Cold Iron Truth

My grandfather used to say: “Son, keep your powder dry.” The old aphorism is basically a reminder to keep your power or influence in reserve until you really need it. In my case, he could simply have been trying to quiet an overly talkative kid. But anything my grandfather said that had to do with guns carried great authority with me. He owned a shotgun that had been converted from a flintlock by his grandfather, and we grandchildren were schooled in its use.

I was recently reminded of my grandfather’s advice as I was about to participate in a planned meeting. One of the meeting leaders pulled me aside to tell me that I was not to ask questions, and informed me that if I did ask questions, I would be punished to the fullest extent possible. I also was not to challenge the preordained conclusion.

I was simultaneously aghast and impressed. Never had I heard such a trifecta of terrible leadership uttered in a single breath. It was a reminder to revisit the premises of all the books I had read and the conferences I had attended on leadership.

There are basic prerequisites of building consensus and adopting new ideas.

First, you must introduce the wonderful idea and explain it to everyone. It is even better when you are able to back up someone else’s great idea.

Next, you must allow the group to discuss the idea and be open to change. This may involve shelving, or even killing, your shiny new idea.

You must allow time for things to sink in regarding the idea. If you want something to stick, people have to adapt and adopt. If your idea is truly wonderful, you should be able to attract advocates and get a majority to agree to the plan. You should make sure they get to vote on the plan. If you lose the vote, don’t try any maneuvers to undo your loss. Accept it and move on. If your idea is good, it will surface again as someone else’s idea and be a much easier pitch.

Finally, never, ever bully or threaten. Memories are long, and while some may not agree with your idea, they won’t actively try to kill it later or undermine future projects. Pinch yourself every day, and remember that you are a servant of the group. You are a facilitator, not an autocrat.

That said, leaders differ in their styles of leadership. I think the best leaders are not afraid to listen to their boards and membership. Their actions focus thoughts and move things along. If you let your board members own their actions, they will respect you. You will build up tremendous goodwill (and powder). With any luck, you may never need to draw on this goodwill; but if there is a crisis and you need to put a bullet through something quickly, your intentions will not be questioned. At a minimum, you will have plenty of opportunity to explain your actions.

So it saddens me to see leaders burn all their powder and lose their influence. It’s not good for them or their organization, and they will likely have to overcome unexpected resistance in the future.

Leaders, keep your powder dry!

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Coldiron is the chair of SkinPAC for 2019-2021; this is an unpaid volunteer position. Write to him at dermnews@mdedge.com.

My grandfather used to say: “Son, keep your powder dry.” The old aphorism is basically a reminder to keep your power or influence in reserve until you really need it. In my case, he could simply have been trying to quiet an overly talkative kid. But anything my grandfather said that had to do with guns carried great authority with me. He owned a shotgun that had been converted from a flintlock by his grandfather, and we grandchildren were schooled in its use.

I was recently reminded of my grandfather’s advice as I was about to participate in a planned meeting. One of the meeting leaders pulled me aside to tell me that I was not to ask questions, and informed me that if I did ask questions, I would be punished to the fullest extent possible. I also was not to challenge the preordained conclusion.

I was simultaneously aghast and impressed. Never had I heard such a trifecta of terrible leadership uttered in a single breath. It was a reminder to revisit the premises of all the books I had read and the conferences I had attended on leadership.

There are basic prerequisites of building consensus and adopting new ideas.

First, you must introduce the wonderful idea and explain it to everyone. It is even better when you are able to back up someone else’s great idea.

Next, you must allow the group to discuss the idea and be open to change. This may involve shelving, or even killing, your shiny new idea.

You must allow time for things to sink in regarding the idea. If you want something to stick, people have to adapt and adopt. If your idea is truly wonderful, you should be able to attract advocates and get a majority to agree to the plan. You should make sure they get to vote on the plan. If you lose the vote, don’t try any maneuvers to undo your loss. Accept it and move on. If your idea is good, it will surface again as someone else’s idea and be a much easier pitch.

Finally, never, ever bully or threaten. Memories are long, and while some may not agree with your idea, they won’t actively try to kill it later or undermine future projects. Pinch yourself every day, and remember that you are a servant of the group. You are a facilitator, not an autocrat.

That said, leaders differ in their styles of leadership. I think the best leaders are not afraid to listen to their boards and membership. Their actions focus thoughts and move things along. If you let your board members own their actions, they will respect you. You will build up tremendous goodwill (and powder). With any luck, you may never need to draw on this goodwill; but if there is a crisis and you need to put a bullet through something quickly, your intentions will not be questioned. At a minimum, you will have plenty of opportunity to explain your actions.

So it saddens me to see leaders burn all their powder and lose their influence. It’s not good for them or their organization, and they will likely have to overcome unexpected resistance in the future.

Leaders, keep your powder dry!

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Coldiron is the chair of SkinPAC for 2019-2021; this is an unpaid volunteer position. Write to him at dermnews@mdedge.com.

My grandfather used to say: “Son, keep your powder dry.” The old aphorism is basically a reminder to keep your power or influence in reserve until you really need it. In my case, he could simply have been trying to quiet an overly talkative kid. But anything my grandfather said that had to do with guns carried great authority with me. He owned a shotgun that had been converted from a flintlock by his grandfather, and we grandchildren were schooled in its use.

I was recently reminded of my grandfather’s advice as I was about to participate in a planned meeting. One of the meeting leaders pulled me aside to tell me that I was not to ask questions, and informed me that if I did ask questions, I would be punished to the fullest extent possible. I also was not to challenge the preordained conclusion.

I was simultaneously aghast and impressed. Never had I heard such a trifecta of terrible leadership uttered in a single breath. It was a reminder to revisit the premises of all the books I had read and the conferences I had attended on leadership.

There are basic prerequisites of building consensus and adopting new ideas.

First, you must introduce the wonderful idea and explain it to everyone. It is even better when you are able to back up someone else’s great idea.

Next, you must allow the group to discuss the idea and be open to change. This may involve shelving, or even killing, your shiny new idea.

You must allow time for things to sink in regarding the idea. If you want something to stick, people have to adapt and adopt. If your idea is truly wonderful, you should be able to attract advocates and get a majority to agree to the plan. You should make sure they get to vote on the plan. If you lose the vote, don’t try any maneuvers to undo your loss. Accept it and move on. If your idea is good, it will surface again as someone else’s idea and be a much easier pitch.

Finally, never, ever bully or threaten. Memories are long, and while some may not agree with your idea, they won’t actively try to kill it later or undermine future projects. Pinch yourself every day, and remember that you are a servant of the group. You are a facilitator, not an autocrat.

That said, leaders differ in their styles of leadership. I think the best leaders are not afraid to listen to their boards and membership. Their actions focus thoughts and move things along. If you let your board members own their actions, they will respect you. You will build up tremendous goodwill (and powder). With any luck, you may never need to draw on this goodwill; but if there is a crisis and you need to put a bullet through something quickly, your intentions will not be questioned. At a minimum, you will have plenty of opportunity to explain your actions.

So it saddens me to see leaders burn all their powder and lose their influence. It’s not good for them or their organization, and they will likely have to overcome unexpected resistance in the future.

Leaders, keep your powder dry!

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Coldiron is the chair of SkinPAC for 2019-2021; this is an unpaid volunteer position. Write to him at dermnews@mdedge.com.

Payment policy for physicians is now set at the federal level. The Centers for Medicare and Medicaid Services generates a yearly final rule and a fee schedule, and all the Medicare carriers, AND the Medicare Advantage plans AND the private insurers use the rule and fee schedule as a payment guide.

mathisworks

Sometimes these rules can be at odds with best practices for dermatology patients. That is why lobbying is so critically important for us and for our patients. Lobbying provides access to legislators and enables us to educate them about the impact of proposed changes in coverage.

Each year, SkinPAC contributes up to $5,000 a year to individual congressional races. The extent of contributions is based on an impartial scorecard that ranks congressional members by leadership position as well as the member’s understanding and history of support on our critical issues. I want to emphasize that the personal political leanings of the SkinPAC board members have no bearing on the level of support. We contribute to campaigns based on the congressional members’ positions on our issues, period. Full disclosure: I am the chair of SkinPAC for 2019-2021. This is an unpaid volunteer position.

To dermatologists who question the effectiveness of lobbying, I can attest that I have seen your political action committee contributions in action.

When Congress planned on tightening the Stark exceptions 5 years ago, our Washington office was able to gain access to key legislators. As a result of our good long-term relationships with these congress members and their staff, our lobbying group was able to explain the importance for dermatologists to be able to read their own slides and the value of global periods. Imagine the disasters of being unable to read our own dermatopathology slides, not performing diagnostic frozen sections before Mohs, and charging patients for suture removals. Lobbying efforts averted those potential catastrophes.

Unfortunately, the same issues are coming back. In the most recent Federal Register proposals, CMS again wanted to eliminate global periods and modifier 25, which allows you to bill for a procedure on the same day as an evaluation and management code. This action has been delayed for 2 years but will come back up for consideration next year.

Global periods are follow-up visits that are embedded in the destruction, excision, and repair codes that you currently use. For example, $42 of the $72 you get for destroying a premalignant lesion or a wart is a prepayment for the follow-up visit. Sure, if the global period is eliminated, you can bill the patient for the follow-up visit, but imagine the difficulty of collecting additional copays and deductibles. And imagine the impact of those additional costs on our patients.

This brings me to your 100,000 reasons to contribute to your PAC. In Medicare alone, elimination of global periods and modifier 25 will shift $1.4 billion dollars per year away from dermatology. Assuming you will be able to recoup some payment from follow-up visits and by rescheduling some procedures, you are still looking at $1 billion or so, per year, cut from about 10,000 dermatologists with the expense shifted to patients. That’s a $100,000 loss per dermatologist per year and a $1 billion per year additional responsibility for Medicare insureds.

Yes, this will require a legislative fix. And unless it is fixed, the results will be viewed as price gouging by patients with disastrous implications for the physician-patient relationship. Imagine what your patient will say when you charge them to remove their sutures.

Your SkinPAC contribution should be viewed as a disaster insurance policy, just like any other insurance you buy. It covers the very real possibility of not a hurricane or a tornado, but a catastrophic blunder that will put you out of business as surely as any natural disaster. Support your SkinPAC! Support your patients and yourself.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Coldiron is the chair of SkinPAC for 2019-2021; this is an unpaid volunteer position. Write to him at dermnews@mdedge.com.

Payment policy for physicians is now set at the federal level. The Centers for Medicare and Medicaid Services generates a yearly final rule and a fee schedule, and all the Medicare carriers, AND the Medicare Advantage plans AND the private insurers use the rule and fee schedule as a payment guide.

mathisworks

Sometimes these rules can be at odds with best practices for dermatology patients. That is why lobbying is so critically important for us and for our patients. Lobbying provides access to legislators and enables us to educate them about the impact of proposed changes in coverage.

Each year, SkinPAC contributes up to $5,000 a year to individual congressional races. The extent of contributions is based on an impartial scorecard that ranks congressional members by leadership position as well as the member’s understanding and history of support on our critical issues. I want to emphasize that the personal political leanings of the SkinPAC board members have no bearing on the level of support. We contribute to campaigns based on the congressional members’ positions on our issues, period. Full disclosure: I am the chair of SkinPAC for 2019-2021. This is an unpaid volunteer position.

To dermatologists who question the effectiveness of lobbying, I can attest that I have seen your political action committee contributions in action.

When Congress planned on tightening the Stark exceptions 5 years ago, our Washington office was able to gain access to key legislators. As a result of our good long-term relationships with these congress members and their staff, our lobbying group was able to explain the importance for dermatologists to be able to read their own slides and the value of global periods. Imagine the disasters of being unable to read our own dermatopathology slides, not performing diagnostic frozen sections before Mohs, and charging patients for suture removals. Lobbying efforts averted those potential catastrophes.

Unfortunately, the same issues are coming back. In the most recent Federal Register proposals, CMS again wanted to eliminate global periods and modifier 25, which allows you to bill for a procedure on the same day as an evaluation and management code. This action has been delayed for 2 years but will come back up for consideration next year.

Global periods are follow-up visits that are embedded in the destruction, excision, and repair codes that you currently use. For example, $42 of the $72 you get for destroying a premalignant lesion or a wart is a prepayment for the follow-up visit. Sure, if the global period is eliminated, you can bill the patient for the follow-up visit, but imagine the difficulty of collecting additional copays and deductibles. And imagine the impact of those additional costs on our patients.

This brings me to your 100,000 reasons to contribute to your PAC. In Medicare alone, elimination of global periods and modifier 25 will shift $1.4 billion dollars per year away from dermatology. Assuming you will be able to recoup some payment from follow-up visits and by rescheduling some procedures, you are still looking at $1 billion or so, per year, cut from about 10,000 dermatologists with the expense shifted to patients. That’s a $100,000 loss per dermatologist per year and a $1 billion per year additional responsibility for Medicare insureds.

