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  • Private Equity / Derm / Academia

    thought this crowd might find this interesting

    https://www.nytimes.com/2018/10/26/health/private-equity-dermatology.html

  • #2
    Interesting article. The question is whether the billing for service is accurate and the PE firms are purchasing the highly profitable practices, which is what good PE firms do or if there is a smoking gun with the billing at these practices. It may be hard to truly find this out, given the shadiness of the article being pulled.

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    • #3
      It already went through a peer reviewed process and then got pulled when those with vested interests were offended? Shady indeed.

      Comment


      • #4
        I guess instead of the cockroaches scattering when the light came on, somehow the cockroaches were able to turn the light back off.

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        • #5
          With no apologies to the dermatologists out there, the reimbursement is too high compared to their contribution to healthcare. The rates of melanoma dx have skyrocketed, but yet there's no improval in overall survival, just over diagnosis. I'm sure these firms are acquiring practices that perform a high number of procedures. There's already a loophole for the Stark law, which promotes additional procedures for them. This is pretty unethical of Dr Elston to pull this article. Get a backbone.

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          • #6
            Who would have thought incentives could affect medicine or academic journals ? I’m shocked.

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            • #7




              With no apologies to the dermatologists out there, the reimbursement is too high compared to their contribution to healthcare. The rates of melanoma dx have skyrocketed, but yet there’s no improval in overall survival, just over diagnosis. I’m sure these firms are acquiring practices that perform a high number of procedures. There’s already a loophole for the Stark law, which promotes additional procedures for them. This is pretty unethical of Dr Elston to pull this article. Get a backbone.
              Click to expand...


              I'm not quite sure I understand the logic here.  I'm fine with people arguing that certain reimbursement is too high, but there are several reasons why this argument should be more nuanced than based in overall survival for a specific diagnosis.  First, the rates of melanoma have been rising because of things like tanning beds and the population being stupid, not because a particular field is running around submitting false diagnoses.  Melanoma is an objectively diagnosed entity based on pathology, so I'm not sure how a field or anyone for that matter can "over diagnose" melanoma - unless you are claiming that people are committing rampant fraud (calling something melanoma on pathology when it's just a mole).  The second reason I don't think this is an appropriate argument is because melanoma is a disease treated by multiple specialties - General Surgery, ENT, Dermatology, Plastic Surgery, Oncology, and Radiation Oncology to name the bigger players.  To put the overall survival burden on the laps of one field overlooks the multi-disciplinary management of this disease.  Lastly, even if Dermatology was the only treating specialty for melanoma - doing all the resections, all the chemo, the radiation, the pharmaceutical development, all clinical trials and research into gene therapy/immune therapy/chemo/radiation/etc. - you would need all else equal over time (disease process/genetics itself, patient compliance, workforce ratios, etc.) to put any sort of blame at the feet of that specialty.

              Comment


              • #8
                Not a dermatologist, but also don’t get the ‘they get paid too much’ argument across the board. Someone was taking shots at my specialty recently saying it would get cut. Maybe right, maybe wrong it’s like trying to time the market. I feel that there is usually some underlying jealousy/envy in these statements. Apparently blowing out my candle makes yours glow brighter...

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                • #9
                  Shady is a difficult thing, is it moral or legal or actually medical. There are lots of ways to legally yet shrewdly focus only on things that make the most money/time/risk etc...ancillary services, etc...as opposed to just doing what comes through the door or focusing on service. Theres really a ton money in medicine, and most doctors arent (rightfully mostly) able to nor care to even come close maximizing profits or margin. So its not out of the realm some practices exist that are doing more and/or can be taken over by business interests can come in and do the optimization.

                  Obviously, these companies do not care about anything other than making a ton of money for as little actual work as they can. We have them in plastics as well, I am not a fan of their practices, basically letting high school grads screen, h/p and set up pts for surgery. Docs meet day of, which of course incentivizes towards operating even if maybe on your own you wouldnt have. Also, its pretty bad to demonstrate that a high schooler can do your job and Im sure that wont come back to hurt doctors in the future.

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                  • #10




                    I’m not quite sure I understand the logic here.  I’m fine with people arguing that certain reimbursement is too high, but there are several reasons why this argument should be more nuanced than based in overall survival for a specific diagnosis.  First, the rates of melanoma have been rising because of things like tanning beds and the population being stupid, not because a particular field is running around submitting false diagnoses.  Melanoma is an objectively diagnosed entity based on pathology, so I’m not sure how a field or anyone for that matter can “over diagnose” melanoma – unless you are claiming that people are committing rampant fraud (calling something melanoma on pathology when it’s just a mole).  The second reason I don’t think this is an appropriate argument is because melanoma is a disease treated by multiple specialties – General Surgery, ENT, Dermatology, Plastic Surgery, Oncology, and Radiation Oncology to name the bigger players.  To put the overall survival burden on the laps of one field overlooks the multi-disciplinary management of this disease.  Lastly, even if Dermatology was the only treating specialty for melanoma – doing all the resections, all the chemo, the radiation, the pharmaceutical development, all clinical trials and research into gene therapy/immune therapy/chemo/radiation/etc. – you would need all else equal over time (disease process/genetics itself, patient compliance, workforce ratios, etc.) to put any sort of blame at the feet of that specialty.
                    Click to expand...


