doctors never bothered to secondary bill the patient for the balance that insurance didn't pay because it was usually very little left over. Now, insurance companies offer you less coverage per dollar in premium, and doctors get blamed for trying to preserve their practices.

 

[happygilmore]

Sadly, patients without insurance will get billed that full price. If the service was done at a hospital or other facility where the doctor is not involved with billing, you can bet the facility will go after the patient for as much as they can (definitely more than what the patient and insurance company together would otherwise pay). It's quite sad.

Exactly!

This is the whole point. They are screwing people over with these charges.

If the truth was, "we don't ever get paid that fee" then there would be no reason to charge 25,000 instead of 3,000. Reality is, they just collected or sued someone for 25,000. Even if it's only a few people here or there, that's a lot!

Let's say you sell houses for 125k. You make a profit off that. Imagine occasionally billing 1 million for the same house. You just converted profits of a few thousand to 900 thousand dollars! Depending on the margin.

It's a dirty business practice and the bills remain high because some people get screwed over every year. Not most but some.

That's my whole point. The business of medicine is robbing a few people here and there for huge profits. Derm is just one of many. One poster said above, "that's higher than I would charge". Well that's great but others doctors or admin of doctors DO charge these wild fees and some DO collect or sue patients for these fees. Not everyone has insurance or Medicare!

 

[asmallchild]

Sadly, patients without insurance will get billed that full price. If the service was done at a hospital or other facility where the doctor is not involved with billing, you can bet the facility will go after the patient for as much as they can (definitely more than what the patient and insurance company together would otherwise pay). It's quite sad.

Exactly!

This is the whole point. They are screwing people over with these charges.

If the truth was, "we don't ever get paid that fee" then there would be no reason to charge 25,000 instead of 3,000. Reality is, they just collected or sued someone for 25,000. Even if it's only a few people here or there, that's a lot!

Let's say you sell houses for 125k. You make a profit off that. Imagine occasionally billing 1 million for the same house. You just converted profits of a few thousand to 900 thousand dollars! Depending on the margin.

It's a dirty business practice and the bills remain high because some people get screwed over every year. Not most but some.

Who exactly is they? Have you read the response to the NYTimes article by Scott Fosko, the president of the ACMS?

To the Editor:

The American College of Mohs Surgery is disappointed with your article. Commonly, the Mohs surgeon excises the skin cancer under local anesthetic, ensures that the cancer is fully removed by microscopic examination, and immediately reconstructs the surgical defect or allows it to heal on its own, all in a single, office-based visit.

Subsequently, the charges for the skin cancer removal are bundled together with no additional laboratory, anesthesia or hospital charges. This integrated approach is highly cost-effective over a traditional removal and reconstruction in the operating room.

Mohs surgery exemplifies how medicine will be practiced in the future: It will be safe, effective, highly specialized and patient-centered.

SCOTT W. FOSKO
President, American
College of Mohs Surgery
St. Louis, Jan. 20, 2014

The vast majority of Mohs procedures are performed in an outpatient office with no additional lab, anesthesia, hospital, or operating room charges (The Mohs surgeon at my current practice is able to utilize this integrated approach to provide affordable care to the large uninsured population with skin cancers in our area). But you prefer to use the rogue examples provided by the NYT to mar an entire specialty?

Sensationalist journalism at its best with sadly the ill-informed sheep bleating in the background in its aftermath.

 

[happygilmore]

Who exactly is they? Have you read the response to the NYTimes article by Scott Fosko, the president of the ACMS?

To the Editor:

The American College of Mohs Surgery is disappointed with your article. Commonly, the Mohs surgeon excises the skin cancer under local anesthetic, ensures that the cancer is fully removed by microscopic examination, and immediately reconstructs the surgical defect or allows it to heal on its own, all in a single, office-based visit.

Subsequently, the charges for the skin cancer removal are bundled together with no additional laboratory, anesthesia or hospital charges. This integrated approach is highly cost-effective over a traditional removal and reconstruction in the operating room.

Mohs surgery exemplifies how medicine will be practiced in the future: It will be safe, effective, highly specialized and patient-centered.

