John
Dalman had been in the waiting room at a Loxahatchee, Fla., dermatology
clinic for less than 15 minutes when he turned to his wife and told her
they needed to leave. Now.
“It was like a fight or flight impulse,” he said.
His
face numbed for skin-cancer surgery, Mr. Dalman, 69, sat surrounded by a
half-dozen other patients with bandages on their faces, scalps, necks,
arms and legs. At a previous visit, a young physician assistant had
taken 10 skin biopsies, which showed slow growing, nonlethal cancerous
lesions. Expecting to have the lesions simply scraped off at the next
visit, he had instead been told he needed surgery on many of them, as
well as a full course of radiation lasting many weeks.
The
once sleepy field of dermatology is bustling these days, as baby
boomers, who spent their youth largely unaware of the sun’s risk, hit
old age. The number of skin cancer diagnoses in people over 65, along
with corresponding biopsies and treatment, is soaring. But some in the
specialty, as well as other medical experts, are beginning to question
the necessity of aggressive screening and treatment, especially in
frail, elderly patients, given that the majority of skin cancers are
unlikely to be fatal.
“You
can always do things,” said Dr. Charles A. Crecelius, a St. Louis
geriatrician who has studied care of medically complex seniors. “But
just because you can do it, does that mean you should do it?”
Mr.
Dalman’s instinct to question his treatment plan was validated when he
went to see a dermatologist in a different practice. The doctor
dismissed radiation as unnecessary, removed many of the lesions with a
scrape, applied small Band-Aids, and was finished in 30 minutes.
Continue reading the main story
Dermatology
— a specialty built not on flashy, leading edge medicine but on
thousands of small, often banal procedures — has become increasingly
lucrative in recent years. The annual dermatology services market in the
United States, excluding cosmetic procedures, is nearly $11 billion and
growing, according to IBISWorld, a market research firm. The business
potential has attracted private equity firms, which are buying up
dermatology practices around the country, and installing crews of
lesser-trained practitioners — like the physician assistants who saw Mr.
Dalman — to perform exams and procedures in even greater volume.
The
vast majority of dermatologists care for patients with integrity and
professionalism, and their work has played an essential role in the
diagnosis of complex skin-related diseases, including melanoma, the most
dangerous form of skin cancer, which is increasingly caught early.
But
while melanoma is on the rise, it remains relatively uncommon. The
incidence of basal and squamous cell carcinomas of the skin, which are
rarely life-threatening, is 18 to 20 times higher than that of melanoma. Each year in the United States more than 5.4 million such cases are treated in more than 3.3 million people, a 250 percent rise since 1994.
The
New York Times analyzed Medicare billing data for dermatology from 2012
through 2015, as well as a national database of medical services
maintained by the American Medical Association that goes back more than a
decade. Nearly all dermatologic procedures are performed on an
outpatient, fee-for-service basis.
The
Times analysis found a marked increase in the number of skin biopsies
per Medicare beneficiary in the past decade; a sharp rise in the number
of physician assistants, mostly unsupervised, performing dermatologic
procedures; and large numbers of invasive dermatologic procedures
performed on elderly patients near the end of life.
In
2015, the most recent year for which data was available, the number of
skin biopsies performed on patients in the traditional Medicare Part B
program had risen 55 percent from a decade earlier — despite a slight
decrease in the program’s enrollment over all.
Skin
cancers are more common in older people, which means Medicare pays for
much of the treatment. In 2015, 5.9 million skin biopsies on Medicare
recipients were performed.
More
than 15 percent of the biopsies billed to Medicare that year were
performed by physician assistants or nurse practitioners working
independently. In 2005, almost none were, said Dr. Brett Coldiron, a
former president of the American Academy of Dermatology, who has studied
the use of clinicians who are not physicians in medical practices.
Dr.