Yes, this will require a legislative fix. And unless it is fixed, the results will be viewed as price gouging by patients with disastrous implications for the physician-patient relationship. Imagine what your patient will say when you charge them to remove their sutures.

Your SkinPAC contribution should be viewed as a disaster insurance policy, just like any other insurance you buy. It covers the very real possibility of not a hurricane or a tornado, but a catastrophic blunder that will put you out of business as surely as any natural disaster. Support your SkinPAC! Support your patients and yourself.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Coldiron is the chair of SkinPAC for 2019-2021; this is an unpaid volunteer position. Write to him at dermnews@mdedge.com.

Payment policy for physicians is now set at the federal level. The Centers for Medicare and Medicaid Services generates a yearly final rule and a fee schedule, and all the Medicare carriers, AND the Medicare Advantage plans AND the private insurers use the rule and fee schedule as a payment guide.

mathisworks

Sometimes these rules can be at odds with best practices for dermatology patients. That is why lobbying is so critically important for us and for our patients. Lobbying provides access to legislators and enables us to educate them about the impact of proposed changes in coverage.

Each year, SkinPAC contributes up to $5,000 a year to individual congressional races. The extent of contributions is based on an impartial scorecard that ranks congressional members by leadership position as well as the member’s understanding and history of support on our critical issues. I want to emphasize that the personal political leanings of the SkinPAC board members have no bearing on the level of support. We contribute to campaigns based on the congressional members’ positions on our issues, period. Full disclosure: I am the chair of SkinPAC for 2019-2021. This is an unpaid volunteer position.

To dermatologists who question the effectiveness of lobbying, I can attest that I have seen your political action committee contributions in action.

When Congress planned on tightening the Stark exceptions 5 years ago, our Washington office was able to gain access to key legislators. As a result of our good long-term relationships with these congress members and their staff, our lobbying group was able to explain the importance for dermatologists to be able to read their own slides and the value of global periods. Imagine the disasters of being unable to read our own dermatopathology slides, not performing diagnostic frozen sections before Mohs, and charging patients for suture removals. Lobbying efforts averted those potential catastrophes.

Unfortunately, the same issues are coming back. In the most recent Federal Register proposals, CMS again wanted to eliminate global periods and modifier 25, which allows you to bill for a procedure on the same day as an evaluation and management code. This action has been delayed for 2 years but will come back up for consideration next year.

Global periods are follow-up visits that are embedded in the destruction, excision, and repair codes that you currently use. For example, $42 of the $72 you get for destroying a premalignant lesion or a wart is a prepayment for the follow-up visit. Sure, if the global period is eliminated, you can bill the patient for the follow-up visit, but imagine the difficulty of collecting additional copays and deductibles. And imagine the impact of those additional costs on our patients.

This brings me to your 100,000 reasons to contribute to your PAC. In Medicare alone, elimination of global periods and modifier 25 will shift $1.4 billion dollars per year away from dermatology. Assuming you will be able to recoup some payment from follow-up visits and by rescheduling some procedures, you are still looking at $1 billion or so, per year, cut from about 10,000 dermatologists with the expense shifted to patients. That’s a $100,000 loss per dermatologist per year and a $1 billion per year additional responsibility for Medicare insureds.

Yes, this will require a legislative fix. And unless it is fixed, the results will be viewed as price gouging by patients with disastrous implications for the physician-patient relationship. Imagine what your patient will say when you charge them to remove their sutures.

Your SkinPAC contribution should be viewed as a disaster insurance policy, just like any other insurance you buy. It covers the very real possibility of not a hurricane or a tornado, but a catastrophic blunder that will put you out of business as surely as any natural disaster. Support your SkinPAC! Support your patients and yourself.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Dr. Coldiron is the chair of SkinPAC for 2019-2021; this is an unpaid volunteer position. Write to him at dermnews@mdedge.com.

My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).

I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.

I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.

coldsnowstorm/iStock/Getty Images Plus

Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.

I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.

My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.


Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.

Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. We all must all step up, learn the signs of potential human trafficking, and stop allowing our young people to be fed to monsters.

The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).

I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.

I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.

coldsnowstorm/iStock/Getty Images Plus

Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.

I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.

My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.


Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.

Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. We all must all step up, learn the signs of potential human trafficking, and stop allowing our young people to be fed to monsters.

The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).

I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.

I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.

coldsnowstorm/iStock/Getty Images Plus

Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.

I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.

My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.


Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.

Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. We all must all step up, learn the signs of potential human trafficking, and stop allowing our young people to be fed to monsters.

The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

If it’s happening in Cincinnati, it is happening everywhere. All the young doctors are being hired by hospital systems at better pay than private practices can afford. When I asked the CEO at one Cincinnati hospital about the trend, he explained: “We like to have referrals available for our primary care physicians.” Sounds nice, but I don’t believe it.

Hospital outpatient facilities have been reaping the benefits of site-of-service differential payments for years. Under the current Centers for Medicare/Medicaid Services payment scales, identical services are reimbursed at extraordinarily higher rates – differentials amounting to, on average, approximately 360% of Medicare’s payment for the same mix of services when they are performed in a physician’s office – if they are delivered at off-campus hospital outpatient departments rather than independent doctors’ offices. Technically, these outpatient departments can be an office that has been bought by the hospital and proximity is not an issue. Many off-campus hospital outpatient departments in my area are as far away as 35 miles, some in strip malls no less!

That situation may soon change, though. The CMS has proposed eliminating the site-of-service differentials for hospital outpatient services. The proposal is being aggressively opposed by hospital lobbyists and has even inspired lawsuits because it would blow the lid off the extraordinary payment differential available to hospital outpatient departments (“Proposed site-neutral payment policy sets the stage for battle royale between CMS, hospitals,” Modern Healthcare, July 26, 2018).

It’s a change that’s long overdue.

In the period from 2001 to 2017, Medicare Part B payments to physicians increased only 6%, while Medicare’s index of inflation measuring the cost of running a medical practice increased 30%. After adjustment for inflation in practice costs, physician pay has declined 19%, thus failing to match increases in office overhead costs. In that same 17-year period, Medicare hospital payments increased roughly 50%, including average annual increases of 2.6% for inpatient services and 2.5% per year for outpatient services. Hospitals have thus received payment increases more than eightfold greater than payment adjustments to physicians in the period from 2001 to 2017!

I think we have found the secret sauce!

Obviously, some of this largesse was spread over the recruitment of physicians, buying offices, and creating of secret sauce clinics. Hospital purchases of private offices and physician employment at hospitals soared to nearly 33%.

But much went to the hospital’s bottom line.

Hospitals have enjoyed 28 annual year-over-year increases in payments for services rendered in hospital outpatient facilities.

Many of these hospital systems claim to make no extra money using the hospital outpatient system. If so, eliminating the site-of-service differential will not affect them. We will see.

I think the elimination of the site-of-service differential will have profound impacts on office medicine. While the AMA is asking that the savings (several billion over 10 years) be funneled back into the office setting to correct past underpayments, just the correction of the distortion will benefit office practice. The recruitment of new physicians by hospitals, and the practice-buying binge, appear to have subsided. Expect many of these satellites to close, and their employed physicians, young and old, to be coming back into the job market. Expect Medicare beneficiaries to pay lower copays and deductibles.

Corrections of distortions like the site-of-service differential empower patients and independent physicians. Thank the AMA for exposing the unfairness and allowing the CMS to act. You may not know it, but the American Medical Association puts together a tremendous – some would say overwhelming – amount of research together on topics of importance to physicians. Some of this is fascinating. I direct you to the AMA’s Report 4 of the Council on Medical Service (I-18)

This report lays it all out, and explains what has happened.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

If it’s happening in Cincinnati, it is happening everywhere. All the young doctors are being hired by hospital systems at better pay than private practices can afford. When I asked the CEO at one Cincinnati hospital about the trend, he explained: “We like to have referrals available for our primary care physicians.” Sounds nice, but I don’t believe it.

Hospital outpatient facilities have been reaping the benefits of site-of-service differential payments for years. Under the current Centers for Medicare/Medicaid Services payment scales, identical services are reimbursed at extraordinarily higher rates – differentials amounting to, on average, approximately 360% of Medicare’s payment for the same mix of services when they are performed in a physician’s office – if they are delivered at off-campus hospital outpatient departments rather than independent doctors’ offices. Technically, these outpatient departments can be an office that has been bought by the hospital and proximity is not an issue. Many off-campus hospital outpatient departments in my area are as far away as 35 miles, some in strip malls no less!

That situation may soon change, though. The CMS has proposed eliminating the site-of-service differentials for hospital outpatient services. The proposal is being aggressively opposed by hospital lobbyists and has even inspired lawsuits because it would blow the lid off the extraordinary payment differential available to hospital outpatient departments (“Proposed site-neutral payment policy sets the stage for battle royale between CMS, hospitals,” Modern Healthcare, July 26, 2018).

It’s a change that’s long overdue.

In the period from 2001 to 2017, Medicare Part B payments to physicians increased only 6%, while Medicare’s index of inflation measuring the cost of running a medical practice increased 30%. After adjustment for inflation in practice costs, physician pay has declined 19%, thus failing to match increases in office overhead costs. In that same 17-year period, Medicare hospital payments increased roughly 50%, including average annual increases of 2.6% for inpatient services and 2.5% per year for outpatient services. Hospitals have thus received payment increases more than eightfold greater than payment adjustments to physicians in the period from 2001 to 2017!

I think we have found the secret sauce!

Obviously, some of this largesse was spread over the recruitment of physicians, buying offices, and creating of secret sauce clinics. Hospital purchases of private offices and physician employment at hospitals soared to nearly 33%.

But much went to the hospital’s bottom line.

Hospitals have enjoyed 28 annual year-over-year increases in payments for services rendered in hospital outpatient facilities.

Many of these hospital systems claim to make no extra money using the hospital outpatient system. If so, eliminating the site-of-service differential will not affect them. We will see.

I think the elimination of the site-of-service differential will have profound impacts on office medicine. While the AMA is asking that the savings (several billion over 10 years) be funneled back into the office setting to correct past underpayments, just the correction of the distortion will benefit office practice. The recruitment of new physicians by hospitals, and the practice-buying binge, appear to have subsided. Expect many of these satellites to close, and their employed physicians, young and old, to be coming back into the job market. Expect Medicare beneficiaries to pay lower copays and deductibles.

Corrections of distortions like the site-of-service differential empower patients and independent physicians. Thank the AMA for exposing the unfairness and allowing the CMS to act. You may not know it, but the American Medical Association puts together a tremendous – some would say overwhelming – amount of research together on topics of importance to physicians. Some of this is fascinating. I direct you to the AMA’s Report 4 of the Council on Medical Service (I-18)

This report lays it all out, and explains what has happened.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

If it’s happening in Cincinnati, it is happening everywhere. All the young doctors are being hired by hospital systems at better pay than private practices can afford. When I asked the CEO at one Cincinnati hospital about the trend, he explained: “We like to have referrals available for our primary care physicians.” Sounds nice, but I don’t believe it.

Hospital outpatient facilities have been reaping the benefits of site-of-service differential payments for years. Under the current Centers for Medicare/Medicaid Services payment scales, identical services are reimbursed at extraordinarily higher rates – differentials amounting to, on average, approximately 360% of Medicare’s payment for the same mix of services when they are performed in a physician’s office – if they are delivered at off-campus hospital outpatient departments rather than independent doctors’ offices. Technically, these outpatient departments can be an office that has been bought by the hospital and proximity is not an issue. Many off-campus hospital outpatient departments in my area are as far away as 35 miles, some in strip malls no less!

That situation may soon change, though. The CMS has proposed eliminating the site-of-service differentials for hospital outpatient services. The proposal is being aggressively opposed by hospital lobbyists and has even inspired lawsuits because it would blow the lid off the extraordinary payment differential available to hospital outpatient departments (“Proposed site-neutral payment policy sets the stage for battle royale between CMS, hospitals,” Modern Healthcare, July 26, 2018).

It’s a change that’s long overdue.

In the period from 2001 to 2017, Medicare Part B payments to physicians increased only 6%, while Medicare’s index of inflation measuring the cost of running a medical practice increased 30%. After adjustment for inflation in practice costs, physician pay has declined 19%, thus failing to match increases in office overhead costs. In that same 17-year period, Medicare hospital payments increased roughly 50%, including average annual increases of 2.6% for inpatient services and 2.5% per year for outpatient services. Hospitals have thus received payment increases more than eightfold greater than payment adjustments to physicians in the period from 2001 to 2017!

I think we have found the secret sauce!

Obviously, some of this largesse was spread over the recruitment of physicians, buying offices, and creating of secret sauce clinics. Hospital purchases of private offices and physician employment at hospitals soared to nearly 33%.

