Nilf

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So the public option is alive and kicking, and the federal government is poised to wrap its ugly tentacles all over medicine, including dermatology.
1. How do you think dermatology will fare IN CASE there will indeed be a Medicare-for-all type of entitlement program, which would be 'covering' all citizens, and setting the reimbursement rates pegged to Medicare?
2. Do you think dermatologists are in such high demand that they will be able to eschew the government-set reimbursement rate and make they own rules on how they get paid and by whom?
3. Why? Why not?
 

Doublecortin

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So the public option is alive and kicking, and the federal government is poised to wrap its ugly tentacles all over medicine, including dermatology.
1. How do you think dermatology will fare IN CASE there will indeed be a Medicare-for-all type of entitlement program, which would be 'covering' all citizens, and setting the reimbursement rates pegged to Medicare?
2. Do you think dermatologists are in such high demand that they will be able to eschew the government-set reimbursement rate and make they own rules on how they get paid and by whom?
3. Why? Why not?
Yeah, I am also interested to hear from people in the know.

One of the things about derm that appeals to me is that you can have a well diversified practice with some medical/surgical derm and some cosmetic derm, where patients pay cash. So if everything goes to hell, you can just say f this, and switch to an all cash practice
 
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Uhm, no. That was three days ago. Today Blue Dogs caved in and the House put forward the liberal version with minimal concessions for Blue Dogs. Senate will come up with a version of their own. It's unclear what the final bill look like, but public option is a real threat.
Ah. I see.

:barf:
 

deltamed

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Yeah, I am also interested to hear from people in the know.

One of the things about derm that appeals to me is that you can have a well diversified practice with some medical/surgical derm and some cosmetic derm, where patients pay cash. So if everything goes to hell, you can just say f this, and switch to an all cash practice
It's actually pretty hard to switch to an all cash practice. Derm exists about 90% on medical derm and 10% on cosmetics. There is fierce competition for those cosmetic patients so you can't just "switch" to a cash practice without battling your colleagues- there aren't enough patients that will pay out-of-pocket to go around, especially in this economy.

The public option will affect all doctors and the healthcare debated now will most likely screw the specialists more. Articles and talk going around are saying specialists earn on average "five times" more than PCPs, which is grossly wrong. Think about mohs- patients can't pay for it themselves and if the public option cuts that code (again) the specialty will all but dissapear. Same for dermpath reimbursements. There is talk of cutting prodecure reimbursement as well, which will really hurt genderm.

Overall the public plan will hurt our salaries.... I'd guess a 30% cut at least. Same for all specialists and derm is certainly not immune. Sadly, I might be willing to accept this if we got good health care in this nation... but the things they are proposing will do nothing about stopping cost increases.... just more will go to drug companies, administrative overhead, insurance companies and trial lawyers. Sad.
 

asmallchild

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There is fierce competition for those cosmetic patients so you can't just "switch" to a cash practice without battling your colleagues- there aren't enough patients that will pay out-of-pocket to go around, especially in this economy.
Admittedly, I haven't been back to see my hometown dermatologist since leaving for medical school so I cannot comment on how he's doing in these economic circumstances. But he used to run a successful cash-based non-cosmetic practice despite battling with 5-6 other (we lived in a large suburban area) dermatologists in the area who did take insurance plans.

He may be the exception but for those who are exceedingly friendly, available, and of course, good at what they do, transitioning to a cash practice may still be feasible (I certainly agree this would be something in general derm and not MOHS or dermpath)

I don't doubt derm will be hit but I feel it's still better positioned than most fields because of the high volume of patients, the small procedures, and the option to add cosmetics to the mix.
 

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Actually, probably going to hurt the drug industry as well. I foresee less R&D, less money from VCs, and so on. Not only that, academics could see a bust... Again, funding. I truly hope this doesn't happen. But it might.
 

Doublecortin

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Actually, probably going to hurt the drug industry as well. I foresee less R&D, less money from VCs, and so on. Not only that, academics could see a bust... Again, funding. I truly hope this doesn't happen. But it might.
even more bust than now? :eek:

With ever increasing tuitions and cost of living and declining reimbursements, who in their right mind would go into academics?
 

N-Surge

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even more bust than now? :eek:

With ever increasing tuitions and cost of living and declining reimbursements, who in their right mind would go into academics?
Sure, but I would hope not.

And some of us are not in our right mind. :p
 

Doublecortin

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Sure, but I would hope not.

And some of us are not in our right mind. :p
I was being facetious. But seriously, if money weren't an issue, and I were independently wealthy, I would go into academics in a heartbeat. However, I am going to be looking at ~ 200 K in debt (and that's coming out of public school), and I don't think I'll be able to sacrifice a large part of my income to go into academics
 
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Nilf

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Admittedly, I haven't been back to see my hometown dermatologist since leaving for medical school so I cannot comment on how he's doing in these economic circumstances. But he used to run a successful cash-based non-cosmetic practice despite battling with 5-6 other (we lived in a large suburban area) dermatologists in the area who did take insurance plans.

He may be the exception but for those who are exceedingly friendly, available, and of course, good at what they do, transitioning to a cash practice may still be feasible (I certainly agree this would be something in general derm and not MOHS or dermpath)

I don't doubt derm will be hit but I feel it's still better positioned than most fields because of the high volume of patients, the small procedures, and the option to add cosmetics to the mix.
How interesting... I hope the highlighted part will hold true... And I hope you're wrong about Moh's and dermpath.

Moh's and dermpath are based on general derm, i.e. general derm feeds business to Moh's and dermpath. If general derm survives onslaught of public option and remains firmly under dermatologists', and not government's control, then so will Moh's and dermpath.