                    The logic is that dermatologists are monetarily incentivized to increase the number of biopsies of patients.  They explain the medical need for early detection and prevention of melanoma.  However, there's a lack of data to support this.  See this from USPSTF regarding the evidence for clinical skin checks:  https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/skin-cancer-screening2#fig

                    "Overdiagnosis and overtreatment—the identification and treatment of cancer that would never have harmed the patient in the absence of screening—is also a potential outcome of concern. It is not possible to directly determine for any individual patient whether a diagnosed cancer will progress or not; as such, measuring overdiagnosis is not a straightforward process and must be indirectly quantified. In the case of skin cancer, there is limited research to estimate the potential magnitude of the burden of overdiagnosis associated with screening. An ecologic study linking melanoma incidence and mortality data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program with Medicare claims for skin biopsy among patients 65 years and older found that from 1986 to 2001, the average incidence of melanoma increased 2.4 times (from 45 to 108 cases per 100,000 persons), while the average biopsy rate increased 2.5 times (from 2847 to 7222 biopsies performed per 100,000 persons). However, the increased cancer incidence was entirely due to extra cases of in situ and local disease, without the expected complementary decrease in the incidence of advanced melanoma or death from melanoma. The authors concluded that this pattern strongly suggested that screening efforts in the United States were generating overdiagnosis, rather than depicting a true increase in the occurrence of melanoma."

                    Melanoma is absolutely overdiagnosed in this country.  It's not an objective diagnosis.  It comes across clinically as objective, but the diagnosis is based on the morphologic impression and opinion of the dermatopathologist interpreting the H&E slide.  There's a lot of gray area in diagnosis.  I'm not saying it's fraud.  I'm saying if you biopsy 50 atypical nevi and send them to a dermatopathologist, a few of those will get diagnosed as outright melanoma.  The distinction between dysplastic nevi and melanoma in situ is vague and seemingly arbitrary in some cases.

                    And I'm not putting the burden or blame of melanoma deaths on dermatologists.  I'm attributing the increased incidence to them, which is a product of a financial incentive to increase the number of biopsies.  Notice in this article, the private equity firms just seem to buy the practices that have the highest revenue, many of which have their own labs.

                    Comment


                    • #11


                      However, the increased cancer incidence was entirely due to extra cases of in situ and local disease, without the expected complementary decrease in the incidence of advanced melanoma or death from melanoma. The authors concluded that this pattern strongly suggested that screening efforts in the United States were generating overdiagnosis, rather than depicting a true increase in the occurrence of melanoma.”
                      Click to expand...


                      I'm not in derm or path but that is an interesting conclusion to draw from that first sentence.

                      Is it possible that because we are catching in situ and local disease earlier and preventing them from becoming advanced melanomas that the mortality rate has stabilised?

                      Isn't it possible for there to be an increase in the incidence of melanoma, a concurrent increase in the biopsy rate and diagnosis, and for the mortality rate to stay stable because the early ones are being caught before they become bad ones?

                      It seems a bit cavalier to me to simply attribute this pattern to overdiagnosis. Wouldn't pathologists share equally in this overdiagnosis "problem"? As far as I know, dermatologists aren't making the melanoma call at the microscope right?

                      Comment


                      • #12
                        I'm not sure what that study proves.  You could look at the results as a success story as much as you might look at it as "over-biopsying".  They don't comment on the screening protocols that may have differed over the 15 years of study.  A lowering rate of melanoma diagnosed per overall biopsy performed would be far more suggestive of doing too many biopsies, but even that can't lead you to the conclusion that someone is doing it because of greed.  Could be making up for lack of screening knowledge.  More likely, it could be due to the 3 malpractice crises over that period of time that undoubtedly inspired more intervention to CYA.  After all, this is the top reason doctors cite for overtreatment.  Also, how many of these biopsies in that study were done by Derm vs Primary care?  Does it distinguish?  If not, hard to reach the conclusion that the fault of over-biopsying is at the feet of Dermatologists.

                        I'm not saying most systems don't incentivize more care - they do.  But there are 2 processes that help to control this for the over-biopsying concern. The first is the payers.  They have no incentive to pay more to, keep deductibles stable for, and not audit charts for providers who are outliers in care.  The second is the RUC - 31 members, only one of which is a Derm rep.  The same thing happened in ENT where sinus codes were being over-used, or probably more accurately were over-valued to begin with.  They have come down and other CPTs have gained value via the RUC process.

                        Comment


                        • #13
                          our college has been advocating to stop this practice of in-office ancillary pathology services (particularly derm, GI and urology). But until pathologists boycott these jobs, some poor soul will take it......until hopefully it is made illegal.   This type of set-up is very lucrative and like this article showed, then sucked up by PE.