But much went to the hospital’s bottom line.

Hospitals have enjoyed 28 annual year-over-year increases in payments for services rendered in hospital outpatient facilities.

Many of these hospital systems claim to make no extra money using the hospital outpatient system. If so, eliminating the site-of-service differential will not affect them. We will see.

I think the elimination of the site-of-service differential will have profound impacts on office medicine. While the AMA is asking that the savings (several billion over 10 years) be funneled back into the office setting to correct past underpayments, just the correction of the distortion will benefit office practice. The recruitment of new physicians by hospitals, and the practice-buying binge, appear to have subsided. Expect many of these satellites to close, and their employed physicians, young and old, to be coming back into the job market. Expect Medicare beneficiaries to pay lower copays and deductibles.

Corrections of distortions like the site-of-service differential empower patients and independent physicians. Thank the AMA for exposing the unfairness and allowing the CMS to act. You may not know it, but the American Medical Association puts together a tremendous – some would say overwhelming – amount of research together on topics of importance to physicians. Some of this is fascinating. I direct you to the AMA’s Report 4 of the Council on Medical Service (I-18)

This report lays it all out, and explains what has happened.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

I recall in college we used to talk a lot about the relationship between town and gown, that is, the town community and the academic community, and how they relate to each other. This remains pertinent today as we consider the dermatology academic community and practicing dermatologists. There should be a virtuous circle between dermatologists in their community and their academic medical center.

Academic medical centers are up to date and on the cutting edge of science and treatments – and happy to share with community dermatologists. This is where you will learn about teledermatology and how to use the latest biologics.

They provide educational opportunities such as grand rounds and visiting speakers. They allow community physicians to attend staff and resident lectures, bring their most challenging cases to grand rounds, and get feedback and suggestions, with everyone learning from the experience. They host dermatology events for all. They allow community physicians to staff resident clinics where both benefit from the interaction. The academic center provides a charity care network for the community – and usually provides the experts of last resort for difficult cases as they are often on the cutting edge of research and newest treatments.

Large multispecialty practices– and private equity groups – are not going to fill this role.

Dermatology is a highly isolated specialty and the interaction with others at the academic center may be the only physical link to the outside world of medicine. Having an academic dermatology program in your community is a serious asset that community dermatologists should appreciate and support.

However, as the gown supports the town, so should the town support the gown. There is a pervasive inaccuracy in the community that these academic dermatology departments are supported by government funds or a “state line” of support. This is incorrect. These departments support themselves with clinical work. In addition, the dean and/or the medical school takes a generous cut out of their profits, and the departments also must compete – furiously – for grants, of which the medical school immediately takes about 55% for indirect “overhead,” a frequent complaint of academic physicians.

If you practice near such an academic center and benefit from its virtuous circle, you can consider sending them some of your dermatopathology or Mohs, even if you are a large group and could handle them yourselves. You can join the local dermatologic society and bring cases to grand rounds. You can offer to teach the residents in their clinic, or in your office, and expose them to real life practice.

If you have the means, you could consider funding a lectureship or an endowed departmental chair. No matter the virtual content available online, the quality of learning one on one from another specialist cannot be beat. So make the effort to visit the gown from the town. You will be warmly welcomed and join a virtuous circle of lifelong learners.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

I recall in college we used to talk a lot about the relationship between town and gown, that is, the town community and the academic community, and how they relate to each other. This remains pertinent today as we consider the dermatology academic community and practicing dermatologists. There should be a virtuous circle between dermatologists in their community and their academic medical center.

Academic medical centers are up to date and on the cutting edge of science and treatments – and happy to share with community dermatologists. This is where you will learn about teledermatology and how to use the latest biologics.

They provide educational opportunities such as grand rounds and visiting speakers. They allow community physicians to attend staff and resident lectures, bring their most challenging cases to grand rounds, and get feedback and suggestions, with everyone learning from the experience. They host dermatology events for all. They allow community physicians to staff resident clinics where both benefit from the interaction. The academic center provides a charity care network for the community – and usually provides the experts of last resort for difficult cases as they are often on the cutting edge of research and newest treatments.

Large multispecialty practices– and private equity groups – are not going to fill this role.

Dermatology is a highly isolated specialty and the interaction with others at the academic center may be the only physical link to the outside world of medicine. Having an academic dermatology program in your community is a serious asset that community dermatologists should appreciate and support.

However, as the gown supports the town, so should the town support the gown. There is a pervasive inaccuracy in the community that these academic dermatology departments are supported by government funds or a “state line” of support. This is incorrect. These departments support themselves with clinical work. In addition, the dean and/or the medical school takes a generous cut out of their profits, and the departments also must compete – furiously – for grants, of which the medical school immediately takes about 55% for indirect “overhead,” a frequent complaint of academic physicians.

If you practice near such an academic center and benefit from its virtuous circle, you can consider sending them some of your dermatopathology or Mohs, even if you are a large group and could handle them yourselves. You can join the local dermatologic society and bring cases to grand rounds. You can offer to teach the residents in their clinic, or in your office, and expose them to real life practice.

If you have the means, you could consider funding a lectureship or an endowed departmental chair. No matter the virtual content available online, the quality of learning one on one from another specialist cannot be beat. So make the effort to visit the gown from the town. You will be warmly welcomed and join a virtuous circle of lifelong learners.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

I recall in college we used to talk a lot about the relationship between town and gown, that is, the town community and the academic community, and how they relate to each other. This remains pertinent today as we consider the dermatology academic community and practicing dermatologists. There should be a virtuous circle between dermatologists in their community and their academic medical center.

Academic medical centers are up to date and on the cutting edge of science and treatments – and happy to share with community dermatologists. This is where you will learn about teledermatology and how to use the latest biologics.

They provide educational opportunities such as grand rounds and visiting speakers. They allow community physicians to attend staff and resident lectures, bring their most challenging cases to grand rounds, and get feedback and suggestions, with everyone learning from the experience. They host dermatology events for all. They allow community physicians to staff resident clinics where both benefit from the interaction. The academic center provides a charity care network for the community – and usually provides the experts of last resort for difficult cases as they are often on the cutting edge of research and newest treatments.

Large multispecialty practices– and private equity groups – are not going to fill this role.

Dermatology is a highly isolated specialty and the interaction with others at the academic center may be the only physical link to the outside world of medicine. Having an academic dermatology program in your community is a serious asset that community dermatologists should appreciate and support.

However, as the gown supports the town, so should the town support the gown. There is a pervasive inaccuracy in the community that these academic dermatology departments are supported by government funds or a “state line” of support. This is incorrect. These departments support themselves with clinical work. In addition, the dean and/or the medical school takes a generous cut out of their profits, and the departments also must compete – furiously – for grants, of which the medical school immediately takes about 55% for indirect “overhead,” a frequent complaint of academic physicians.

If you practice near such an academic center and benefit from its virtuous circle, you can consider sending them some of your dermatopathology or Mohs, even if you are a large group and could handle them yourselves. You can join the local dermatologic society and bring cases to grand rounds. You can offer to teach the residents in their clinic, or in your office, and expose them to real life practice.

If you have the means, you could consider funding a lectureship or an endowed departmental chair. No matter the virtual content available online, the quality of learning one on one from another specialist cannot be beat. So make the effort to visit the gown from the town. You will be warmly welcomed and join a virtuous circle of lifelong learners.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

I was at a meeting in Orlando, sitting in the front row. The speaker was a former Disney executive who was telling us how to improve our offices. He kept walking very close to the edge of the stage – so close I was worried he might step off with the Klieg lights in his eyes. Then he got to the heart of his message, telling us that we need to make each patient encounter a marvelous experience, and how he and his staff had done so for millions of mouseketeers. “You need to make each customer feel special,” he said. He went on with saccharine examples of staff going above and beyond – for example, replacing toddlers’ dropped ice creams before they could cry.

That hit my trigger. From that point on, I was almost hoping he would fall off the stage.

Of course, there is a story behind my reaction.

One sunny day, while I was sitting at the most cluttered desk in the world, one of my staff came into my office to tell me a patient had called. The patient was very unhappy, I was told, and she planned to stink bomb me on social media. Concerned, I pulled the patient’s before-and-after photos. It looked as though she had a great result from her treatment, so I was perplexed. I phoned the patient, but she refused to tell me why she was unhappy. “I’m very unhappy, and I’m going to punish you,” she said. I urged her to come to the office and see me, at her convenience.

When we spoke face-to-face, I examined her nose and took a picture. I explained that her cancer was cured; her result was beautiful, the site was almost imperceptible. I added that I thought the appearance would continue to improve with time.

My patient refused to look at me, and refused to look at the site in the mirror. She shoved the preop defect photo away without giving it a glance. Instead, she told me how inconvenient it was for her to have had a skin cancer at all. Traffic had been terrible coming into the office on the morning of the procedure. There had been a 45-minute backup on the bridge on her way home. Her ex-husband had refused to help with her wound care. She continued in a similar vein for 15 minutes as I waited for her to accuse me of my transgressions. She concluded with a scowl and a whimper, “You just didn’t make me feel special.”

Everyone has difficult patients, and everyone has bad days, but I can’t recall ever being ambushed quite so adroitly in my 30 years of practice. I recognized my patient was being passive-aggressive and was playing a social media–augmented game of “Now I’ve got you, you S.O.B,” right out of Eric Berne’s book “Games People Play.” I’d say that this book should still be required reading for dealing with difficult patients.

There are ways to defuse such patients. One of the best is to slow things down and spread them around. The wider the array of interactions with people (the medical assistant, the nurse, the fellow, the Mohs surgeon, maybe the plastic surgeon), the more times the patient has to vent and the anger is defused across many targets. This also speaks to the value of requiring a preoperative consultation days before the procedure As I thought about this patient, I recalled that, because of the distance she was traveling, I had not done so.

I looked my patient in the eye and told her I was sorry she was unhappy. I told her I would be glad to see her again. I told her I realized how far she was driving and thought the traffic would not be a problem this early in the afternoon. I thanked her and showed her to the door. She stalked out of the office.

Technically and emotionally difficult patients are sometimes referred to you. They are patients who you might prefer not to take on but you do because, as a specialist, you may be at the end of the referral pipeline. Sometimes you can win the day, striking up a friendship or jollying them past their resentment at the world.

And there are times when, as a physician and healer, you must recognize that patient criticism cannot be taken personally. The third law of surviving internship from Samuel Shem’s book “The House of God” is germane here. Remember, “the patient is the one with the disease.” And sometimes the disease is complicated by the patient’s emotional baggage. This is one of the reasons social media ratings can be so unfair. We have to realize that we are all going to be trashed unfairly at some point, and probably sued unfairly as well. As a malpractice attorney told me once, “You doctors shouldn’t take this so personally; it’s just business.”

And my patient? Despite my admonishments to you not to take things personally, I did feel bad for a week or so after our encounter. I did mail her a copy of her pre- and postoperative photographs. I have not seen her again. I did not look to see whether she burned me online.

But, by gosh, I’d really like to lock that Disney executive in a room with her for five minutes.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

I was at a meeting in Orlando, sitting in the front row. The speaker was a former Disney executive who was telling us how to improve our offices. He kept walking very close to the edge of the stage – so close I was worried he might step off with the Klieg lights in his eyes. Then he got to the heart of his message, telling us that we need to make each patient encounter a marvelous experience, and how he and his staff had done so for millions of mouseketeers. “You need to make each customer feel special,” he said. He went on with saccharine examples of staff going above and beyond – for example, replacing toddlers’ dropped ice creams before they could cry.

That hit my trigger. From that point on, I was almost hoping he would fall off the stage.

Of course, there is a story behind my reaction.

One sunny day, while I was sitting at the most cluttered desk in the world, one of my staff came into my office to tell me a patient had called. The patient was very unhappy, I was told, and she planned to stink bomb me on social media. Concerned, I pulled the patient’s before-and-after photos. It looked as though she had a great result from her treatment, so I was perplexed. I phoned the patient, but she refused to tell me why she was unhappy. “I’m very unhappy, and I’m going to punish you,” she said. I urged her to come to the office and see me, at her convenience.

When we spoke face-to-face, I examined her nose and took a picture. I explained that her cancer was cured; her result was beautiful, the site was almost imperceptible. I added that I thought the appearance would continue to improve with time.

My patient refused to look at me, and refused to look at the site in the mirror. She shoved the preop defect photo away without giving it a glance. Instead, she told me how inconvenient it was for her to have had a skin cancer at all. Traffic had been terrible coming into the office on the morning of the procedure. There had been a 45-minute backup on the bridge on her way home. Her ex-husband had refused to help with her wound care. She continued in a similar vein for 15 minutes as I waited for her to accuse me of my transgressions. She concluded with a scowl and a whimper, “You just didn’t make me feel special.”