Coldiron, a dermatologist in Cincinnati, said he was skeptical of the
growing use of such clinicians in the specialty. “Ads will say ‘See our
dermatology providers,’” he said. “But what’s really going on is these
practices, with all this private equity money behind them, hire a bunch
of P.A.’s and nurses and stick them out in clinics on their own. And
they’re acting like doctors.”
Dermatology on Wheels
Bedside
Dermatology, a mobile practice in Michigan, sends clinicians to 72
nursing homes throughout the state for skin checks and treatment.
Dr.
Steven K. Grekin, a dermatologist, said that when he founded Bedside,
many of the nursing home patients had not been examined by a
dermatologist for several years.
“We were seeing a real unmet need,” he said.
In
2015, Bedside Dermatology’s traveling crews performed thousands of
cryosurgeries — spraying liquid nitrogen on precancerous lesions with an
instrument that resembles a blowtorch. Other spots on the nursing home
patients’ skin were injected with steroids, or removed with minor
surgery.
Examining
the 2015 Medicare billing codes of three physician assistants and one
nurse practitioner employed by Bedside Dermatology, The Times found that
75 percent of the patients they treated for various skin problems had
been diagnosed with Alzheimer’s disease. Most of the lesions on these
patients were very unlikely to be dangerous, experts said, and the
patients might not even have been aware of them.
“Patients
with a high level of disease burden still deserve and require
treatment,” Dr. Grekin said. “If they are in pain, it should be treated.
If they itch, they deserve relief.”
Dr. Eleni Linos, a dermatologist and epidemiologist at the University of California, San Francisco, who has argued against aggressive treatment
of skin cancers other than melanomas in the frail elderly, said that if
a lesion was bothering a patient, “of course we would recommend
treatment.” However, she added, many such lesions are asymptomatic.
Dr.
Linos added that physicians underestimate the side effects of skin
cancer procedures. Complications such as poor wound healing, bleeding
and infection are common in the months following treatment, especially
among older patients with multiple other problems. About 27 percent report problems, her research has found.
“A procedure that is simple for a young healthy person may be a lot harder for someone who is very frail,” she said.
The
work of Bedside Dermatology reflects a wider tendency to diagnose and
treat patients for skin issues near the end of life. Arcadia Healthcare
Solutions, a health analytics firm, analyzed dermatologic procedures
done on 17,820 patients over age 65 in the last year of life, and found
that skin biopsies and the freezing of precancerous lesions were
performed frequently, often weeks before death.
Arcadia
found that the same was true for Mohs surgery, a sophisticated
procedure for basal and squamous cell skin cancers that involves slicing
off a skin cancer in layers, with microscopic pathology performed each
time a layer is excised until the growth has been entirely removed. Each
layer taken is reimbursed separately.
In 2015, one out of every five Mohs procedures reimbursed by Medicare was performed on a patient 85 or older, The Times found.
Rise of Physician Assistants
Bedside
Dermatology is owned by Advanced Dermatology and Cosmetic Surgery, the
largest dermatology practice in the country, with a database of four
million active or recently established patients. Last year, Harvest
Partners, a private equity firm, invested a reported $600 million in the
practice, known as ADCS.
ADCS
has its headquarters in Maitland, Fla., in a sleek suite of offices and
cubicles the size of a football field. One morning early this year, the
buzz of corporate expansion was everywhere. A delivery crew wheeled in a
stack of cubicle partitions. Employees at a large phone bank scheduled
appointments around the country. A transition team was preparing to
visit a newly acquired practice in Pennsylvania, and Dr. Matt Leavitt,
ADCS’s founder and chief executive, was congratulating his director of
business development on snagging a sought-after recruit.
In
an email last week, Dr. Leavitt said the company currently has 192
physicians, but declined to confirm other numbers because ADCS is
privately held. The company’s website advertises “180+ locations.” The
website also lists 124 physician assistants. That is a 400 percent
increase from 2008, according to web pages preserved by the Internet
Archive’s Wayback Machine. ADCS offers a six-month fellowship program
for physician assistants to provide additional training in dermatology.