SCOTT W. FOSKO
President, American
College of Mohs Surgery
St. Louis, Jan. 20, 2014

The vast majority of Mohs procedures are performed in an outpatient office with no additional lab, anesthesia, hospital, or operating room charges (The Mohs surgeon at my current practice is able to utilize this integrated approach to provide affordable care to the large uninsured population with skin cancers in our area). But you prefer to use the rogue examples provided by the NYT to mar an entire specialty?

Sensationalist journalism at its best with sadly the ill-informed sheep bleating in the background in its aftermath.

Vast majority... What a great vague term that tells us nothing and also doesn't rule out that the practice is occurring.

Here is an example. Husband and wife... "Honey, have you cheated on me?" "In the vast majority of cases, no."

NSA, "are you illegally spying on Americans and abusing your power?" "In the vast majority of cases, that doesn't happen."

Great!

At least we know that only a minority of people are getting screwed. Is that 1% or 49%? Who knows? It's just not most. Derm may be wrongly targeted but they are still one of many operating this scheme. And MOHs surgeons are part of it. Absolutely.

The 90th percentile income is a recent MGMA survey showed MOHs earning over 1 million a year!!! That's right, a million per year. Do you think those guys are charging the minimum fees? Haha. Oh to be naive. The comments above, "I don't know anyone earning that", well they are. They are getting in on all the revenue streams I mentioned earlier. Business of medicine is popping people for huge sums.

 

[doctalaughs]

Vast majority... What a great vague term that tells us nothing and also doesn't rule out that the practice is occurring.

Here is an example. Husband and wife... "Honey, have you cheated on me?" "In the vast majority of cases, no."

NSA, "are you illegally spying on Americans and abusing your power?" "In the vast majority of cases, that doesn't happen."

Great!

At least we know that only a minority of people are getting screwed. Is that 1% or 49%? Who knows? It's just not most. Derm may be wrongly targeted but they are still one of many operating this scheme. And MOHs surgeons are part of it. Absolutely.

The 90th percentile income is a recent MGMA survey showed MOHs earning over 1 million a year!!! That's right, a million per year. Do you think those guys are charging the minimum fees? Haha. Oh to be naive. The comments above, "I don't know anyone earning that", well they are. They are getting in on all the revenue streams I mentioned earlier. Business of medicine is popping people for huge sums.

I still don't think you understand why people are outraged about this article. Have you ever set foot in a dermatology (or mohs) practice? It's not 49% or even 1% ... more like 0.01% and not under control of the doctor. Should we fix the problem of uninsured people getting large bills for medicine in general? Of course we should, and it needs to be addressed mostly with the insurance company contracts, hospitals etc. so that practices aren't forced to set a high fee that only applies to the uninsured.

I still can't understand why the majority of this article is targeting dermatology when 1) the article admits that only about 10% of the bill was attributed to the mohs surgeon 2) this woman HAD insurance so the "bill" wasn't even real - it was fictional, before her contact kicked in 3) it was clearly a single patient experience and rare.

If you want to argue that mohs surgeons (or any doctor) makes too much money then go ahead. But don't make up numbers and pretend they are making any significant portion of their income off of "$25,000 a case" and "using patients as ATM machines" when this is totally invented - not even true in the patient THEY highlighted! Like people have mentioned before, the few doctors that might make a million a year are doing a high volume of cases and maybe making $900 a case. You can go ahead and argue that's too much, sure. Then again, why don't you just go ahead and attack any successful business owner who provides a lot of "services" and makes good living?

 

[happygilmore]

I still don't think you understand why people are outraged about this article. Have you ever set foot in a dermatology (or mohs) practice? It's not 49% or even 1% ... more like 0.01% and not under control of the doctor. Should we fix the problem of uninsured people getting large bills for medicine in general? Of course we should, and it needs to be addressed mostly with the insurance company contracts, hospitals etc. so that practices aren't forced to set a high fee that only applies to the uninsured.

I still can't understand why the majority of this article is targeting dermatology when 1) the article admits that only about 10% of the bill was attributed to the mohs surgeon 2) this woman HAD insurance so the "bill" wasn't even real - it was fictional, before her contact kicked in 3) it was clearly a single patient experience and rare.