Everyone has difficult patients, and everyone has bad days, but I can’t recall ever being ambushed quite so adroitly in my 30 years of practice. I recognized my patient was being passive-aggressive and was playing a social media–augmented game of “Now I’ve got you, you S.O.B,” right out of Eric Berne’s book “Games People Play.” I’d say that this book should still be required reading for dealing with difficult patients.

There are ways to defuse such patients. One of the best is to slow things down and spread them around. The wider the array of interactions with people (the medical assistant, the nurse, the fellow, the Mohs surgeon, maybe the plastic surgeon), the more times the patient has to vent and the anger is defused across many targets. This also speaks to the value of requiring a preoperative consultation days before the procedure As I thought about this patient, I recalled that, because of the distance she was traveling, I had not done so.

I looked my patient in the eye and told her I was sorry she was unhappy. I told her I would be glad to see her again. I told her I realized how far she was driving and thought the traffic would not be a problem this early in the afternoon. I thanked her and showed her to the door. She stalked out of the office.

Technically and emotionally difficult patients are sometimes referred to you. They are patients who you might prefer not to take on but you do because, as a specialist, you may be at the end of the referral pipeline. Sometimes you can win the day, striking up a friendship or jollying them past their resentment at the world.

And there are times when, as a physician and healer, you must recognize that patient criticism cannot be taken personally. The third law of surviving internship from Samuel Shem’s book “The House of God” is germane here. Remember, “the patient is the one with the disease.” And sometimes the disease is complicated by the patient’s emotional baggage. This is one of the reasons social media ratings can be so unfair. We have to realize that we are all going to be trashed unfairly at some point, and probably sued unfairly as well. As a malpractice attorney told me once, “You doctors shouldn’t take this so personally; it’s just business.”

And my patient? Despite my admonishments to you not to take things personally, I did feel bad for a week or so after our encounter. I did mail her a copy of her pre- and postoperative photographs. I have not seen her again. I did not look to see whether she burned me online.

But, by gosh, I’d really like to lock that Disney executive in a room with her for five minutes.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

I was at a meeting in Orlando, sitting in the front row. The speaker was a former Disney executive who was telling us how to improve our offices. He kept walking very close to the edge of the stage – so close I was worried he might step off with the Klieg lights in his eyes. Then he got to the heart of his message, telling us that we need to make each patient encounter a marvelous experience, and how he and his staff had done so for millions of mouseketeers. “You need to make each customer feel special,” he said. He went on with saccharine examples of staff going above and beyond – for example, replacing toddlers’ dropped ice creams before they could cry.

That hit my trigger. From that point on, I was almost hoping he would fall off the stage.

Of course, there is a story behind my reaction.

One sunny day, while I was sitting at the most cluttered desk in the world, one of my staff came into my office to tell me a patient had called. The patient was very unhappy, I was told, and she planned to stink bomb me on social media. Concerned, I pulled the patient’s before-and-after photos. It looked as though she had a great result from her treatment, so I was perplexed. I phoned the patient, but she refused to tell me why she was unhappy. “I’m very unhappy, and I’m going to punish you,” she said. I urged her to come to the office and see me, at her convenience.

When we spoke face-to-face, I examined her nose and took a picture. I explained that her cancer was cured; her result was beautiful, the site was almost imperceptible. I added that I thought the appearance would continue to improve with time.

My patient refused to look at me, and refused to look at the site in the mirror. She shoved the preop defect photo away without giving it a glance. Instead, she told me how inconvenient it was for her to have had a skin cancer at all. Traffic had been terrible coming into the office on the morning of the procedure. There had been a 45-minute backup on the bridge on her way home. Her ex-husband had refused to help with her wound care. She continued in a similar vein for 15 minutes as I waited for her to accuse me of my transgressions. She concluded with a scowl and a whimper, “You just didn’t make me feel special.”

Everyone has difficult patients, and everyone has bad days, but I can’t recall ever being ambushed quite so adroitly in my 30 years of practice. I recognized my patient was being passive-aggressive and was playing a social media–augmented game of “Now I’ve got you, you S.O.B,” right out of Eric Berne’s book “Games People Play.” I’d say that this book should still be required reading for dealing with difficult patients.

There are ways to defuse such patients. One of the best is to slow things down and spread them around. The wider the array of interactions with people (the medical assistant, the nurse, the fellow, the Mohs surgeon, maybe the plastic surgeon), the more times the patient has to vent and the anger is defused across many targets. This also speaks to the value of requiring a preoperative consultation days before the procedure As I thought about this patient, I recalled that, because of the distance she was traveling, I had not done so.

I looked my patient in the eye and told her I was sorry she was unhappy. I told her I would be glad to see her again. I told her I realized how far she was driving and thought the traffic would not be a problem this early in the afternoon. I thanked her and showed her to the door. She stalked out of the office.

Technically and emotionally difficult patients are sometimes referred to you. They are patients who you might prefer not to take on but you do because, as a specialist, you may be at the end of the referral pipeline. Sometimes you can win the day, striking up a friendship or jollying them past their resentment at the world.

And there are times when, as a physician and healer, you must recognize that patient criticism cannot be taken personally. The third law of surviving internship from Samuel Shem’s book “The House of God” is germane here. Remember, “the patient is the one with the disease.” And sometimes the disease is complicated by the patient’s emotional baggage. This is one of the reasons social media ratings can be so unfair. We have to realize that we are all going to be trashed unfairly at some point, and probably sued unfairly as well. As a malpractice attorney told me once, “You doctors shouldn’t take this so personally; it’s just business.”

And my patient? Despite my admonishments to you not to take things personally, I did feel bad for a week or so after our encounter. I did mail her a copy of her pre- and postoperative photographs. I have not seen her again. I did not look to see whether she burned me online.

But, by gosh, I’d really like to lock that Disney executive in a room with her for five minutes.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Most of us have a 5-, 10-, or even a necessarily vague 15-year plan for our practices. As you begin your New Year assessments, keep the following overriding considerations in mind to aid in your planning.

1) You are probably never going to be reimbursed better than you are today.

“Wait,” you say, “Don’t we get occasional Medicare updates?”

Yes, but these never keep up with inflation, just as any unlikely increases from private insurers always lag behind the cost of providing the service and have been grinding down toward Medicare rates – or even below them – for years. Any other sweeping insurance proposals, such as Medicare for All, include a hefty cut to physician reimbursement. One exception might be allowing those under age 55 years to buy into the existing Medicare program, which would be beneficial in areas where current private insurers and Medicare Advantage plans pay less than Medicare. It is also possible that you could see some increase if you are on the right side of bundled payments, although this has been more of a threat of penalty rather than a reward so far.

2) Don’t expect an imminent repeal of the ACA

The Affordable Care Act (ACA) favors large groups, and it is still the law, and it’s likely to remain the law for at least the next 5-10 years. Republicans could not repeal it when they held both the Senate and House, as well as the presidency, and certainly Democrats won’t repeal it.

There are myriad regulations and rules that only allow larger groups to reap the benefits from the ACA. Recall President Obama visiting the Cleveland Clinic and touting it and the Geisinger Clinic as examples of the way American medicine should be practiced.

Participation in alternative payment models that bypass many of the onerous requirements of “quality improvement,” and may even allow shared cost savings, are only practical for large groups. A notable exception is the recently proposed “site neutrality of payment” rule proposed by the current administration. This reduces by 50% or so the premium paid to large physician/hospital groups that are not located on the hospital campus to the prevailing rate of pay in the community. No more $3,000echocardiograms that used to cost $300.

Still, this does not increase the overall payments to physicians. Possibly, the proposed new telemedicine reimbursement rules may allow you to more efficiently manage patients without dramatically increasing your overhead.

An estimated 10,000 Baby Boomers are turning age 65 years every day. This ensures an increasing supply of patients, but also strains a federal government that has overpromised on Medicare and Social Security benefits. Recall that on average every Medicare recipient takes out far more than what they put into the program.

It is pay-up time, and the IOUs in the lockbox are unredeemable. This makes inflation and cutting reimbursements the easiest way to cope with older voters and a looming budget crisis.
 

4) Physicians are the weakest leg of the health care chair.

Hospitals, pharma, and insurers all have more powerful lobbying groups, donate more, and are better organized than physician groups. In our system of government, that means they will be favored in health care–related legislation. Physicians are the easiest to cut, although we account for only 15.9% of expenditures, according to 2014 data from the AMA.

The hospitals can close, insurers can refuse to write policies, and pharma can refuse to develop new drugs or manufacture generic ones. Big money (for example, Amazon, Berkshire Hathaway, and JPMorgan Chase) wants to consolidate health care and vertically integrate it. Most physicians cannot even unionize.

So what cheerful conclusions can we draw? If you go to work for a big group, try to negotiate the least restrictive practice covenant possible – or at least one that is not applicable if you are terminated without “cause.” The big group may have to disgorge you someday, and it could be disastrous to have to move or not be able to practice. If you opt for a small group or private practice, keep it small and lean. Build no palaces. There are special small practice situations that will survive or even prosper. Tightly managing your overhead is the key to survival.

Young physicians should recognize that the opportunity costs of an extensive residency after medical school may not be worth it. In fact, considering tuition that results in huge debt, lost income, and lost years of practice, high school graduates aspiring to a career in health care may do better from an economic perspective by pursuing a career as a nurse practitioner or physician assistant than one as a physician. The ACA, with its favoritism to large groups, will not be repealed anytime soon, and the regulations favoring larger groups are not even under discussion. This makes even hospital management more attractive as a career choice.

5. You’ll be doing more with less.

With a projected shortage of more than 100,000 physicians in the next 11 years, prepare for a high volume of patients, less pay for each encounter, and responsibility for multiple extenders. Practice will be much more stressful and difficult than simply managing your own panel of patients. Expect physician networks so narrow that they include only primary care physicians, with all other physicians having moved, died, or retired. It is much easier for insurers to save money by not receiving bills. Start thinking about integrating telemedicine into your practice because this may be a lifeline considering the most recent Medicare final rule that provides for payment for several new telehealth codes.

That all said, I must quote a lawmaker who, when discussing the ACA, told me “Well, you doctors are awfully late to the punch bowl” to which I replied, “Without doctors, there is no punch in the punch bowl.”
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Most of us have a 5-, 10-, or even a necessarily vague 15-year plan for our practices. As you begin your New Year assessments, keep the following overriding considerations in mind to aid in your planning.

1) You are probably never going to be reimbursed better than you are today.

“Wait,” you say, “Don’t we get occasional Medicare updates?”

Yes, but these never keep up with inflation, just as any unlikely increases from private insurers always lag behind the cost of providing the service and have been grinding down toward Medicare rates – or even below them – for years. Any other sweeping insurance proposals, such as Medicare for All, include a hefty cut to physician reimbursement. One exception might be allowing those under age 55 years to buy into the existing Medicare program, which would be beneficial in areas where current private insurers and Medicare Advantage plans pay less than Medicare. It is also possible that you could see some increase if you are on the right side of bundled payments, although this has been more of a threat of penalty rather than a reward so far.

2) Don’t expect an imminent repeal of the ACA

The Affordable Care Act (ACA) favors large groups, and it is still the law, and it’s likely to remain the law for at least the next 5-10 years. Republicans could not repeal it when they held both the Senate and House, as well as the presidency, and certainly Democrats won’t repeal it.

There are myriad regulations and rules that only allow larger groups to reap the benefits from the ACA. Recall President Obama visiting the Cleveland Clinic and touting it and the Geisinger Clinic as examples of the way American medicine should be practiced.

Participation in alternative payment models that bypass many of the onerous requirements of “quality improvement,” and may even allow shared cost savings, are only practical for large groups. A notable exception is the recently proposed “site neutrality of payment” rule proposed by the current administration. This reduces by 50% or so the premium paid to large physician/hospital groups that are not located on the hospital campus to the prevailing rate of pay in the community. No more $3,000echocardiograms that used to cost $300.

Still, this does not increase the overall payments to physicians. Possibly, the proposed new telemedicine reimbursement rules may allow you to more efficiently manage patients without dramatically increasing your overhead.

An estimated 10,000 Baby Boomers are turning age 65 years every day. This ensures an increasing supply of patients, but also strains a federal government that has overpromised on Medicare and Social Security benefits. Recall that on average every Medicare recipient takes out far more than what they put into the program.

It is pay-up time, and the IOUs in the lockbox are unredeemable. This makes inflation and cutting reimbursements the easiest way to cope with older voters and a looming budget crisis.
 

4) Physicians are the weakest leg of the health care chair.

Hospitals, pharma, and insurers all have more powerful lobbying groups, donate more, and are better organized than physician groups. In our system of government, that means they will be favored in health care–related legislation. Physicians are the easiest to cut, although we account for only 15.9% of expenditures, according to 2014 data from the AMA.

The hospitals can close, insurers can refuse to write policies, and pharma can refuse to develop new drugs or manufacture generic ones. Big money (for example, Amazon, Berkshire Hathaway, and JPMorgan Chase) wants to consolidate health care and vertically integrate it. Most physicians cannot even unionize.

