Appropriate use criteria head to dermatology
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Mohs surgery goes under the microscope

In an effort to determine appropriateness of care, fueled in part by health system reform and in part growing scrutiny by the government and third-party payers, appropriate use criteria (AUC) are gaining momentum in the medical specialty community. The trend is about to make its way to dermatology, specifically with regard to Mohs micrographic surgery.

The concept of appropriate use criteria is rooted in the observation that the frequency of utilization of medical procedures varies across the U.S., and thus, so may the quality of care. The cause for such variation remains obscure; are patients being overtreated in some geographic locations or undertreated in others? This notion brewing in the midst of health system reform is resulting in both medical leaders and the government calling for greater accountability and scrutiny.

To date, a handful of medical specialty organizations have answered the call by developing appropriate use criteria. At the forefront are the American College of Radiology (ACR) and the American College of Cardiology (ACC). During the 1990s, the ACR began developing AUC to help referring physicians and other providers make the most appropriate imaging or treatment decision for a specific clinical condition. This past April, the ACR updated more than 40 Appropriateness Criteria topics and added seven new criteria, for a grand total of more than 175 topics. Since 2006, the ACC has issued 10 AUC documents on five topics, including various types of imaging modalities for the diagnosis and management of cardiovascular disease, including echocardiography. In addition, the ACC has eight new AUC in development. The ACC has partnered with several different specialty organizations, depending on the focus, to develop its AUC and expand their credibility and impact. This past summer, the American Academy of Orthopaedic Surgeons announced that it will begin developing AUC; its first topic will be distal radius fractures.[pagebreak]

Other evidence of this growing trend is the Institute for Healthcare Improvement’s foray into AUC with its 2010 white paper entitled Reducing Costs Through the Appropriate Use of Specialty Services. The Institute has developed a six-step framework to reduce unnecessary health care costs and deliver better care that is applicable across many specialties, procedures, and types of organizations.

Dermatology has dipped its toes in the AUC pond with the formation of the Ad Hoc Task Force (AHTF) for Appropriate Use Criteria for Mohs Surgery this past February. “Our specialty needs to take a proactive role regarding the use of Mohs surgery to preserve the ability to use this procedure for patients where the benefit is most widely accepted,” said Suzanne Connolly, MD, chair of the task force and the American Academy of Dermatology’s vice president. The AHTF plans to draft an AUC document by year’s end. (See sidebar.)

Dermatology is on the radar of the Centers for Medicare and Medicaid Services (CMS) because although dermatologists comprise approximately 1 percent of all physicians, they receive nearly 3 percent of the total Medicare physician reimbursement, said Mark Zalla, MD, who serves as the American Society for Dermatologic Surgery Association (ASDSA) representative on the AHTF. “Mohs is a target because utilization has increased significantly during the past 10 years.”

Mohs on the rise

It’s no secret that the utilization of Mohs surgery has risen dramatically in recent years. Between 1995 and 2009, the use of Mohs surgery increased 400 percent, from approximately one in 15 cancers treated to one in four, based on Medicare data, noted Brett Coldiron, MD, president of the American College of Mohs Surgery (ACMS) and member of the Academy’s Board of Directors, who is also an AHTF member. Other procedures on the rise include skin biopsies, destructions, and excisions.

Additionally, utilization for CPT code 17313, for Mohs performed on the trunk and extremities, has increased more than 10 percent in the past two years. The American Medical Association’s Relative Value Scale Update Committee,  or RUC, automatically reviews codes that increase 10 percent per year for three consecutive years, the outcome of which may result in changes to reimbursement.

Along with increased utilization of Mohs, there is some variation across the country. For example, utilization is significantly higher in Florida than in California, and reasons for this variation are not entirely clear. While Florida may have more retirees than California, it doesn’t have more sun, said Dr. Coldiron, adding, “When you have these interstate variations, it makes it difficult to say that it’s all appropriate.”[pagebreak]

Reasons for increase

“Dermatologic procedures have increased so much because there is an epidemic in skin cancer,” Dr. Coldiron continued. There were an estimated 3.5 million non-melanoma skin cancers (NMSCs) in the U.S. population in 2006, according to a study using the Multiple Medicare and National Ambulatory Medical Care Service databases. Based on this current rate of increase, there are projected to be nearly four million new cases of NMSC in this country each year, significantly more than the one million cases commonly quoted, said Dr. Coldiron, who was a co-author of the 2010 study.