                          There have been numerous studies to show these pod labs lead to #1 more biopsies and #2 overdiagnosis......it is a vicious cycle to pad the pockets of the practice owners.....often the practice owners not only recoup ALL the pathology technical fees, they also take a cut of the pathologist professional fee. Ugh.

                          Because the pathologists are "shorted" income in these set-ups, often they order a crap-load of special stains and immunohistochemisty to recoup more money per case.  These are studies which have verified this as well..... I personally see this all the time when cases are sent in for continuity of care and anything coming from one of these types of labs (physician owned pathology lab) is loaded with unnecessary stuff....  i'm not saying all pathologists are at fault in these settings.....but it's pretty evident nationally.

                          Unfortunately, pathology is a small voice in medicine compared to other colleges and despite myself and many others in my college going to the Hill every year to get bill sponsors to stop this along with other agenda items, it is like a hamster wheel.  We have a few items hanging now and depending what happens in the mid terms and the lame duck session may have to start at square one....it is frustrating because most of the issues are non-partisan, but when the bill sponsors don't get re-elected....ugh......

                          why do I care? 1) it's wrong for patients 2) it hurts the remainder of the specialty because our reimbursements are getting cut when Medicare decides they need to "crack down" on ordering of immunohistochemistry.......wouldn't be as big of a problem if these labs would go away.....

                          quoted from above "As far as I know, dermatologists aren’t making the melanoma call at the microscope right?"   just an aside....a dermatologist can do a dermpath fellowship and read their own slides...so yes...they can totally make their own overdiagnosis..........

                          if anyone wants light reading .  You can join me on the Hill this spring......

                          https://www.cap.org/advocacy/lobbying-and-political-action/self-referral

                          Comment


                          • #14





                            However, the increased cancer incidence was entirely due to extra cases of in situ and local disease, without the expected complementary decrease in the incidence of advanced melanoma or death from melanoma. The authors concluded that this pattern strongly suggested that screening efforts in the United States were generating overdiagnosis, rather than depicting a true increase in the occurrence of melanoma.” 
                            Click to expand…


                            Is it possible that because we are catching in situ and local disease earlier and preventing them from becoming advanced melanomas that the mortality rate has stabilised?




                            Unlikely.  Melanoma seems to come in two distinct flavors.  There are a lot of indolent ones that get labeled in situ or have just an early component of invasion that are sun-related.  These tend to be much more indolent (esp. in situ) and are the ones that I think are overdiagnosed (and probably increasing because of tanning bed exposure).  These are the ones that are most frequently biopsied in clinics during mole checks.  The aggressive ones can present as a growing mass, are often nodular (no epidermal involvement), and will be much more lethal, or just simply show up with metastatic disease without a known primary.  Skin checks won't catch these latter ones.





                            It seems a bit cavalier to me to simply attribute this pattern to overdiagnosis. Wouldn’t pathologists share equally in this overdiagnosis “problem”? As far as I know, dermatologists aren’t making the melanoma call at the microscope right?
                            Click to expand...


                            Oftentimes, the dermatologists are.  They read a lot of their own slides.  As mentioned in the article to start this post, when they describe having their own labs, usually they have a dermatologist in the practice who will read their own slides.  Medicare rates are around $70 per biopsy.




                            A lowering rate of melanoma diagnosed per overall biopsy performed would be far more suggestive of doing too many biopsies, but even that can’t lead you to the conclusion that someone is doing it because of greed.  Could be making up for lack of screening knowledge.  More likely, it could be due to the 3 malpractice crises over that period of time that undoubtedly inspired more intervention to CYA.  After all, this is the top reason doctors cite for overtreatment.




                            I completely agree on this point.  I don't think $$$ is the only reason for the increased diagnosis.  I think CYA medicine plays a much larger role as long as the dermatologists' desire to "catch" melanoma early although I think it has negligible benefits.  However, I think a handful of people are abusing it though, and those with the highest biopsy rates were the ones selling to private equity firms (tying back to the original post).  When a paper was set to get published that mentions this, it got the axe.





                            I’m not saying most systems don’t incentivize more care – they do.  But there are 2 processes that help to control this for the over-biopsying concern. The first is the payers.  They have no incentive to pay more to, keep deductibles stable for, and not audit charts for providers who are outliers in care.  The second is the RUC – 31 members, only one of which is a Derm rep.  The same thing happened in ENT where sinus codes were being over-used, or probably more accurately were over-valued to begin with.  They have come down and other CPTs have gained value via the RUC process.
                            Click to expand...


                            To the first part, then why didn't payers audit the charts of those facilities that sold to private equity firms?  And it's funny you mention the RUC because the biopsy code got whacked a few years ago, largely because of pod labs like dermatology (and GI and GU).

                            Comment


                            • #15
                              Based on the OP, it looks like the article was fairly widely disseminated before it was taken down.  I would really like to read it.  If anyone has a copy please PM me.

                              Comment

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