So what cheerful conclusions can we draw? If you go to work for a big group, try to negotiate the least restrictive practice covenant possible – or at least one that is not applicable if you are terminated without “cause.” The big group may have to disgorge you someday, and it could be disastrous to have to move or not be able to practice. If you opt for a small group or private practice, keep it small and lean. Build no palaces. There are special small practice situations that will survive or even prosper. Tightly managing your overhead is the key to survival.

Young physicians should recognize that the opportunity costs of an extensive residency after medical school may not be worth it. In fact, considering tuition that results in huge debt, lost income, and lost years of practice, high school graduates aspiring to a career in health care may do better from an economic perspective by pursuing a career as a nurse practitioner or physician assistant than one as a physician. The ACA, with its favoritism to large groups, will not be repealed anytime soon, and the regulations favoring larger groups are not even under discussion. This makes even hospital management more attractive as a career choice.

5. You’ll be doing more with less.

With a projected shortage of more than 100,000 physicians in the next 11 years, prepare for a high volume of patients, less pay for each encounter, and responsibility for multiple extenders. Practice will be much more stressful and difficult than simply managing your own panel of patients. Expect physician networks so narrow that they include only primary care physicians, with all other physicians having moved, died, or retired. It is much easier for insurers to save money by not receiving bills. Start thinking about integrating telemedicine into your practice because this may be a lifeline considering the most recent Medicare final rule that provides for payment for several new telehealth codes.

That all said, I must quote a lawmaker who, when discussing the ACA, told me “Well, you doctors are awfully late to the punch bowl” to which I replied, “Without doctors, there is no punch in the punch bowl.”
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Most of us have a 5-, 10-, or even a necessarily vague 15-year plan for our practices. As you begin your New Year assessments, keep the following overriding considerations in mind to aid in your planning.

1) You are probably never going to be reimbursed better than you are today.

“Wait,” you say, “Don’t we get occasional Medicare updates?”

Yes, but these never keep up with inflation, just as any unlikely increases from private insurers always lag behind the cost of providing the service and have been grinding down toward Medicare rates – or even below them – for years. Any other sweeping insurance proposals, such as Medicare for All, include a hefty cut to physician reimbursement. One exception might be allowing those under age 55 years to buy into the existing Medicare program, which would be beneficial in areas where current private insurers and Medicare Advantage plans pay less than Medicare. It is also possible that you could see some increase if you are on the right side of bundled payments, although this has been more of a threat of penalty rather than a reward so far.

2) Don’t expect an imminent repeal of the ACA

The Affordable Care Act (ACA) favors large groups, and it is still the law, and it’s likely to remain the law for at least the next 5-10 years. Republicans could not repeal it when they held both the Senate and House, as well as the presidency, and certainly Democrats won’t repeal it.

There are myriad regulations and rules that only allow larger groups to reap the benefits from the ACA. Recall President Obama visiting the Cleveland Clinic and touting it and the Geisinger Clinic as examples of the way American medicine should be practiced.

Participation in alternative payment models that bypass many of the onerous requirements of “quality improvement,” and may even allow shared cost savings, are only practical for large groups. A notable exception is the recently proposed “site neutrality of payment” rule proposed by the current administration. This reduces by 50% or so the premium paid to large physician/hospital groups that are not located on the hospital campus to the prevailing rate of pay in the community. No more $3,000echocardiograms that used to cost $300.

Still, this does not increase the overall payments to physicians. Possibly, the proposed new telemedicine reimbursement rules may allow you to more efficiently manage patients without dramatically increasing your overhead.

An estimated 10,000 Baby Boomers are turning age 65 years every day. This ensures an increasing supply of patients, but also strains a federal government that has overpromised on Medicare and Social Security benefits. Recall that on average every Medicare recipient takes out far more than what they put into the program.

It is pay-up time, and the IOUs in the lockbox are unredeemable. This makes inflation and cutting reimbursements the easiest way to cope with older voters and a looming budget crisis.
 

4) Physicians are the weakest leg of the health care chair.

Hospitals, pharma, and insurers all have more powerful lobbying groups, donate more, and are better organized than physician groups. In our system of government, that means they will be favored in health care–related legislation. Physicians are the easiest to cut, although we account for only 15.9% of expenditures, according to 2014 data from the AMA.

The hospitals can close, insurers can refuse to write policies, and pharma can refuse to develop new drugs or manufacture generic ones. Big money (for example, Amazon, Berkshire Hathaway, and JPMorgan Chase) wants to consolidate health care and vertically integrate it. Most physicians cannot even unionize.

So what cheerful conclusions can we draw? If you go to work for a big group, try to negotiate the least restrictive practice covenant possible – or at least one that is not applicable if you are terminated without “cause.” The big group may have to disgorge you someday, and it could be disastrous to have to move or not be able to practice. If you opt for a small group or private practice, keep it small and lean. Build no palaces. There are special small practice situations that will survive or even prosper. Tightly managing your overhead is the key to survival.

Young physicians should recognize that the opportunity costs of an extensive residency after medical school may not be worth it. In fact, considering tuition that results in huge debt, lost income, and lost years of practice, high school graduates aspiring to a career in health care may do better from an economic perspective by pursuing a career as a nurse practitioner or physician assistant than one as a physician. The ACA, with its favoritism to large groups, will not be repealed anytime soon, and the regulations favoring larger groups are not even under discussion. This makes even hospital management more attractive as a career choice.

5. You’ll be doing more with less.

With a projected shortage of more than 100,000 physicians in the next 11 years, prepare for a high volume of patients, less pay for each encounter, and responsibility for multiple extenders. Practice will be much more stressful and difficult than simply managing your own panel of patients. Expect physician networks so narrow that they include only primary care physicians, with all other physicians having moved, died, or retired. It is much easier for insurers to save money by not receiving bills. Start thinking about integrating telemedicine into your practice because this may be a lifeline considering the most recent Medicare final rule that provides for payment for several new telehealth codes.

That all said, I must quote a lawmaker who, when discussing the ACA, told me “Well, you doctors are awfully late to the punch bowl” to which I replied, “Without doctors, there is no punch in the punch bowl.”
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

At a New Year’s Eve party a few years back, I noticed a man sitting nearby clutching his left upper arm. He was ashen and obviously uncomfortable. Acute coronary insufficiency, I thought, and I asked him if I could call the life squad for him. “Oh no,” he said, “I have these spells several times a day, the nitro will kick in after a minute, and this will ease off.” I listened as he explained he had a “widow maker,” a 90% plus left main occlusion, but “I am Canadian, and my government is going to pay for my bypass,” he said. “I just have to wait 6 more weeks.” The irony? He was the son of our host, and we were sitting in his mothers’ multimillion dollar home in the Florida Keys. He could be in a Miami hospital’s operating room in an hour or 2.

Wow. Click. Got it.

Fast forward to a lobbying discussion on Capitol Hill: A sympathetic U.S. senator tossed me this softball: ‘What do you think about Medicare reimbursement?” I expect he thought I was going to complain about how bad Medicare is, about its failure to keep current with inflation (currently about 30% behind), and the obtuse quality metrics it now requires. Instead, I found myself saying, “Medicare is my most reliable payer, paying on time – in 2 weeks for clean claims – and the private insurers have beaten me up badly. Medicare is one of my best payers.”

Wrong answer, but true statement.

There is much talk these days about Medicare for all, single-payer, and universal health care. American physicians and patients are disgusted with the current system, particularly considering all the barriers to care. (See my recent column, “Produce and Promises.”) Physicians and patients endure a mutual misery inflicted by private insurance companies.

What to do about health care in America?

First, let’s deal with the extraordinary costs of health care in the United States – 19% of our gross domestic product. About 3%-4 % of this figure is an accounting gimmick, since it includes nursing home care, which is considered “domiciliary” care rather than health care in Europe. In addition, drug costs are higher in the U.S., largely to cover the development of new drugs that cost less in the rest of the world. Wait lists are largely unheard of in the United States, and if you have such ready capacity, that means you incur the costs of idle capacity. Also, rarely is a new miracle drug flatly denied for coverage in the United States. If you persist, you will usually get your drug.

We are a commodity-driven society, and that is the real reason that health care costs so much in this country. Hence, we come to the real debate, the “R” word. How do we ration access to care? (See my 2017 column, “Why the Affordable Care Act will be Greatly Modified.”)

There are a plethora of proposals to fund single payer out there, none of which address rationing. And while single payer affords free universal coverage, it does not assure better care. As health economist Devon Herrick, Ph.D., wrote in his health care blog in 2016: “A single payer is not some magical entity that rains down savings from Heaven by being unconcerned about profit. Rather, an efficient single payer operates more like a predatory HMO with no competition. It is currently in vogue for hipsters to matter-of-factly announce the simple solution to health reform is single payer. Be careful what you wish for; you may end up with Medicaid for All.”

In fact, if you try to ferret out how physician income will be affected by universal health care, there would be an estimated pay cut of 11%-40%, depending on how the numbers are manipulated.

Some single-payer proposals use the term “exchange rates,” which for the uninformed means Medicaid rates. In addition, payment is usually given to the local hospital system, or “authority” to dole out. I have a very bad feeling that any small practitioner in an office-based practice would be severely shortchanged in such a system. In fact, if you cut pay for office-based physicians at all, you may begin to see them disappear.

Policy wonks argue for pay cuts for American physicians because European physicians “make less money.” Those numbers are all wrong. U.S. physicians are paid for their work, and for their practice expense. That is, how much it costs to provide the service in their office, which is around 40%-50% of published income. In Europe, almost all procedures are performed in the hospital setting, and the hospital absorbs the practice expense, which is ignored in this current health care reform debate. (See my 2015 column, “Doctor, Why DO you get paid so much?”)

The big selling point of single payer for physicians is that they might have less paperwork and get paid more for seeing Medicaid patients. Yet the paperwork will persist to avoid lawsuits, electronic medical records are now ingrained into the system, and most Medicaid patients are currently seen in the federal or hospital outpatient clinic where higher rates or other subsidies are available. The comically low Medicaid rates paid to physician offices are largely evaded or not even filed for.

Single-payer advocates are basically saying, “Yes, you will be seeing patients at a loss but you will make it up in volume.” This ignores the reality that most physicians don’t need or want more volume.

Here is my plan for single-payer health care. Call it ColdironCare.

• Set payment rates for physicians at 130% of current Medicare, about where we were 30 years ago, considering inflation. Tie the reimbursement rate to the cost of living index, same as social security. If you cut physician pay 11%-40%, you will see mass retirement and the elimination of the most efficient care, office-based practice.
• Remove the practice expense payment from government-reported physician income since this is overhead spent to provide the care.
• Let all physicians participate, and don’t pay site-of-service differentials.
• Enact national tort reform, which would decrease the paperwork, overhead, and much useless defensive medicine.
• Press the generic drug manufacturers (but not the innovators) regarding drug costs. Bite the bullet, and set national coverage standards (ration care) to be revisited every 5 years, which will eliminate step therapy and prior authorizations. Allow individuals to pay out of pocket for additional treatments they want, including that questionable additional 90 days of life they may get from the $250,000 drug for the off-label indication.
• Press the hospitals, and don’t complain when many of them close, especially rural ones.
• Allow individuals, hospitals, and physicians to contract outside of the government plan (in contrast to Canada).
• Downsize the health insurance companies, and have them sell private supplemental insurance to whomever wants it.

Finally, make all of this a constitutional amendment. If not put out of reach, in 15 years we will have the same system we have today. The politicians simply will not be able to resist degrading (reforming, improving, refunding, defunding) the original plan. Or, you could simply increase Medicaid rates to Medicare rates and call it a day.

Oh, by the way, I saw that man from the New Year’s Eve party at the airport the following Christmas. He survived to get his government bypass and is doing well.

The health care system we have is miserable, except compared with all the others.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

At a New Year’s Eve party a few years back, I noticed a man sitting nearby clutching his left upper arm. He was ashen and obviously uncomfortable. Acute coronary insufficiency, I thought, and I asked him if I could call the life squad for him. “Oh no,” he said, “I have these spells several times a day, the nitro will kick in after a minute, and this will ease off.” I listened as he explained he had a “widow maker,” a 90% plus left main occlusion, but “I am Canadian, and my government is going to pay for my bypass,” he said. “I just have to wait 6 more weeks.” The irony? He was the son of our host, and we were sitting in his mothers’ multimillion dollar home in the Florida Keys. He could be in a Miami hospital’s operating room in an hour or 2.

Wow. Click. Got it.