IMO derm is better positioned than other specialties because of relative scarcity of dermatologists. By the same rationale, so is Moh's and dermpath. Public option can distort the market, but cannot control it.

If you don't share my cautious optimism, please elaborate.
 

asmallchild

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How interesting... I hope the highlighted part will hold true... And I hope you're wrong about Moh's and dermpath.

Moh's and dermpath are based on general derm, i.e. general derm feeds business to Moh's and dermpath. If general derm survives onslaught of public option and remains firmly under dermatologists', and not government's control, then so will Moh's and dermpath.

IMO derm is better positioned than other specialties because of relative scarcity of dermatologists. By the same rationale, so is Moh's and dermpath. Public option can distort the market, but cannot control it.

If you don't share my cautious optimism, please elaborate.
I certainly hope I'm wrong about MOHS and dermpath as well but I just don't see the market of people willing to pay out-of-pocket for MOHS surgery and especially for the privilege of someone to read their skin biopsy slides.

Again, I think the scarcity of dermatologists is a benefit but I can only see people being willing to pay for general visits (assuming it comes with manageable wait times) and smaller procedures (biopsies, small cosmetic procedures, minor excisions, etc...)
 
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Nilf

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I certainly hope I'm wrong about MOHS and dermpath as well but I just don't see the market of people willing to pay out-of-pocket for MOHS surgery and especially for the privilege of someone to read their skin biopsy slides.

Again, I think the scarcity of dermatologists is a benefit but I can only see people being willing to pay for general visits (assuming it comes with manageable wait times) and smaller procedures (biopsies, small cosmetic procedures, minor excisions, etc...)
Of course patients won't pay out of pocket for having their slides read. Dermatologist who is sending the slides will. Since IMO dermatology has a good shot at determining their own reimbursement rates, as dictated by market and not the government, so can dermpath. Patient's will shop around for the best dermatology deal, and dermatologists (and PCPs) will shop around for the best dermatopathology deal.

I don't know much about Moh's but I was under the impression that they are also highly sought-after specialists, so they should be able to defeat any effort of by government to fix prices.

Maybe I'm overly optimistic though--there are so many bad things in HR3200.
 

Doublecortin

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I certainly hope I'm wrong about MOHS and dermpath as well but I just don't see the market of people willing to pay out-of-pocket for MOHS surgery and especially for the privilege of someone to read their skin biopsy slides.

Again, I think the scarcity of dermatologists is a benefit but I can only see people being willing to pay for general visits (assuming it comes with manageable wait times) and smaller procedures (biopsies, small cosmetic procedures, minor excisions, etc...)
I thought skin cancer is kind of an emergency, you can't just walk around with it, so I would think people would be willing to pay to get rid of it as soon as possible?
 

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I guess I am being a little bit picky, but Mohs Micrographic Surgery is spelled "Mohs" after Frederic Mohs who invented the technique (not Moh's or MOHS).

As for the rest of the thread I would feel that general derm would lend itself very well towards the cash only option. I think it would be more difficult to set up a cash only system with Mohs and Dermpath but I guess it could be done, you would just have to have a network of referring M.D.s that were able to set up customers that would pay you straigh up cash. the cash-only option would be very
 
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Nilf

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I guess I am being a little bit picky, but Mohs Micrographic Surgery is spelled "Mohs" after Frederic Mohs who invented the technique (not Moh's or MOHS).

As for the rest of the thread I would feel that general derm would lend itself very well towards the cash only option. I think it would be more difficult to set up a cash only system with Mohs and Dermpath but I guess it could be done, you would just have to have a network of referring M.D.s that were able to set up customers that would pay you straigh up cash. the cash-only option would be very
kk I stand corrected.

I'm theorizing that since derm would lend itself toward out-of-pocket type of option, then so should the practices that obtain business from general derm. So much for theory, I don't know how it will play out in practice.

Maybe you can help me gain some basic insight into how derm practices are run.

Case 1 scenario: Let's say you have a patient with private insurance. You take a biopsy and you send it out to a dermatopathologist. You and the dermatopathologist bill the patient insurance, right?

Case 2 scenario: Now, let's say that the patient does not have the insurance. You bill the patient directly. You take biopsy and send it out. Whom does the dermatopathologist send the bill to: you (the dermatologist) or the patient?
 

deltamed

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Case 1 scenario: Let's say you have a patient with private insurance. You take a biopsy and you send it out to a dermatopathologist. You and the dermatopathologist bill the patient insurance, right?


Case 2 scenario: Now, let's say that the patient does not have the insurance. You bill the patient directly. You take biopsy and send it out. Whom does the dermatopathologist send the bill to: you (the dermatologist) or the patient?
In case 1 yes, you both bill the patient's insurance

In case 2 the same. If the dermatologist read the slide himself he can bill for the initial read and send it to the dermatopathologist who then can bill for a consult.

I feel mohs is overutilized, especially in some places. Everything goes for mohs or excision whereas it's debatable if that is overkill... Simple ED&C should be used much more unless it's disfiguring or very high risk. Some places are now saturated with mohs but if they continue to cut the reimbursements it will simply be done less... the derm/surg community will turn to other procedures.

Sure, I don't think derm is in any worse position than other specialties. I don't know if it's in a better position, however. If they stop reimbursing for "pre-malignant" destructions or "inflammed SKs" the world won't end but derm will take a hit and there will be no outcry from patients. If they stop reimbursing for something like knee replacements you bet patients will protest.
 

N-Surge

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<snip>
the cash-only option would be very
Did you get paged away in mid sentence? :)

I am not so sure Mohs couldn't do what I have seen in a Plastics practice where it is all cash. Of course, the Mohs dude may need to supplement with more MedDerm and Cosmetics. But I would think it could be done.