“My
number one goal would be to have people take skin cancer much more
seriously than they have, especially baby boomers,” said Dr. Leavitt, a
dermatologist. “And we’ve got to continue to work at getting better
access for patients.”
Continue reading the main story
While
health care experts agree that access to care is of growing importance,
there is an ongoing debate over whether practitioners who are not
physicians are qualified to make diagnoses, identify skin cancers and
decide when to perform biopsies — skills dermatologists acquire through
extensive training — particularly among the elderly.
The
frequency with which physician assistants and nurse practitioners take
skin biopsies — compared with M.D.’s — was the subject of a 2015 study
at the University of Wisconsin, Madison. Based on 1,102 biopsies from
743 patients, researchers found that physician assistants and nurse
practitioners performed nearly six biopsies for every skin cancer found —
more than twice the number performed by physicians.
Riley
Wood, age 82, arrived one morning last February at an ADCS clinic in
Heathrow, Florida, for a skin check with David Fitzmaurice, a physician
assistant.
For
Mr. Fitzmaurice, the exam was routine; Mr. Wood was one of a few dozen
patients he sees each day. On the day a reporter observed him, Mr.
Fitzmaurice moved quickly through the visits, many of which entailed
procedures like biopsies and cryosurgery.
Mr.
Wood had already had two other cancers — kidney and throat. Mr.
Fitzmaurice decided Mr. Wood needed two biopsies — one on his scalp, for
a suspected squamous cell carcinoma, and a second on his neck, for a
spot that might be a melanoma.
The bleeding from the biopsy wound to Mr. Wood’s neck persisted for several minutes, leaving the patient worried and depleted.
“I
don’t like needles,” said Mr. Wood, in a voice close to a whisper,
adding that the word cancer frightened him. Still, Mr. Wood said, he
usually goes with the recommendations of Mr. Fitzmaurice, whom he called
“Dr. David.” “I like him. He’s very thorough and cordial.”
With
Mr. Wood’s permission, a reporter photographed the area Mr. Fitzmaurice
biopsied for a suspected melanoma, and sent the image to nine
physician-dermatologists. A few dismissed the biopsied lesion as
nothing, while others said it was hard to tell from the photograph. None
said the spot had the telltale signs of melanoma.
Yet
all nine dermatologists, with no prompting, pointed to an adjacent
lesion that had gone unremarked by Mr. Fitzmaurice, saying it looked
like a skin cancer that was not melanoma.
Two
months later in a telephone interview, the reporter asked Dr. Leavitt
about Mr. Fitzmaurice’s apparent oversight. Dr. Leavitt defended his
employee, saying Mr. Fitzmaurice had probably seen the spot but his
higher priority was the suspected melanoma.
The
morning after the interview, Mr. Wood received a call from ADCS,
telling him to come in for a second look. The spot Mr. Fitzmaurice
biopsied for melanoma turned out to be benign. The one next to it, which
Mr. Fitzmaurice did not flag, was in fact a squamous cell carcinoma in
situ, Dr. Leavitt said in a follow-up email.
While
Dr. Leavitt pointed out that “routine skin checks are a great way to
catch potential problems early,” Dr. Coldiron said he was wary of
clinicians who are not physicians doing basic skin checks, given the
evidence that those often lead to unnecessary biopsies.
Arielle
Rought, a physician assistant with ADCS who is in her late 20s, called
skin checks “our bread and butter.” On the day a reporter visited, Ms.
Rought biopsied a spot on a patient’s hand to rule out melanoma. Her
supervising physician was standing out in the hall, yet she did not ask
him to take a look. Asked why she had not called him into the room, she
said she did not consider it necessary. The biopsy was negative.
In
an emailed statement, the president of the American Academy of
Dermatology, Dr. Henry W. Lim, said: “The AAD believes the optimum
degree of dermatologic care is delivered when a board-certified
physician dermatologist provides direct, on-site supervision to all
non-dermatologist personnel.”