Fast forward to a lobbying discussion on Capitol Hill: A sympathetic U.S. senator tossed me this softball: ‘What do you think about Medicare reimbursement?” I expect he thought I was going to complain about how bad Medicare is, about its failure to keep current with inflation (currently about 30% behind), and the obtuse quality metrics it now requires. Instead, I found myself saying, “Medicare is my most reliable payer, paying on time – in 2 weeks for clean claims – and the private insurers have beaten me up badly. Medicare is one of my best payers.”

Wrong answer, but true statement.

There is much talk these days about Medicare for all, single-payer, and universal health care. American physicians and patients are disgusted with the current system, particularly considering all the barriers to care. (See my recent column, “Produce and Promises.”) Physicians and patients endure a mutual misery inflicted by private insurance companies.

What to do about health care in America?

First, let’s deal with the extraordinary costs of health care in the United States – 19% of our gross domestic product. About 3%-4 % of this figure is an accounting gimmick, since it includes nursing home care, which is considered “domiciliary” care rather than health care in Europe. In addition, drug costs are higher in the U.S., largely to cover the development of new drugs that cost less in the rest of the world. Wait lists are largely unheard of in the United States, and if you have such ready capacity, that means you incur the costs of idle capacity. Also, rarely is a new miracle drug flatly denied for coverage in the United States. If you persist, you will usually get your drug.

We are a commodity-driven society, and that is the real reason that health care costs so much in this country. Hence, we come to the real debate, the “R” word. How do we ration access to care? (See my 2017 column, “Why the Affordable Care Act will be Greatly Modified.”)

There are a plethora of proposals to fund single payer out there, none of which address rationing. And while single payer affords free universal coverage, it does not assure better care. As health economist Devon Herrick, Ph.D., wrote in his health care blog in 2016: “A single payer is not some magical entity that rains down savings from Heaven by being unconcerned about profit. Rather, an efficient single payer operates more like a predatory HMO with no competition. It is currently in vogue for hipsters to matter-of-factly announce the simple solution to health reform is single payer. Be careful what you wish for; you may end up with Medicaid for All.”

In fact, if you try to ferret out how physician income will be affected by universal health care, there would be an estimated pay cut of 11%-40%, depending on how the numbers are manipulated.

Some single-payer proposals use the term “exchange rates,” which for the uninformed means Medicaid rates. In addition, payment is usually given to the local hospital system, or “authority” to dole out. I have a very bad feeling that any small practitioner in an office-based practice would be severely shortchanged in such a system. In fact, if you cut pay for office-based physicians at all, you may begin to see them disappear.

Policy wonks argue for pay cuts for American physicians because European physicians “make less money.” Those numbers are all wrong. U.S. physicians are paid for their work, and for their practice expense. That is, how much it costs to provide the service in their office, which is around 40%-50% of published income. In Europe, almost all procedures are performed in the hospital setting, and the hospital absorbs the practice expense, which is ignored in this current health care reform debate. (See my 2015 column, “Doctor, Why DO you get paid so much?”)

The big selling point of single payer for physicians is that they might have less paperwork and get paid more for seeing Medicaid patients. Yet the paperwork will persist to avoid lawsuits, electronic medical records are now ingrained into the system, and most Medicaid patients are currently seen in the federal or hospital outpatient clinic where higher rates or other subsidies are available. The comically low Medicaid rates paid to physician offices are largely evaded or not even filed for.

Single-payer advocates are basically saying, “Yes, you will be seeing patients at a loss but you will make it up in volume.” This ignores the reality that most physicians don’t need or want more volume.

Here is my plan for single-payer health care. Call it ColdironCare.

• Set payment rates for physicians at 130% of current Medicare, about where we were 30 years ago, considering inflation. Tie the reimbursement rate to the cost of living index, same as social security. If you cut physician pay 11%-40%, you will see mass retirement and the elimination of the most efficient care, office-based practice.
• Remove the practice expense payment from government-reported physician income since this is overhead spent to provide the care.
• Let all physicians participate, and don’t pay site-of-service differentials.
• Enact national tort reform, which would decrease the paperwork, overhead, and much useless defensive medicine.
• Press the generic drug manufacturers (but not the innovators) regarding drug costs. Bite the bullet, and set national coverage standards (ration care) to be revisited every 5 years, which will eliminate step therapy and prior authorizations. Allow individuals to pay out of pocket for additional treatments they want, including that questionable additional 90 days of life they may get from the $250,000 drug for the off-label indication.
• Press the hospitals, and don’t complain when many of them close, especially rural ones.
• Allow individuals, hospitals, and physicians to contract outside of the government plan (in contrast to Canada).
• Downsize the health insurance companies, and have them sell private supplemental insurance to whomever wants it.

Finally, make all of this a constitutional amendment. If not put out of reach, in 15 years we will have the same system we have today. The politicians simply will not be able to resist degrading (reforming, improving, refunding, defunding) the original plan. Or, you could simply increase Medicaid rates to Medicare rates and call it a day.

Oh, by the way, I saw that man from the New Year’s Eve party at the airport the following Christmas. He survived to get his government bypass and is doing well.

The health care system we have is miserable, except compared with all the others.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

At a New Year’s Eve party a few years back, I noticed a man sitting nearby clutching his left upper arm. He was ashen and obviously uncomfortable. Acute coronary insufficiency, I thought, and I asked him if I could call the life squad for him. “Oh no,” he said, “I have these spells several times a day, the nitro will kick in after a minute, and this will ease off.” I listened as he explained he had a “widow maker,” a 90% plus left main occlusion, but “I am Canadian, and my government is going to pay for my bypass,” he said. “I just have to wait 6 more weeks.” The irony? He was the son of our host, and we were sitting in his mothers’ multimillion dollar home in the Florida Keys. He could be in a Miami hospital’s operating room in an hour or 2.

Wow. Click. Got it.

Fast forward to a lobbying discussion on Capitol Hill: A sympathetic U.S. senator tossed me this softball: ‘What do you think about Medicare reimbursement?” I expect he thought I was going to complain about how bad Medicare is, about its failure to keep current with inflation (currently about 30% behind), and the obtuse quality metrics it now requires. Instead, I found myself saying, “Medicare is my most reliable payer, paying on time – in 2 weeks for clean claims – and the private insurers have beaten me up badly. Medicare is one of my best payers.”

Wrong answer, but true statement.

There is much talk these days about Medicare for all, single-payer, and universal health care. American physicians and patients are disgusted with the current system, particularly considering all the barriers to care. (See my recent column, “Produce and Promises.”) Physicians and patients endure a mutual misery inflicted by private insurance companies.

What to do about health care in America?

First, let’s deal with the extraordinary costs of health care in the United States – 19% of our gross domestic product. About 3%-4 % of this figure is an accounting gimmick, since it includes nursing home care, which is considered “domiciliary” care rather than health care in Europe. In addition, drug costs are higher in the U.S., largely to cover the development of new drugs that cost less in the rest of the world. Wait lists are largely unheard of in the United States, and if you have such ready capacity, that means you incur the costs of idle capacity. Also, rarely is a new miracle drug flatly denied for coverage in the United States. If you persist, you will usually get your drug.

We are a commodity-driven society, and that is the real reason that health care costs so much in this country. Hence, we come to the real debate, the “R” word. How do we ration access to care? (See my 2017 column, “Why the Affordable Care Act will be Greatly Modified.”)

There are a plethora of proposals to fund single payer out there, none of which address rationing. And while single payer affords free universal coverage, it does not assure better care. As health economist Devon Herrick, Ph.D., wrote in his health care blog in 2016: “A single payer is not some magical entity that rains down savings from Heaven by being unconcerned about profit. Rather, an efficient single payer operates more like a predatory HMO with no competition. It is currently in vogue for hipsters to matter-of-factly announce the simple solution to health reform is single payer. Be careful what you wish for; you may end up with Medicaid for All.”

In fact, if you try to ferret out how physician income will be affected by universal health care, there would be an estimated pay cut of 11%-40%, depending on how the numbers are manipulated.

Some single-payer proposals use the term “exchange rates,” which for the uninformed means Medicaid rates. In addition, payment is usually given to the local hospital system, or “authority” to dole out. I have a very bad feeling that any small practitioner in an office-based practice would be severely shortchanged in such a system. In fact, if you cut pay for office-based physicians at all, you may begin to see them disappear.

Policy wonks argue for pay cuts for American physicians because European physicians “make less money.” Those numbers are all wrong. U.S. physicians are paid for their work, and for their practice expense. That is, how much it costs to provide the service in their office, which is around 40%-50% of published income. In Europe, almost all procedures are performed in the hospital setting, and the hospital absorbs the practice expense, which is ignored in this current health care reform debate. (See my 2015 column, “Doctor, Why DO you get paid so much?”)

The big selling point of single payer for physicians is that they might have less paperwork and get paid more for seeing Medicaid patients. Yet the paperwork will persist to avoid lawsuits, electronic medical records are now ingrained into the system, and most Medicaid patients are currently seen in the federal or hospital outpatient clinic where higher rates or other subsidies are available. The comically low Medicaid rates paid to physician offices are largely evaded or not even filed for.

Single-payer advocates are basically saying, “Yes, you will be seeing patients at a loss but you will make it up in volume.” This ignores the reality that most physicians don’t need or want more volume.

Here is my plan for single-payer health care. Call it ColdironCare.

• Set payment rates for physicians at 130% of current Medicare, about where we were 30 years ago, considering inflation. Tie the reimbursement rate to the cost of living index, same as social security. If you cut physician pay 11%-40%, you will see mass retirement and the elimination of the most efficient care, office-based practice.
• Remove the practice expense payment from government-reported physician income since this is overhead spent to provide the care.
• Let all physicians participate, and don’t pay site-of-service differentials.
• Enact national tort reform, which would decrease the paperwork, overhead, and much useless defensive medicine.
• Press the generic drug manufacturers (but not the innovators) regarding drug costs. Bite the bullet, and set national coverage standards (ration care) to be revisited every 5 years, which will eliminate step therapy and prior authorizations. Allow individuals to pay out of pocket for additional treatments they want, including that questionable additional 90 days of life they may get from the $250,000 drug for the off-label indication.
• Press the hospitals, and don’t complain when many of them close, especially rural ones.
• Allow individuals, hospitals, and physicians to contract outside of the government plan (in contrast to Canada).
• Downsize the health insurance companies, and have them sell private supplemental insurance to whomever wants it.

Finally, make all of this a constitutional amendment. If not put out of reach, in 15 years we will have the same system we have today. The politicians simply will not be able to resist degrading (reforming, improving, refunding, defunding) the original plan. Or, you could simply increase Medicaid rates to Medicare rates and call it a day.

Oh, by the way, I saw that man from the New Year’s Eve party at the airport the following Christmas. He survived to get his government bypass and is doing well.

The health care system we have is miserable, except compared with all the others.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Medicare just released its 2019 physician fee schedule, which is called the “final rule.” Of course, there is a new final rule every year, so it really isn’t very final. I know this is confusing to many of you, I was dazed for several days by this year’s proposed final rule.

Each year, the Centers for Medicare & Medicaid Services receives input from innumerable sources and formulates its payment for physicians. These responses are often in response to requests by CMS itself, which wants to make sure reimbursements are accurate. Generally, input comes from the American Medical Association’s RVS Update Committee (RUC), which values new and existing CPT codes, as well as Congress, the Health & Human Services Office of Inspector General, lobbyists, specialty society organizations, public advocacy groups, and anyone who can wrangle an appointment at or write a letter to CMS headquarters in Baltimore. This conflicted brew is hashed over, and published in late July as a proposed rule. Public comments are then solicited (all letters and emails are considered, dermatologists sent 1,500 responses to this one!) and a final rule is published in the fall. I have constructed a flowchart of this process.

This year’s proposed rule was particularly disturbing because of major changes in reimbursement proposed by CMS. As you may recall, officials proposed to collapse all the evaluation and management (E/M) codes into two levels and pay bonuses to certain specialists (but not dermatologists). This might have been agreeable, except Medicare reimbursements are a zero-sum game. If someone is paid more, someone else will be paid less. Of course, you could always let the increase come out of the general pool, but that would decrease the conversion factor, and some health care professionals (usually primary care) might not see an overall increase. So, the proposed rule was going to “pay” for this increase by way of eliminating the 25 modifier, the CPT modifier that allows you to be paid for the evaluation and management (E/M) service on the same day as a procedure. This has been averted, at least for two years.

The final rule also makes a real effort to eliminate some meaningless documentation. Effective Jan. 1, 2019, for established patients, practitioners can focus their notes on patient changes. With new and established patients, they need not personally reenter the chief complaint and history already recorded by staff or the patient, other than simply indicate that they reviewed and verified the information in the medical record. In addition, teaching physicians do not have to duplicate notations by residents. CMS also included practice expense for additional skin biopsies.

CMS is also going to pay for services using communication technology. These include:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012). This is provided by a physician or other qualified health care professional who can report E/M services for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. It is important to note that CMS is allowing for this code to include audio-only, real-time telephone interactions, in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010). This is remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment). The code can be reported effective Jan. 1, 2019, for established patients only.

