by David J. Elpern and Mariah L. Ferrara

Abstract: We have documented the access to dermatology care in the Berkshire County, Massachusetts. Of the six dermatologists practicing in the area only two accept Medicaid patients and for one of these, the wait for an appointment was over six months. Our data show unequal access to dermatologic care in Western Massachusetts

Keywords:  dermatology, access to care, Medicaid, dermatologist, medical insurance. Berkshires, Massachusetts, cryotherapy, liquid nitrogen

Introduction:
It is clear to Medicaid recipients nationwide that they have difficulty in obtaining health care from large numbers of private practitioners There are many reasons for this, but chief among them is that physicians are better reimbursed for seeing Medicare or privately insured patients than Medicaid recipients. As a result, the poorest and most vulnerable individuals receive inferior and more fragmented care. Dermatology appears to be one area in which obtaining care can be especially difficult for Medicaid patients. Herein, we document access to dermatologic care in Berkshire County, Massachusetts in 2014.

Methods:
We collected data on all dermatologists practicing in Berkshire County, Massachusetts in 2014 from the American Academy of Dermatology’s web site.¹ The resulting list was cross-referenced with the Center of Medicare and Medicaid Studies (CMS) database which lists payments to all Medicare participating physicians in the U.S in 2012. The latter information was culled from a link provided by the New York Times.²

Once this data was organized, one of us (MLF ) placed scripted calls to each dermatologist’s office. Assuming the persona of a fictitious young woman with Medicaid who wished to book an appointment for a worrisome, changing mole, she inquired as to whether the practitioner accepted her insurance, and if so, what was the wait time to see the physician.

We also collected reimbursement data for seven common office visits (99202, 99203, 99212, 99213, 99214,11100, and 17000) and compared these for Medicaid, Medicare and Blue Cross Blue Shield. (Appendix)  These data were obtained from a medical billing service, Berkshire Medical Management.

Results:
In the summer of 2014, Berkshire County had six practicing dermatologists.  Two accepted Medicaid patients while four did not participate with the state run health plan.   One of the two dermatologists who accepted Medicaid patients offered our caller an appointment seven months in the future.

Reimbursements for the the CPT codes for cryotheraoy of actinic keratoses are presented in Table 1.  The data show significant payment disparities for common office visits between Medicaid, Blue Cross Blue Shield, and Medicare.

Cryotherapy is a lucrative, fast and low-risk procedure for dermatologists It was instructive to compare Medicare reimbursement for this procedure. For practical purposes, only practitioner # 6 accepts Medicaid patients and sees them in a timely fashion. Medicaid only allows one billing code per visit. So if cryotherapy is performed on a Medicaid patient a dermatologist can only be reimbursed for the office visit or one of the procedure codes. This would significantly limit the visit fee and is a likely reason why most practitioners do not participate with Medicaid or make it difficult for these patients to obtain an appointment in a timely fashion.

Medicare Reimbursement for Cryotherapy for the Six Dermatologists in the Berkshires

Codes
17000 – Cryotherapy for One Lesion
17003 – Cryotherapy for > 1 Lesion

Discussion:
Health care insurance is considered a necessity for every individual in the United States, especially when one considers the present cost of medical treatment. Access to dermatology care has been looked at from a number of standpoints.^3,4,5 Many feel that health care should be a right.⁵ Clearly, this sentimenthis does not include the majority of dermatologists in Berkshire County, Massachusetts. Some of our neediest citizens face have problems finding an insurance plan that fits their income status and that physicians will accept. Medicaid, the lesser value health insurance financed by federal, state, and local funds, pays for hospitalization and, usually, out-patient medical care for persons of all ages within certain lower income limits. Historically, it pays physicians less than private plans. We sought to document access to dermatologic care in Berkshire County for Medicaid patients.

We called the six dermatologists in Berkshire County in an attempt to determine how easy it would be for a young, anxious Medicaid recipient to see a dermatologist for a changing mole. Melanoma is the most feared skin disorder and one can appreciate the emotions of a young person with a suspicious lesion.

Our results show that only two of Berkshire County’s six dermatologists accept Medicaid patients. One of these two offered our surrogate patient an appointment almost seven months in the future for a changing mole! The other Medicaid provider sees all patients with changing moles within two to three weeks.

Our data demonstrate that patients on Medicaid in Berkshire County are at a disadvantage if they have significant skin disease. Also, for those that did accept Medicaid, one had an unacceptably long wait time for new patients of greater than half a year. So, if a patient had an urgent dermatologic issue in Berkshire County it is unlikely that she would be able to be seen expeditiously. She would wind up at an emergency room, which had to see all patients regardless of insurance, and might receive inferior care.

Our comparison or reimbursements for common office visits shows that while Medicare and Blue Cross/Blue Shield are fairly close, dermatologists who treat Medicaid patients do so at a significant discount.  This appears to be a powerful disincentive for a majority of Berkshire County’s dermatologists to participate in the state-provided insurance for low-income people.  The result of the dermatologists non-participation in Medicaid is poor access to specialist skin care for the most vulnerable segments of the population.

Conclusion:
This study documents a two-tiered system of dermatology care in Berkshire County, Massachusetts.  Only two of six dermatologists would see Medicaid patients and for one of these, the wait period was over half a year.  By electing to not participate in Medicaid, a majority of the Berkshire’s dermatologists are denying access to specialized care that residents with higher paying insurance plans get.  In some cases, this will have a negative impact on their health.

Coda:
Two Osler quotes seem pertinent here:

The practice of medicine is an art, not a trade: a calling not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with powders or potions, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, the wise upon the foolish.⁷

Dealing as we do with poor suffering humanity,…you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures.⁸

Physicians in Berkshire County, Massachusetts, and elsewhere in the United States, need to look into their own hearts when excluding vulnerable citizens from their offices.

References:

1) American Academy of Dermatology http://www.aad.org

2) Center for Medicare Services Physician Reimbursement Database:

3. Tsang MW1, Resneck JS Jr. Even patients with changing moles face long dermatology appointment wait-times: a study of simulated patient calls to dermatologists. J Am Acad Dermatol. 2006 Jul;55(1):54-8.
4. Resneck JS Jr1, Isenstein A, Kimball AB. Few Medicaid and uninsured patients are accessing dermatologists. J Am