If you want to argue that mohs surgeons (or any doctor) makes too much money then go ahead. But don't make up numbers and pretend they are making any significant portion of their income off of "$25,000 a case" and "using patients as ATM machines" when this is totally invented - not even true in the patient THEY highlighted! Like people have mentioned before, the few doctors that might make a million a year are doing a high volume of cases and maybe making $900 a case. You can go ahead and argue that's too much, sure. Then again, why don't you just go ahead and attack any successful business owner who provides a lot of "services" and makes good living?

Medicine is not a free market for the consumer. They don't know what they are being charged and can't make intelligent comparative choices often, lack choice often and are not equipped to know when they need treatment or not and to what extent.

This makes it different from most other businesses.

Next, o.o1%? Do you know how ridiculous that sounds? There are around 12,000 dermatologists in the US. So by your numbers, only 1 dermatologist in America is overcharging! Only one in America. Yet there are plenty more earning over 1,000,000 per year in MOHs which others have stated that 500k seems high. Isn't that a huge gap? There's much more than 1 guy doing this.

I don't think derm should be singled out, but it's an easy target because of high salary.

I know a few academic MOHs surgeons. They are awesome. My derm department is fantastic and among the best doctors I've worked with in my 3rd year. I love dermatologists.

 

[doctalaughs]

Medicine is not a free market for the consumer. They don't know what they are being charged and can't make intelligent comparative choices often, lack choice often and are not equipped to know when they need treatment or not and to what extent.

This makes it different from most other businesses.

Next, o.o1%? Do you know how ridiculous that sounds? There are around 12,000 dermatologists in the US. So by your numbers, only 1 dermatologist in America is overcharging! Only one in America. Yet there are plenty more earning over 1,000,000 per year in MOHs which others have stated that 500k seems high. Isn't that a huge gap? There's much more than 1 guy doing this.

I don't think derm should be singled out, but it's an easy target because of high salary.

I know a few academic MOHs surgeons. They are awesome. My derm department is fantastic and among the best doctors I've worked with in my 3rd year. I love dermatologists.

I never said it was 0.01% who were "overcharging" (whatever price you consider that to be). I said that the situation this article highlights (and has the public believe is commonplace) - where a patient goes to a mohs surgeon and ends up with a 25,000 bill that they ACTUALLY owe after any insurance they have - is near to zero. I also said that almost all the mohs surgeons and other procedural specialists that do well achieve that by a high volume of procedures and a reasonable price, NOT by charging outrageous fees to a few people.

Out of curiosity what do you think is a "fair" price to get a mohs surgery? A heart stent? A colonoscopy?
What percentage of cases do you think a mohs surgeon does the whole case vs sends to an additional surgeon for closure?

 

[MOHS_01]

Sadly, patients without insurance will get billed that full price. If the service was done at a hospital or other facility where the doctor is not involved with billing, you can bet the facility will go after the patient for as much as they can (definitely more than what the patient and insurance company together would otherwise pay). It's quite sad.

Not true -- at least not for any institution or private provider that I have had experience with (and that is several). Every single entity that I know has a self pay policy; some of these are more generous than others, but I do not know of a single entity that withholds pricing information from self pay patients and surprises them with a small mortgage. Not. One.

Perhaps a person who is on the hook for the bill should have the gumption God gave a turnip and ask for the price before the service. Nah -- that's crazy talk.

 

[MOHS_01]

Exactly!

This is the whole point. They are screwing people over with these charges.

If the truth was, "we don't ever get paid that fee" then there would be no reason to charge 25,000 instead of 3,000. Reality is, they just collected or sued someone for 25,000. Even if it's only a few people here or there, that's a lot!

Let's say you sell houses for 125k. You make a profit off that. Imagine occasionally billing 1 million for the same house. You just converted profits of a few thousand to 900 thousand dollars! Depending on the margin.

It's a dirty business practice and the bills remain high because some people get screwed over every year. Not most but some.

That's my whole point. The business of medicine is robbing a few people here and there for huge profits. Derm is just one of many. One poster said above, "that's higher than I would charge". Well that's great but others doctors or admin of doctors DO charge these wild fees and some DO collect or sue patients for these fees. Not everyone has insurance or Medicare!

You should have stuck with post #26.

 

[MOHS_01]

Vast majority... What a great vague term that tells us nothing and also doesn't rule out that the practice is occurring.