You can use G2012 to decide if an office visit is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow health care professionals to be paid separately for reviewing patient-transmitted photo or video information whether or not a visit is needed. The encounter must be synchronous (real-time), two-way audio interactions enhanced with video or other kinds of data transmission.

It appears that these would only be practical for established patients, and don’t forget, your Internet and text responses to patients’ messages are not secure, unless they are on a secure portal, although their messages to you are HIPAA compliant. However, the telephone, some Internet portals, and your electronic medical record portals are secure. It is intriguing to me that I might get paid for all those bad pictures patients send me, at least if it is not in a global period.

It also appears that Rural Health Clinics and Federally Qualified Health Centers will be able to bill for new and established patient visits via communication technology.

This is all great news to physicians. Kudos to dermatologists Jack Resneck Jr., MD, American Medical Association trustee; and George Hruza, MD, the American Academy of Dermatology president-elect; and Sabra Sullivan, MD, PhD, chair of the AAD’s Council on Government Affairs and Health Policy Government, who organized this lemonade-making effort. And once again, the AAD’s Washington office has shown its great value. This also aptly demonstrates why you write letters to CMS.

In 2021, levels 2-4 will be collapsed into one code (levels 5 will remain, but remember, very few dermatologists use level 5) and you will have to document only at level 2 code levels. Special add-on codes will be added for exceptionally difficult cases for primary care and all specialist physicians, including dermatology. What is not clear is how this new reimbursement schemata will be funded. CMS is still suspicious that there is overlapping work when procedures are performed on the same day as an E/M (evaluation and management code). We may end up fighting this battle all over again.

Currently CMS is conducting a survey, sent to 1,500 dermatologists, on follow-up visits. CMS has stated that they will evaluate the public comments received and consider whether to propose action at a future date. CMS plans to send a letter describing the requirements, once again, to health care professionals in nine affected states, who are required to report the global period encounter. If you are one of these practitioners, please do fill this out and contact Faith McNicholas at AAD (FMcNicholas@aad.org) if you have questions. The decision to eliminate global periods (disastrous) will be based on this survey.

This is why you need to stay engaged, write letters, join the AMA, donate to SkinPAC, and attend the legislative fly in, the AAD’s legislative conference held every year in Washington. We are a small specialty. If we do not speak up and stay engaged, we will become the lemons for the next pitcher of lemonade.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Medicare just released its 2019 physician fee schedule, which is called the “final rule.” Of course, there is a new final rule every year, so it really isn’t very final. I know this is confusing to many of you, I was dazed for several days by this year’s proposed final rule.

Each year, the Centers for Medicare & Medicaid Services receives input from innumerable sources and formulates its payment for physicians. These responses are often in response to requests by CMS itself, which wants to make sure reimbursements are accurate. Generally, input comes from the American Medical Association’s RVS Update Committee (RUC), which values new and existing CPT codes, as well as Congress, the Health & Human Services Office of Inspector General, lobbyists, specialty society organizations, public advocacy groups, and anyone who can wrangle an appointment at or write a letter to CMS headquarters in Baltimore. This conflicted brew is hashed over, and published in late July as a proposed rule. Public comments are then solicited (all letters and emails are considered, dermatologists sent 1,500 responses to this one!) and a final rule is published in the fall. I have constructed a flowchart of this process.

This year’s proposed rule was particularly disturbing because of major changes in reimbursement proposed by CMS. As you may recall, officials proposed to collapse all the evaluation and management (E/M) codes into two levels and pay bonuses to certain specialists (but not dermatologists). This might have been agreeable, except Medicare reimbursements are a zero-sum game. If someone is paid more, someone else will be paid less. Of course, you could always let the increase come out of the general pool, but that would decrease the conversion factor, and some health care professionals (usually primary care) might not see an overall increase. So, the proposed rule was going to “pay” for this increase by way of eliminating the 25 modifier, the CPT modifier that allows you to be paid for the evaluation and management (E/M) service on the same day as a procedure. This has been averted, at least for two years.

The final rule also makes a real effort to eliminate some meaningless documentation. Effective Jan. 1, 2019, for established patients, practitioners can focus their notes on patient changes. With new and established patients, they need not personally reenter the chief complaint and history already recorded by staff or the patient, other than simply indicate that they reviewed and verified the information in the medical record. In addition, teaching physicians do not have to duplicate notations by residents. CMS also included practice expense for additional skin biopsies.

CMS is also going to pay for services using communication technology. These include:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012). This is provided by a physician or other qualified health care professional who can report E/M services for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. It is important to note that CMS is allowing for this code to include audio-only, real-time telephone interactions, in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010). This is remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment). The code can be reported effective Jan. 1, 2019, for established patients only.

You can use G2012 to decide if an office visit is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow health care professionals to be paid separately for reviewing patient-transmitted photo or video information whether or not a visit is needed. The encounter must be synchronous (real-time), two-way audio interactions enhanced with video or other kinds of data transmission.

It appears that these would only be practical for established patients, and don’t forget, your Internet and text responses to patients’ messages are not secure, unless they are on a secure portal, although their messages to you are HIPAA compliant. However, the telephone, some Internet portals, and your electronic medical record portals are secure. It is intriguing to me that I might get paid for all those bad pictures patients send me, at least if it is not in a global period.

It also appears that Rural Health Clinics and Federally Qualified Health Centers will be able to bill for new and established patient visits via communication technology.

This is all great news to physicians. Kudos to dermatologists Jack Resneck Jr., MD, American Medical Association trustee; and George Hruza, MD, the American Academy of Dermatology president-elect; and Sabra Sullivan, MD, PhD, chair of the AAD’s Council on Government Affairs and Health Policy Government, who organized this lemonade-making effort. And once again, the AAD’s Washington office has shown its great value. This also aptly demonstrates why you write letters to CMS.

In 2021, levels 2-4 will be collapsed into one code (levels 5 will remain, but remember, very few dermatologists use level 5) and you will have to document only at level 2 code levels. Special add-on codes will be added for exceptionally difficult cases for primary care and all specialist physicians, including dermatology. What is not clear is how this new reimbursement schemata will be funded. CMS is still suspicious that there is overlapping work when procedures are performed on the same day as an E/M (evaluation and management code). We may end up fighting this battle all over again.

Currently CMS is conducting a survey, sent to 1,500 dermatologists, on follow-up visits. CMS has stated that they will evaluate the public comments received and consider whether to propose action at a future date. CMS plans to send a letter describing the requirements, once again, to health care professionals in nine affected states, who are required to report the global period encounter. If you are one of these practitioners, please do fill this out and contact Faith McNicholas at AAD (FMcNicholas@aad.org) if you have questions. The decision to eliminate global periods (disastrous) will be based on this survey.

This is why you need to stay engaged, write letters, join the AMA, donate to SkinPAC, and attend the legislative fly in, the AAD’s legislative conference held every year in Washington. We are a small specialty. If we do not speak up and stay engaged, we will become the lemons for the next pitcher of lemonade.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Medicare just released its 2019 physician fee schedule, which is called the “final rule.” Of course, there is a new final rule every year, so it really isn’t very final. I know this is confusing to many of you, I was dazed for several days by this year’s proposed final rule.

Each year, the Centers for Medicare & Medicaid Services receives input from innumerable sources and formulates its payment for physicians. These responses are often in response to requests by CMS itself, which wants to make sure reimbursements are accurate. Generally, input comes from the American Medical Association’s RVS Update Committee (RUC), which values new and existing CPT codes, as well as Congress, the Health & Human Services Office of Inspector General, lobbyists, specialty society organizations, public advocacy groups, and anyone who can wrangle an appointment at or write a letter to CMS headquarters in Baltimore. This conflicted brew is hashed over, and published in late July as a proposed rule. Public comments are then solicited (all letters and emails are considered, dermatologists sent 1,500 responses to this one!) and a final rule is published in the fall. I have constructed a flowchart of this process.

This year’s proposed rule was particularly disturbing because of major changes in reimbursement proposed by CMS. As you may recall, officials proposed to collapse all the evaluation and management (E/M) codes into two levels and pay bonuses to certain specialists (but not dermatologists). This might have been agreeable, except Medicare reimbursements are a zero-sum game. If someone is paid more, someone else will be paid less. Of course, you could always let the increase come out of the general pool, but that would decrease the conversion factor, and some health care professionals (usually primary care) might not see an overall increase. So, the proposed rule was going to “pay” for this increase by way of eliminating the 25 modifier, the CPT modifier that allows you to be paid for the evaluation and management (E/M) service on the same day as a procedure. This has been averted, at least for two years.

The final rule also makes a real effort to eliminate some meaningless documentation. Effective Jan. 1, 2019, for established patients, practitioners can focus their notes on patient changes. With new and established patients, they need not personally reenter the chief complaint and history already recorded by staff or the patient, other than simply indicate that they reviewed and verified the information in the medical record. In addition, teaching physicians do not have to duplicate notations by residents. CMS also included practice expense for additional skin biopsies.

CMS is also going to pay for services using communication technology. These include:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012). This is provided by a physician or other qualified health care professional who can report E/M services for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. It is important to note that CMS is allowing for this code to include audio-only, real-time telephone interactions, in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.
• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010). This is remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment). The code can be reported effective Jan. 1, 2019, for established patients only.

You can use G2012 to decide if an office visit is needed. Similarly, the service of remote evaluation of recorded video and/or images submitted by an established patient would allow health care professionals to be paid separately for reviewing patient-transmitted photo or video information whether or not a visit is needed. The encounter must be synchronous (real-time), two-way audio interactions enhanced with video or other kinds of data transmission.

It appears that these would only be practical for established patients, and don’t forget, your Internet and text responses to patients’ messages are not secure, unless they are on a secure portal, although their messages to you are HIPAA compliant. However, the telephone, some Internet portals, and your electronic medical record portals are secure. It is intriguing to me that I might get paid for all those bad pictures patients send me, at least if it is not in a global period.

It also appears that Rural Health Clinics and Federally Qualified Health Centers will be able to bill for new and established patient visits via communication technology.

This is all great news to physicians. Kudos to dermatologists Jack Resneck Jr., MD, American Medical Association trustee; and George Hruza, MD, the American Academy of Dermatology president-elect; and Sabra Sullivan, MD, PhD, chair of the AAD’s Council on Government Affairs and Health Policy Government, who organized this lemonade-making effort. And once again, the AAD’s Washington office has shown its great value. This also aptly demonstrates why you write letters to CMS.

In 2021, levels 2-4 will be collapsed into one code (levels 5 will remain, but remember, very few dermatologists use level 5) and you will have to document only at level 2 code levels. Special add-on codes will be added for exceptionally difficult cases for primary care and all specialist physicians, including dermatology. What is not clear is how this new reimbursement schemata will be funded. CMS is still suspicious that there is overlapping work when procedures are performed on the same day as an E/M (evaluation and management code). We may end up fighting this battle all over again.

Currently CMS is conducting a survey, sent to 1,500 dermatologists, on follow-up visits. CMS has stated that they will evaluate the public comments received and consider whether to propose action at a future date. CMS plans to send a letter describing the requirements, once again, to health care professionals in nine affected states, who are required to report the global period encounter. If you are one of these practitioners, please do fill this out and contact Faith McNicholas at AAD (FMcNicholas@aad.org) if you have questions. The decision to eliminate global periods (disastrous) will be based on this survey.

This is why you need to stay engaged, write letters, join the AMA, donate to SkinPAC, and attend the legislative fly in, the AAD’s legislative conference held every year in Washington. We are a small specialty. If we do not speak up and stay engaged, we will become the lemons for the next pitcher of lemonade.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.

Six years ago, there was an outbreak of fungal meningitis from improperly manufactured intrathecal steroid by a criminal pharmacist and pharmacy owner. Physicians, who had nothing to do with the pharmacy, are still struggling with the fallout from this.

In particular, 2 years ago, Ohio became the test state for outrageous restrictions on physician’s use of medications in their offices by a state pharmacy board (see “Beware the state pharmacy board,” Dermatology News, June 3, 2016). These rules degrade patient care by making medications inaccessible and much more expensive, and by eliminating office treatment options – and make the practice of medicine much more difficult.

However, since the original promulgation of these rules in Ohio, organized medicine at the state and national level has resisted and has made some progress.

In its recently published draft guidance for industry, the Food and Drug Administration excluded physician offices from enforcement in its compounding rules. While this is a great victory, the guidance also mentioned that physicians may be subject to rules promulgated by the U.S. Pharmacopeia (USP) and state pharmacy boards, who have adopted USP guidelines to physician offices in the past. Thus, our focus shifts to the USP.