Ms.
Rought said it was not unusual for a skin check to lead her to to
freeze as many as 30 precancerous lesions called actinic keratoses on a
patient during a single visit. Actinic keratoses are called precancerous
because they can sometimes turn into squamous cell carcinoma. Ms.
Rought said her “rule of thumb” was that 20 percent of actinic keratoses
progress to cancer.
While
that might once have been the popular understanding, research now
suggests otherwise. Dr. Martin A. Weinstock, a professor of dermatology
and epidemiology at Brown University, reported in a 2009 study
of men with a history of two or more skin cancers that were not
melanomas that the risk of an actinic keratosis progressing to skin
cancer was about 1 percent after a year, and 4 percent after four years.
More than 50 percent of the lesions went away on their own.
Dr.
Lim said the dermatology academy’s position is that actinic keratoses
should be treated, as it is impossible to know which ones will turn into
cancer, but some specialists are questioning whether that’s necessary.
Continue reading the main story
The Doctor Is Not In
The
experience of Mr. Dalman, the patient who fled the waiting room, began
in January, when he made an appointment as a new patient at the clinic
of Dr. Joseph Masessa, believing he would be seen by the dermatologist.
Instead, he was seen by a young woman in a lab coat, whom he assumed was
a physician, though she did not identify herself as one. She biopsied
10 different lesions.
At
his next visit in February, he was seen by another young woman, whom he
also took to be a physician. As it turned out, both women were
physician assistants.
The
second physician assistant told Mr. Dalman that he would need radiation
on basal cell carcinomas on his temple, shoulder and ear. He said he
tried to argue with her, explaining that he’d had many similar lesions
in the past that were removed with a simple scrape.
He
said she countered that if she attempted to remove the lesion above his
right eye, he might end up unable to blink that eye. And without
superficial radiation on his ear, he was in danger of losing the entire
ear. She said he would also need Mohs surgery on several of the basal
cell carcinomas. She did not respond to requests from The New York Times
to speak about the case.
Although
Dr. Masessa signed Mr. Dalman’s chart, Mr. Dalman never met him. This
could be because the clinic he went to, northwest of West Palm Beach,
Fla., is one of more than a dozen clinics scattered across three states
associated with Dr. Masessa, who is based in New Jersey but licensed in
Florida. Supervision of physician assistants is required by state law.
The Florida Department of Health website lists Dr. Masessa as
supervising four physician assistants in the state.
Dr.
Masessa did not respond to repeated requests for comment. An associate,
who identified himself as Jeff Masessa, returned a call and asked for
questions by email. Neither he nor Dr. Masessa responded to a detailed
list of questions, despite repeated follow-up emails from The Times.
On
the day of Mr. Dalman’s surgery, the same physician assistant injected a
local anesthetic, then instructed Mr. Dalman to return to the waiting
room, Mr. Dalman said.
Then
something dawned on him. Since he had not laid eyes on a physician in
several visits, he worried that the physician assistant would be doing
the procedure. The prospect made him nervous and he decided to make a
swift exit.
Mr.
Dalman later went to see Dr. Joseph Francis, a dermatologist near West
Palm Beach. Dr. Francis said there was no indication for superficial
radiation, a treatment of which the American Academy of Dermatology has
voiced skepticism. Moreover, Dr. Francis decided, many of the basal cell
carcinomas could be scraped off.
Dr.
Francis said he was shocked not only by the number of biopsies that had
been taken at once, but also by the aggressive treatment proposed.
Moreover,
when he reviewed Mr. Dalman’s records from Dr. Masessa’s clinic, he saw
four skin exams documented over the four-month period. But when he
examined the patient, Dr. Francis noticed a pigmented, asymmetrical spot
slightly bigger than a pencil eraser on Mr. Dalman’s shoulder.
It
turned out to be a malignant melanoma, not documented by the physician
assistant. Dr. Francis removed it before it had a chance to spread.
No comments:
Post a Comment