Here is an example. Husband and wife... "Honey, have you cheated on me?" "In the vast majority of cases, no."

NSA, "are you illegally spying on Americans and abusing your power?" "In the vast majority of cases, that doesn't happen."

Great!

At least we know that only a minority of people are getting screwed. Is that 1% or 49%? Who knows? It's just not most. Derm may be wrongly targeted but they are still one of many operating this scheme. And MOHs surgeons are part of it. Absolutely.

The 90th percentile income is a recent MGMA survey showed MOHs earning over 1 million a year!!! That's right, a million per year. Do you think those guys are charging the minimum fees? Haha. Oh to be naive. The comments above, "I don't know anyone earning that", well they are. They are getting in on all the revenue streams I mentioned earlier. Business of medicine is popping people for huge sums.

When someone argues from a position of utter ignorance it only follows that their argument will be utter ****. Not 1%. Not 49%. All the time.

Here's the deal, junior -- your argument is based upon working the spreadsheet in reverse order; it does not work that way. You cannot take the number at the bottom right and meaningfully extrapolate back within the construct of healthcare financing.

Let me walk you through this: that end number comes from a variety of things. This would include service mix, payer mix, volumes provided, etc. These services can range from the 17300 micrographic series of codes, reconstructions, any general derm services provided, consulting fees, directorship fees, speaking fees, any share of facility fees, etc. Medicare is strictly price controlled; private insurance contracts are as well. Self pay is a very small percentage of the total book of business and, as I have mentioned time and again, is steeply discounted for the vast majority of instances.

There are plenty of stones to be thrown in any direction in medicine, Mohs included. Here's the problem, though -- you don't know enough to ascertain what they are. Again, it's the whole arguing from a position of ignorance again (you really should reconsider doing this time and again -- ignorance has a way of showing itself at the most inopportune times). Do you want to know why most Mohs cases are performed in the office setting? How about this -- it's not reimbursable for a facility fee! Google ASC facility fee schedule and find 173xx on that list -- I dare you. It's just not there. Second reason? For the past 20 or more years the only docs trained in Mohs have been dermatologists; dermatologist do not operate in hospitals as a rule. There are some who own or operate out of a facility, but the number is small -- and the only financial advantage there is with certain reconstructions. Pick up that stone at will. As for the instances of Mohs cases billed from hospitals -- it is commonly held among the derm surgery community that these actually represent abusive billing coding errors on the part of the surgeon / pathologist acting jointly. There's another stone for you.

Now for the big rock -- utilization. That is the biggie.

...and for ****'s sake stop with the covetous arguments. Look at the wRVU numbers that generated that 90%tile mark. Understand where that number comes from. Understand that the actual Mohs codes do not have large wRVU valuations relative to total RVU... which means that much of the wRVU's being provided come from other services. Hopefully you can put 2+2 together....

 

[reno911]

Perhaps a person who is on the hook for the bill should have the gumption God gave a turnip and ask for the price before the service. Nah -- that's crazy talk.

I agree with everything else you have posted, but this criticism is not always a fair one. My guess is that you work at a private practice, where the separation between you and billing is relatively minimal, so you can easily know and to a large extent control what your billing people tell patients a patient might be charged.

However, if you worked at a large academic medical center or a large multispecialty group it would be different. I have worked in both environments and occasionally patients will ask in advance about costs. In both cases (in my experience), pt is told to call an office that handles these things and most of time be severely misinformed or not get a useful answer. This is also despite my attempts to talk to the billing department and set them straight. I have many colleagues that work in similar settings and they express similar frustrations. However, my colleagues in private practice never have a problem with this (and neither did I in a private practice setting). This is one of the many benefits of private practices that no one ever talks about.

 

[dantt]

The NYT is hardly singling out Derm. This article was only the latest in a series of articles highlighting the high cost of health care with examples such as colonoscopies, obstetrics, and emergency medicine. As I said before, private practices, or practices where physicians control the billing are usually a little bit lenient with regards to what amounts they'll sue. Hospitals or other large entities with billing departments will pursue patients for a balance as little as $20 to hundreds of thousands (even when insurance would have paid half the amount). Sometimes seems the only way for such patients to fight back is to bring their story to the media.