The USP is a private, nongovernmental private organization of mostly pharmacists and national medical society representatives, organized to create a reference of uniform preparations for the most commonly used drugs – with tests to ensure their quality, potency, and purity. This has been a very good thing for American medicine, but the compounding chapter is written by pharmacists, to apply to compounding pharmacies. That is fine. The problem arises when you redefine a physician’s office as a compounding pharmacy. This is what took place in Ohio, and what pharmacy boards want to do nationwide.

Do not be naive. This is a national scope of practice issue that could determine how physicians can use medications in their offices. In Ohio, they were particularly devious in my opinion. The state legislature (in an omnibus spending bill) explicitly expanded the Ohio Board of Pharmacy’s mandate to supervise the “compounding of hazardous medications.” I think the legislature, the state medical society, and everyone else assumed this meant drugs manufactured and sold by compounding pharmacies, such as intrathecal steroids.

The pharmacy board readily recognized an opening here and went on to define hazardous drugs as any prescription drug, and compounding as mixture or even sterile dilution of any prescription drug. The board then proposed a $112 dollar annual licensing fee (since reduced to $55) that would affect, doctors, dentists, and even veterinarians.

When the rules were first published, there was outrage. The board was even going to require a compounding license to reconstitute vaccines. This requirement was quickly withdrawn when it was pointed out that vaccines were advertised for sale at pharmacies, an obvious restraint of trade issue.

So, what’s the big deal with paying $55 a year for a compounding license from the pharmacy board? It involves a 17-page form, and you must agree to unannounced inspections of your office. A northern Ohio physician who obtained his terminal distribution of drugs and compounding license had an almost immediate unannounced inspection, where he was cited for an unlocked sample closet door, expired samples, and for not recording all the lot numbers of each sample dispensed. He also was cited for not having a separate clean drawing room in which he mixed his syringes and for not discarding any reconstitutions or mixtures not used. Think botulinum toxin here. He was required to draft a remediation plan, which includes recording all medications compounded (anything mixed in a syringe!) in separate log books (conventional medical records are not adequate) and recording lot numbers of all samples dispensed. Consider a log entry each time you dilute Kenalog for injection or buffer lidocaine.

Do not think you will fly under the radar here. I expect state pharmacy boards to requisition botulinum toxin and bicarbonate purchase records from supply houses and to investigate purchasers. They can cite you for $3,000 per violation and can also instruct suppliers to no longer sell product to you.

USP Rules

The revised USP rules are a difficult fit for physicians’ offices. Because they have granted a 1-hour exemption, you will have to use buffered lidocaine and reconstituted botulinum toxin in 1 hour or less, then discard it under these rules. This means you cannot draw up all your buffered lidocaine for the day in the morning and use it throughout the day; never mind that there are good data showing redrawn syringes of buffered lidocaine and botulinum toxin are stable for several weeks in a refrigerator (J Clin Neurol. 2013 Jul;9[3]:157-64).

I think these rules eventually will be settled by a restraint of trade lawsuit. After all, none can be shown to improve patient care; in fact, they degrade it and increase the costs to patients and physicians. We may end up being grateful that the U.S. Supreme Court emasculated state professional boards in the famous 2015 North Carolina tooth-whitening ruling.

The USP is accepting comments about the rules until Nov. 30th. The American Academy of Dermatology has a suggested letter to the USP Compounding Expert Committee on its website, which suggests that you ask for at least a 12-hour exemption.

I strongly suggest you write and explain why pharmacy board regulations that interfere with a physician’s ability to administer individualized, customized medication will hurt your patients and will cost more. Physicians have been treating their patients with individualized, customized medications for more than 2,000 years. It seems unreasonable to hand this skillful and essential part of medicine over to pharmacists in the absence of any compelling evidence.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.



 

Six years ago, there was an outbreak of fungal meningitis from improperly manufactured intrathecal steroid by a criminal pharmacist and pharmacy owner. Physicians, who had nothing to do with the pharmacy, are still struggling with the fallout from this.

In particular, 2 years ago, Ohio became the test state for outrageous restrictions on physician’s use of medications in their offices by a state pharmacy board (see “Beware the state pharmacy board,” Dermatology News, June 3, 2016). These rules degrade patient care by making medications inaccessible and much more expensive, and by eliminating office treatment options – and make the practice of medicine much more difficult.

However, since the original promulgation of these rules in Ohio, organized medicine at the state and national level has resisted and has made some progress.

In its recently published draft guidance for industry, the Food and Drug Administration excluded physician offices from enforcement in its compounding rules. While this is a great victory, the guidance also mentioned that physicians may be subject to rules promulgated by the U.S. Pharmacopeia (USP) and state pharmacy boards, who have adopted USP guidelines to physician offices in the past. Thus, our focus shifts to the USP.

The USP is a private, nongovernmental private organization of mostly pharmacists and national medical society representatives, organized to create a reference of uniform preparations for the most commonly used drugs – with tests to ensure their quality, potency, and purity. This has been a very good thing for American medicine, but the compounding chapter is written by pharmacists, to apply to compounding pharmacies. That is fine. The problem arises when you redefine a physician’s office as a compounding pharmacy. This is what took place in Ohio, and what pharmacy boards want to do nationwide.

Do not be naive. This is a national scope of practice issue that could determine how physicians can use medications in their offices. In Ohio, they were particularly devious in my opinion. The state legislature (in an omnibus spending bill) explicitly expanded the Ohio Board of Pharmacy’s mandate to supervise the “compounding of hazardous medications.” I think the legislature, the state medical society, and everyone else assumed this meant drugs manufactured and sold by compounding pharmacies, such as intrathecal steroids.

The pharmacy board readily recognized an opening here and went on to define hazardous drugs as any prescription drug, and compounding as mixture or even sterile dilution of any prescription drug. The board then proposed a $112 dollar annual licensing fee (since reduced to $55) that would affect, doctors, dentists, and even veterinarians.

When the rules were first published, there was outrage. The board was even going to require a compounding license to reconstitute vaccines. This requirement was quickly withdrawn when it was pointed out that vaccines were advertised for sale at pharmacies, an obvious restraint of trade issue.

So, what’s the big deal with paying $55 a year for a compounding license from the pharmacy board? It involves a 17-page form, and you must agree to unannounced inspections of your office. A northern Ohio physician who obtained his terminal distribution of drugs and compounding license had an almost immediate unannounced inspection, where he was cited for an unlocked sample closet door, expired samples, and for not recording all the lot numbers of each sample dispensed. He also was cited for not having a separate clean drawing room in which he mixed his syringes and for not discarding any reconstitutions or mixtures not used. Think botulinum toxin here. He was required to draft a remediation plan, which includes recording all medications compounded (anything mixed in a syringe!) in separate log books (conventional medical records are not adequate) and recording lot numbers of all samples dispensed. Consider a log entry each time you dilute Kenalog for injection or buffer lidocaine.

Do not think you will fly under the radar here. I expect state pharmacy boards to requisition botulinum toxin and bicarbonate purchase records from supply houses and to investigate purchasers. They can cite you for $3,000 per violation and can also instruct suppliers to no longer sell product to you.

USP Rules

The revised USP rules are a difficult fit for physicians’ offices. Because they have granted a 1-hour exemption, you will have to use buffered lidocaine and reconstituted botulinum toxin in 1 hour or less, then discard it under these rules. This means you cannot draw up all your buffered lidocaine for the day in the morning and use it throughout the day; never mind that there are good data showing redrawn syringes of buffered lidocaine and botulinum toxin are stable for several weeks in a refrigerator (J Clin Neurol. 2013 Jul;9[3]:157-64).

I think these rules eventually will be settled by a restraint of trade lawsuit. After all, none can be shown to improve patient care; in fact, they degrade it and increase the costs to patients and physicians. We may end up being grateful that the U.S. Supreme Court emasculated state professional boards in the famous 2015 North Carolina tooth-whitening ruling.

The USP is accepting comments about the rules until Nov. 30th. The American Academy of Dermatology has a suggested letter to the USP Compounding Expert Committee on its website, which suggests that you ask for at least a 12-hour exemption.

I strongly suggest you write and explain why pharmacy board regulations that interfere with a physician’s ability to administer individualized, customized medication will hurt your patients and will cost more. Physicians have been treating their patients with individualized, customized medications for more than 2,000 years. It seems unreasonable to hand this skillful and essential part of medicine over to pharmacists in the absence of any compelling evidence.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.



 

Six years ago, there was an outbreak of fungal meningitis from improperly manufactured intrathecal steroid by a criminal pharmacist and pharmacy owner. Physicians, who had nothing to do with the pharmacy, are still struggling with the fallout from this.

In particular, 2 years ago, Ohio became the test state for outrageous restrictions on physician’s use of medications in their offices by a state pharmacy board (see “Beware the state pharmacy board,” Dermatology News, June 3, 2016). These rules degrade patient care by making medications inaccessible and much more expensive, and by eliminating office treatment options – and make the practice of medicine much more difficult.

However, since the original promulgation of these rules in Ohio, organized medicine at the state and national level has resisted and has made some progress.

In its recently published draft guidance for industry, the Food and Drug Administration excluded physician offices from enforcement in its compounding rules. While this is a great victory, the guidance also mentioned that physicians may be subject to rules promulgated by the U.S. Pharmacopeia (USP) and state pharmacy boards, who have adopted USP guidelines to physician offices in the past. Thus, our focus shifts to the USP.

The USP is a private, nongovernmental private organization of mostly pharmacists and national medical society representatives, organized to create a reference of uniform preparations for the most commonly used drugs – with tests to ensure their quality, potency, and purity. This has been a very good thing for American medicine, but the compounding chapter is written by pharmacists, to apply to compounding pharmacies. That is fine. The problem arises when you redefine a physician’s office as a compounding pharmacy. This is what took place in Ohio, and what pharmacy boards want to do nationwide.

Do not be naive. This is a national scope of practice issue that could determine how physicians can use medications in their offices. In Ohio, they were particularly devious in my opinion. The state legislature (in an omnibus spending bill) explicitly expanded the Ohio Board of Pharmacy’s mandate to supervise the “compounding of hazardous medications.” I think the legislature, the state medical society, and everyone else assumed this meant drugs manufactured and sold by compounding pharmacies, such as intrathecal steroids.

The pharmacy board readily recognized an opening here and went on to define hazardous drugs as any prescription drug, and compounding as mixture or even sterile dilution of any prescription drug. The board then proposed a $112 dollar annual licensing fee (since reduced to $55) that would affect, doctors, dentists, and even veterinarians.

When the rules were first published, there was outrage. The board was even going to require a compounding license to reconstitute vaccines. This requirement was quickly withdrawn when it was pointed out that vaccines were advertised for sale at pharmacies, an obvious restraint of trade issue.

So, what’s the big deal with paying $55 a year for a compounding license from the pharmacy board? It involves a 17-page form, and you must agree to unannounced inspections of your office. A northern Ohio physician who obtained his terminal distribution of drugs and compounding license had an almost immediate unannounced inspection, where he was cited for an unlocked sample closet door, expired samples, and for not recording all the lot numbers of each sample dispensed. He also was cited for not having a separate clean drawing room in which he mixed his syringes and for not discarding any reconstitutions or mixtures not used. Think botulinum toxin here. He was required to draft a remediation plan, which includes recording all medications compounded (anything mixed in a syringe!) in separate log books (conventional medical records are not adequate) and recording lot numbers of all samples dispensed. Consider a log entry each time you dilute Kenalog for injection or buffer lidocaine.

Do not think you will fly under the radar here. I expect state pharmacy boards to requisition botulinum toxin and bicarbonate purchase records from supply houses and to investigate purchasers. They can cite you for $3,000 per violation and can also instruct suppliers to no longer sell product to you.

USP Rules

The revised USP rules are a difficult fit for physicians’ offices. Because they have granted a 1-hour exemption, you will have to use buffered lidocaine and reconstituted botulinum toxin in 1 hour or less, then discard it under these rules. This means you cannot draw up all your buffered lidocaine for the day in the morning and use it throughout the day; never mind that there are good data showing redrawn syringes of buffered lidocaine and botulinum toxin are stable for several weeks in a refrigerator (J Clin Neurol. 2013 Jul;9[3]:157-64).

I think these rules eventually will be settled by a restraint of trade lawsuit. After all, none can be shown to improve patient care; in fact, they degrade it and increase the costs to patients and physicians. We may end up being grateful that the U.S. Supreme Court emasculated state professional boards in the famous 2015 North Carolina tooth-whitening ruling.

The USP is accepting comments about the rules until Nov. 30th. The American Academy of Dermatology has a suggested letter to the USP Compounding Expert Committee on its website, which suggests that you ask for at least a 12-hour exemption.

I strongly suggest you write and explain why pharmacy board regulations that interfere with a physician’s ability to administer individualized, customized medication will hurt your patients and will cost more. Physicians have been treating their patients with individualized, customized medications for more than 2,000 years. It seems unreasonable to hand this skillful and essential part of medicine over to pharmacists in the absence of any compelling evidence.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.