Another reason for the increased utilization is the growing number of dermatologists who have been trained to perform Mohs surgery in recent years, Dr. Zalla added. “Since Mohs does have the highest cure rate for any of the cancers, it’s only natural that dermatologic surgeons would want to provide it for their patients.” 

While the increase in Mohs utilization may be justified on the basis of the skin cancer epidemic and increased numbers of providers, Dr. Coldiron said, the development of AUC is an attempt to ensure that inappropriate use is not a contributing factor. “Unfortunately the government and insurers don’t look at it that way,” he added. “They just look at any procedure that is increasing rapidly as something that is overvalued and must be cut.”

How AUC works

At the core of the AUC approach is the Appropriateness Method developed in the 1980s by RAND/University of California Los Angeles, which set out to answer the variation question. Both the ACR and the ACC have adapted this original methodology to improve the utility and credibility of the final AUC document. The Mohs AUC will similarly follow these current adaptations. The appropriateness method uses a minimum nine-member panel comprising a mix of clinical specialists to conduct sequential rounds of ratings using a modified Delphi method. After reviewing the available literature for a list of clinical indications, the expert panel reviews and rates the clinical indications for appropriateness based on a nine-point scale with one being the lowest score and nine the highest. A procedure that is deemed appropriate is considered an acceptable approach for the specific clinical indication. In other words, the expected clinical benefits outweigh the negative consequences or risk. “AUC are a patient-centered resource for helping the dermatologist determine whether use of Mohs micrographic surgery is appropriate and acceptable for specific clinical indications, unlike guidelines of care, which often focus on disease itself,” Dr. Connolly said. 

Appropriate use criteria have been shown in multiple studies to improve patient selection for medical interventions, and lead to improvements in diagnostic yield, clinical outcomes, and health-related quality of life, while reducing overall cost and resource utilization.

Whether AUC will do that for Mohs surgery remains to be seen.[pagebreak]

Potential impact of AUC on Mohs

While Mohs surgery doesn’t cost much more than excision, there is some concern that some smaller tumors on the trunk and extremities, and early tumors on the head and neck, that could be treated with other less expensive modalities are being treated with Mohs, according to Dr. Coldiron. “It’s an area I think is important to address so that we don’t have the government stepping in and saying that this procedure won’t be available to our patients in the future,” he added. “We are trying to protect this procedure for our patients who suffer from skin cancers. That’s why it is important that we develop appropriate use criteria.” Those criteria should help ensure that Mohs surgery is performed when clinical evidence suggests it is the best intervention for the patient. 

Dr. Zalla pointed out that there is good data showing that Mohs is not only cost competitive with other excision procedures, but more cost effective in some cases. “The most common treatment of low-risk skin cancers in my practice is still curettage, which has been shown to be very effective for these cancers,” he said. Dr. Zalla added that if providers shift to curettage, as opposed to Mohs, for low-risk cancers, then there will be some cost savings realized. But if they use routine excision and frozen sections to treat these cancers, then no significant cost savings will likely be realized. 

The goal of AUC is not directly to curb costs, but rather to ensure that procedures are used for clinically appropriate indications, Dr. Zalla said. “If certain procedures are being used inappropriately, reduction in that utilization may have the effect of reduction in overall cost. We don’t know that Mohs is being used inappropriately,” he added. [pagebreak]

Another advantage of the development of AUC will be seen by non-Mohs dermatologists, who will have a valuable resource to help them determine when it is appropriate to refer patients to a Mohs surgeon for treatment. “Although most dermatologists are probably familiar with most indications for Mohs, I do receive occasional referrals for low-risk tumors which probably don’t need Mohs, and guidance from AUC criteria might save patients time and inconvenience of unnecessary trips,” Dr. Zalla said.

The outcome of the ratings process is yet to be determined, so it’s too early to know how the AUC will specifically affect the practice of Mohs surgeons; however, the hope is that their existence will ensure justifiable utilization rates in the future. “I think it may decrease the use of Mohs on very small tumors that can be treated with single destruction or excision,” Dr. Coldiron predicted. He said he also hopes the use of AUC will benefit Mohs surgeons by decreasing negative arbitrary payment decisions. The Ratings Panel is currently evaluating more than 300 clinical scenarios developed by the AHTF.