Who exactly is they? Have you read the response to the NYTimes article by Scott Fosko, the president of the ACMS?

To the Editor:

The American College of Mohs Surgery is disappointed with your article. Commonly, the Mohs surgeon excises the skin cancer under local anesthetic, ensures that the cancer is fully removed by microscopic examination, and immediately reconstructs the surgical defect or allows it to heal on its own, all in a single, office-based visit.

Subsequently, the charges for the skin cancer removal are bundled together with no additional laboratory, anesthesia or hospital charges. This integrated approach is highly cost-effective over a traditional removal and reconstruction in the operating room.

Mohs surgery exemplifies how medicine will be practiced in the future: It will be safe, effective, highly specialized and patient-centered.

SCOTT W. FOSKO
President, American
College of Mohs Surgery
St. Louis, Jan. 20, 2014

The vast majority of Mohs procedures are performed in an outpatient office with no additional lab, anesthesia, hospital, or operating room charges (The Mohs surgeon at my current practice is able to utilize this integrated approach to provide affordable care to the large uninsured population with skin cancers in our area). But you prefer to use the rogue examples provided by the NYT to mar an entire specialty?

Sensationalist journalism at its best with sadly the ill-informed sheep bleating in the background in its aftermath.

 

[Dral]

Self pay is a very small percentage of the total book of business and, as I have mentioned time and again, is steeply discounted for the vast majority of instances.

True. Not long ago we did an SCC excision with simple closure for $500. That includes all services (surg, path, f/u).

Number of times we see self pay for something that extensive? Two or three times a year tops.

 

[happygilmore]

When someone argues from a position of utter ignorance it only follows that their argument will be utter ****. Not 1%. Not 49%. All the time.

Here's the deal, junior -- your argument is based upon working the spreadsheet in reverse order; it does not work that way. You cannot take the number at the bottom right and meaningfully extrapolate back within the construct of healthcare financing.

Let me walk you through this: that end number comes from a variety of things. This would include service mix, payer mix, volumes provided, etc. These services can range from the 17300 micrographic series of codes, reconstructions, any general derm services provided, consulting fees, directorship fees, speaking fees, any share of facility fees, etc. Medicare is strictly price controlled; private insurance contracts are as well. Self pay is a very small percentage of the total book of business and, as I have mentioned time and again, is steeply discounted for the vast majority of instances.

There are plenty of stones to be thrown in any direction in medicine, Mohs included. Here's the problem, though -- you don't know enough to ascertain what they are. Again, it's the whole arguing from a position of ignorance again (you really should reconsider doing this time and again -- ignorance has a way of showing itself at the most inopportune times). Do you want to know why most Mohs cases are performed in the office setting? How about this -- it's not reimbursable for a facility fee! Google ASC facility fee schedule and find 173xx on that list -- I dare you. It's just not there. Second reason? For the past 20 or more years the only docs trained in Mohs have been dermatologists; dermatologist do not operate in hospitals as a rule. There are some who own or operate out of a facility, but the number is small -- and the only financial advantage there is with certain reconstructions. Pick up that stone at will. As for the instances of Mohs cases billed from hospitals -- it is commonly held among the derm surgery community that these actually represent abusive billing coding errors on the part of the surgeon / pathologist acting jointly. There's another stone for you.

Now for the big rock -- utilization. That is the biggie.

...and for ****'s sake stop with the covetous arguments. Look at the wRVU numbers that generated that 90%tile mark. Understand where that number comes from. Understand that the actual Mohs codes do not have large wRVU valuations relative to total RVU... which means that much of the wRVU's being provided come from other services. Hopefully you can put 2+2 together....

It's fairly obvious you will know more about billing than I do, I'm a M3.

Nevermind. You win. You are the better person. You are smarter than me. I am ignorant. I don't know enough to ascertain anything. I can't put 2 + 2 together. The $1,000,000 salaries are completely justified. No dermatologists have ever ripped off a patient.

Good luck in your career. I hope you earn lots of money.

 

[MOHS_01]

True. Not long ago we did an SCC excision with simple closure for $500. That includes all services (surg, path, f/u).

Number of times we see self pay for something that extensive? Two or three times a year tops.

