By Abby S. Van Voorhees, MD, May 01, 2014
Dermatology is sitting at an interesting juncture. We’ve dedicated this issue of Dermatology World to melanoma — a topic near and dear to all of dermatology. There have been some wonderful discoveries in this area lately which are hugely exciting. I hope that you will read our piece on the new tools that are being developed in diagnosing this cancer. The article crackles with excitement discussing this rapidly changing area. Dermoscopy and confocal microscopy have moved diagnostic skills forward, while other imaging tools, in development, are exciting to consider. It suggests that our future may offer options beyond the biopsying of suspicious lesions. Non-invasive imaging seems poised to have a role in our field.
We also write in this issue about the successes in the treatment of melanoma that now regularly grace the pages of our scientific journals. Just a few years ago these treatments were unimaginable. It is so wonderful to read about agents that can potentially prolong life for those with advanced melanoma. And the more we learn, the more we realize that we need to learn. With each passing month we hear about more treatment strategies. We see the beginnings of personalized medicine as we figure out who will be responders and whose results will be less robust. These discoveries put us on the edge of some of the most exciting new developments in medical science.
So you are probably wondering why I started this month’s column by saying that we were at an interesting time in dermatology. This is because unfortunately these treatments come with large price tags. As Keith Flaherty, MD, says, they are “inordinately expensive.” Dr. Jeffrey S. Weber tells us that most insurance companies cover these costs, with pharmaceutical companies filling in the gaps when needed. As a consequence, by “hook or crook,” melanoma patients get access to these treatments. I found it interesting to learn that generally it is assumed that an additional year of life for most patients is thought to be worth somewhere between $50,000 to $100,000 if they bore the cost. Balancing the desire to extend life against the huge cost will be a challenge. How are ACOs going to react? Research and discovery are critical to the future success of dermatology, and therefore we want to keep pharmaceutical companies focused on our medical needs, solving the problems of our patients. But where is the line when these treatments for patients are no longer affordable for those who most need them?
We are getting pushed from other directions too. Our legal column this month explains why the in-office ancillary services exception to the Stark law has been under attack. There is no question that there are many benefits from having an “in-house” lab, not least of which is the ability to talk to the person reading the specimens and confer about challenging cases. However, the growth in number of specimens seen in these “in-office” labs is raising alarms, because it far outstrips the growth in the number of specimens when no “in-office” lab is present. So far, the exception has held, but stay tuned. This is an area that the GAO is watching. In his coding column, Alex Miller, MD, also reminds us of the critical need to bill as accurately as possible. None of us want to bill in a way that could be construed as fraudulent just trying to “be nice” to the patient on the table. I, for one, don’t have any desire to switch my “look” to one of orange jumpsuits! Orange is not my black.
Interesting juncture it is. Good science, tricky policy issues to navigate, increasing regulation...guess this is the present and there is no escaping it. Hopefully the discoveries will balance the administrative hassles.
Enjoy your reading.