“With the passage of the health care reform bill, it’s very important that we as dermatologists be proactive in making sure everything we do is appropriate, cost efficient, doesn’t squander resources, and is best for our patients,” he said. “If we act proactively, we’ll come out better in this tumultuous time of change in health care.”

Task force develops appropriate use criteria for Mohs

The Ad Hoc Task Force (AHTF) for Appropriate Use Criteria for Mohs Surgery, which held its first meeting this past March, is comprised of members of the American Academy of Dermatology, American College of Mohs Surgery (ACMS), American Society for Mohs Surgery (ASMS), and American Society for Dermatologic Surgery Association (ASDSA). “It was important to get representation from each of these groups so that the final document will represent a collaborative effort,” said Suzanne Connolly, MD, chair of the task force and vice president of the Academy.

The AHTF has been charged with developing clinical indications, creating definitions of terms, gathering evidence on the use of Mohs in the United States, and drafting a final AUC document inclusive of the appropriate use ratings and supporting text. The clinical scenarios crafted by the AHTF members are reflective of those that occur commonly in the dermatologist’s office, she noted.

With more than 300 articles for review, extracting the relevant data and compiling them into evidence tables was a very labor-intensive process, Dr. Connolly said. The data are very complex and often do not include information related to surgical and/or disease outcomes based on tumor type. “We were very appreciative to have the assistance of AAD staff, as well as eight Mohs fellows and third-year dermatology residents, to expedite this time-consuming portion of the AUC process,” she said.

There have been several studies demonstrating that Mohs is a clinically valuable and cost-effective intervention for treating specific types of tumors or those in certain locations, noted ASMS President Paul Storrs, MD, who is an AHTF member. But there hasn’t been a comprehensive document that pulls all of that data together. “The AUC document not only synthesizes this knowledge, but does so in a well-accepted format that can be used by dermatologists and third-party payers,” he said.

“The AUC document is not about comparative effectiveness, that is, this is not a comparative rating of various approaches which might be undertaken for tumor management,” Dr. Connolly noted. “AUC for Mohs is specifically addressing the question of whether Mohs is appropriate for common, defined clinical scenarios seen in practice.”In August, the AHTF forwarded the draft AUC framework to the Indication Reviewers, who include 45 prominent dermatologists from across the country and three representatives from Medicare carriers. This group reviewed the draft clinical indications and evidence tables to ensure their completeness and clarity. “The AHTF has taken great care to have an extremely well-balanced group of individuals from private practice and academia, as well as from representative geographic parts of the country,” Dr. Storrs said. “Including payers on the panel will ensure that we included clinical scenarios about which the payers’ have expressed concern,” said Mark Zalla, MD, the ASDSA representative on the AHTF. It also increases the buy-in from payers and the document’s overall credibility, he added.

During early September the AHTF members evaluated all reviewer comments and worked to address this feedback. The reviewers’ comments were helpful to the task force in refining the indications, Dr. Connolly said. By late September, the AHTF had forwarded the revised document to the Ratings Panel.

This month, the 17-member panel is meeting to discuss its first round of clinical indication ratings as well as the supporting evidence and clinical experience that underpins these scores. The panel, which will work toward achieving consensus, consists of nine non-Mohs surgeons and eight Mohs surgeons. Having a majority of non-Mohs surgeons on the panel will help to mitigate any conflict of interest, said ACMS President Brett Coldiron, MD, who serves on the AHTF. 

The AHTF plans to draft an AUC document by year’s end, Dr. Connolly said. That document will be presented to the boards of directors of the various dermatologic groups that participated in the process. Once they approve the document, the next step is to publish the AUC in the Journal of the American Academy of Dermatology and the Journal of Dermatologic Surgery, most likely in the spring of 2012. The boards-approved AUC will also be posted on “If all the groups buy in, then the recommendations will carry more weight,” Dr. Coldiron said. “When the AUC gets published, then the government and insurers will pick up on them, as well.”

Dr. Connolly added, “By establishing AUC for Mohs, we will maintain the ability to utilize a particular resource, and utilize it well and wisely.” For more detail on the process used to develop the AUC go to

It’s very important that we as dermatologists be proactive in making sure everything we do is appropriate, cost efficient, doesn’t squander resources, and is best for our patients.



Task force develops appropriate use criteria for Mohs