There are 10 Mohs trained guys in my state; I cannot speak for the three up north, but I am the only one of the remaining 7 that I am aware of who does not actively limit the number of self (no) pays. I live in a very poor state besieged by poor health, poor education, and general poor economics -- poor systems that have been greatly worsened by government regulations. Anyway... I probably do more charity cases than anyone as I do a couple hundred a year. My self pay Mohs cases are asked to bring $300 with them at the date of service if they can; no one is turned away. I always do whatever reconstruction I can as you simply cannot find a plastic surgeon willing to cut a deal -- even the University (especially the University) are douches to deal with. Their total bill never exceeds $1000 and I personally cannot remember charging more than $500. Excisions, regardless of repair, have been charged $250. I more often than not never see that; in 2013 I had accumulated over $350k in bad debt stretching back to June of 2010 -- the last time I purged the books of bad debt -- and this is at those discounts.

Yes, people who do what I do can be and often are paid well. We do it on volume and sheer work effort. I know that it may not be a popular or politically correct opinion to profess, but the people who self select for any given profession will play a significant determining role in how well that profession performs... and those of us who self select out for Mohs would trend toward the more productive.

What our dear M3 does not understand is that the income of the procedural dermatologist is not extravagantly high because he or she is paid better for any given service than any other specialty providing the same service; it's that we are quite busy and proficient at what we do... which drives a volume of services not matched by many... and the economics of it are such that greater revenues translate into greater profits in a nonlinear fashion.

 

[MOHS_01]

It's fairly obvious you will know more about billing than I do, I'm a M3.

Nevermind. You win. You are the better person. You are smarter than me. I am ignorant. I don't know enough to ascertain anything. I can't put 2 + 2 together. The $1,000,000 salaries are completely justified. No dermatologists have ever ripped off a patient.

You're coming around, there may be hope for you yet. I'm a cynic by birth, though, and you have yet to change my outlook here.

Borrowing your line of logic for a moment, maybe some consideration should be given to this whole antivaccine movement -- I hear they've been known to hurt some people along the way. Maybe police forces, too -- I hear they have been known to kill people (particularly people of color -- they look for any opportunity to do that! Hell yeah!)

p.s. They're not salaries.

Good luck in your career. I hope you earn lots of money.

Thanks. Me too.

 

[MOHS_01]

I agree with everything else you have posted, but this criticism is not always a fair one. My guess is that you work at a private practice, where the separation between you and billing is relatively minimal, so you can easily know and to a large extent control what your billing people tell patients a patient might be charged.

However, if you worked at a large academic medical center or a large multispecialty group it would be different. I have worked in both environments and occasionally patients will ask in advance about costs. In both cases (in my experience), pt is told to call an office that handles these things and most of time be severely misinformed or not get a useful answer. This is also despite my attempts to talk to the billing department and set them straight. I have many colleagues that work in similar settings and they express similar frustrations. However, my colleagues in private practice never have a problem with this (and neither did I in a private practice setting). This is one of the many benefits of private practices that no one ever talks about.

Billing staff **** things up all the time -- and the larger the entity, the greater the likelihood for the screw up. I worked for a large MSG for a year and some change during a transition period while waiting on construction delays at the specialty hospital my wife was going to work at and yeah, that is a real pain in the ass. I'm sure that the culture of varying institutions come into play, but even as an employed doc (okay, I had brought in an established private practice that generated profits in excess of 1.5x my annual salary so I was in a better position than most owners) I could pick up the phone and tell billing what we would be charging for any service I provided. Even were that not the case, a patient should have the sense to call and get an expected price or range of prices prior to agreeing to the service; if they cannot do so at your institution, they should feel free to find another institution. There is no way in hell that I would order off of a menu without prices -- and I expect others to do the same.

My (unfortunate) experience is that many of them could not care less what the charge will be as they have no intention of paying anyway.

 

[dantt]

Thank you for your service and sacrifice. As you mention though, you're in the minority.

What I hope would happen more often is institutions taking self pay patients, and charging them the true cost of the procedure up front plus a fair mark up to compensate them for their time. What they're charging self pay patients right now does not reflect any sane rationale. It's absurd justifying the excess charges the the most vulnerable to cover other uncompensated care.

I hate to compare people to machines but imagine you got into an accident and damaged your car. You go to the auto body shop and you try to get as accurate an estimate as possible. We all know more damage may be hiding underneath and that possibility is disclosed at the beginning. However, the estimate is the same whether the insurance or the owner pays (in theory).

There are 10 Mohs trained guys in my state; I cannot speak for the three up north, but I am the only one of the remaining 7 that I am aware of who does not actively limit the number of self (no) pays. I live in a very poor state besieged by poor health, poor education, and general poor economics -- poor systems that have been greatly worsened by government regulations. Anyway... I probably do more charity cases than anyone as I do a couple hundred a year. My self pay Mohs cases are asked to bring $300 with them at the date of service if they can; no one is turned away. I always do whatever reconstruction I can as you simply cannot find a plastic surgeon willing to cut a deal -- even the University (especially the University) are douches to deal with. Their total bill never exceeds $1000 and I personally cannot remember charging more than $500. Excisions, regardless of repair, have been charged $250. I more often than not never see that; in 2013 I had accumulated over $350k in bad debt stretching back to June of 2010 -- the last time I purged the books of bad debt -- and this is at those discounts.

Yes, people who do what I do can be and often are paid well. We do it on volume and sheer work effort. I know that it may not be a popular or politically correct opinion to profess, but the people who self select for any given profession will play a significant determining role in how well that profession performs... and those of us who self select out for Mohs would trend toward the more productive.

What our dear M3 does not understand is that the income of the procedural dermatologist is not extravagantly high because he or she is paid better for any given service than any other specialty providing the same service; it's that we are quite busy and proficient at what we do... which drives a volume of services not matched by many... and the economics of it are such that greater revenues translate into greater profits in a nonlinear fashion.

 

[happygilmore]

You're coming around, there may be hope for you yet. I'm a cynic by birth, though, and you have yet to change my outlook here.

Borrowing your line of logic for a moment, maybe some consideration should be given to this whole antivaccine movement -- I hear they've been known to hurt some people along the way. Maybe police forces, too -- I hear they have been known to kill people (particularly people of color -- they look for any opportunity to do that! Hell yeah!)

p.s. They're not salaries.



Thanks. Me too.

You are right and I am wrong. I admit this. I have no ego nor anything to prove. I honestly wish you well.

 

[MOHS_01]

Thank you for your service and sacrifice. As you mention though, you're in the minority.

What I hope would happen more often is institutions taking self pay patients, and charging them the true cost of the procedure up front plus a fair mark up to compensate them for their time. What they're charging self pay patients right now does not reflect any sane rationale. It's absurd justifying the excess charges the the most vulnerable to cover other uncompensated care.

I hate to compare people to machines but imagine you got into an accident and damaged your car. You go to the auto body shop and you try to get as accurate an estimate as possible. We all know more damage may be hiding underneath and that possibility is disclosed at the beginning. However, the estimate is the same whether the insurance or the owner pays (in theory).

How would you propose we should determine this price? Serious question. You come up with a metric and I'll shoot you some numbers. My bet is you will be surprised at how costly it is to provide some services, but we'll see.

Charity want not for itself -- I make no big deal of it, never even so much as mention it outside of this *anonymous* forum. It is recognized and discussed, though, which is actually a bad thing -- when one gets to be known as the softie willing to work for free Gresham's law takes hold and kills your practice.

 

[Dral]

...and that's a slippery slope. It's easier in gen/med derm: "I'm sorry, insurance will not pay to have these benign skin tags removed. Thus it is classified as cosmetic and we would not get paid to perform this. Our policy is to not perform cosmetic procedures for free. Normal insurance co-pays do not cover the cost either."

If a skin tag is larger than 0.5 cm, I'll take it gratis and send it to path. I've found a pinkus tumor in a large 'skin tag' before. If there are multiple small ones, pt has to pay a cosmetic fee.

This is not as easy for a Mohs surgeon...they are dealing with skin cancer. Do you just turn away someone with SCC on their cheek because they can't pay? At most hospitals, there are at least sliding scale services that help. If your out in private practice, how do you handle that? It's not an easy thing to handle if you have a bunch of skin cancers with no insurance cards or dollar bills in their pocket knocking on your door.