Symbiotic societies

By Ruth Carol, Contributing Writer, April 1, 2022

What do you get when you enable networking, advocacy, education, leadership development, and community volunteerism on a state level? A state dermatology society.

“State societies provide a local hub for dermatologists to connect, network, share best practices, and learn from each other,” noted Sandra Ring, the Academy’s senior manager of State Society and Patient Advocate Relations. “State societies also provide an opportunity to get involved in advocacy and leadership at the local level.”  

The Academy is best equipped to address federal advocacy issues and national payment policy challenges, but that’s not the case for issues that occur at the state level. Each state dermatology society is best positioned to identify issues that are impacting members at the local level. “Where the real value of state societies lies is in partnering with the Academy when an issue does arise,” said Brent R. Moody, MD, FAAD, chair of the Academy’s Payer Access and Patient Relations Committee.

While the Academy doesn’t have any formal oversight of state dermatology societies, it has worked hard to develop a strong collaborative and bi-directional relationship with them, Ring explained. “The Academy focuses on efforts and initiatives that bring unity to the specialty and enable the voices of dermatologists to be heard on local, state, regional, and national stages when issues arise that may impact the profession, Academy members, and patients who rely on expert dermatology care,” she said.

A cooperative relationship 

Most federal advocacy issues and payment policy challenges are detected at the state level first, Ring noted. “The state societies are the local watchdogs,” Dr. Moody said. The Academy becomes aware of an issue either through a state society or a member, he explained. When a member contacts the Academy, for example, about a local, regional, or state payer, Academy staff will touch base with the state society to determine the extent of the issue, if the state society has been working on it, and how best the Academy can assist, said Louis A. Terranova, MHA, the Academy’s assistant director of practice advocacy. “We recognize that state societies have their own contacts and relationships,” he said. “We want to support, not impede, those relationships.” Local carriers are more receptive to meeting and working with local physicians rather than the Academy, because they may not view the Academy as their constituency, Dr. Moody added.

It’s important to determine the scope of impact on patient care, and whether the issue in question is affecting a particular member, all dermatologists in the state, or all physicians practicing there, he said. Patch testing is relatively specific to dermatology, but modifier 25 impacts many specialties. The answers to these questions will dictate the Academy’s approach. The AAD will work closely with the state society to try to resolve issues specific to dermatology whereas they will reach out to other specialty state societies and/or state medical associations to build a coalition for issues that affect the house of medicine. 

“We encourage specialty societies to bring issues forward as soon as they hear about them, so we can build a collaborative approach and work together to get ahead of them,” Ring said. “Addressing an issue before legislation is in place, for example, is much easier than trying to turn it back,” she added.

“We recognize that state societies have their own contacts and relationships...We want to support, not impede, those relationships.”

Moreover, an issue in one state can quickly spread to others. Payers are in a competitive environment, Terranova said. If they are successful in implementing a new policy in one state, they may be quick to implement it in other states, and eventually across the country. “Larger states tend to have more members, larger societies, and, therefore, more hot-button advocacy issues to address,” noted Ann Haas, MD, FAAD, chair of the Academy’s State Society Relationships Committee (SSRC). “Smaller states may not have the bandwidth to recognize issues early or to know the best process for response and action. The Academy works in partnership to share best practices among states and provide guidance regarding a coordinated approach to addressing these emerging issues.” 

There are currently 48 state societies; the Academy is working to form them in Alaska and North Dakota. They range in size from 15 members to more than 500. “Even two to three people in a state who are active can make a huge difference,” Dr. Haas said. Advocacy wins in a couple of states can thwart similar issues being raised in other states, she noted. One example is that after California passed an indoor tanning ban for minors under the age of 18, it made it easier for other states to do the same. Today, more than 20 states have an indoor tanning ban for individuals younger than 18 years of age. “You start with one victory, and you just keep chipping away,” Dr. Haas added. 

The recent win in Colorado to prevent physician assistants from gaining independent practice is another good example. “The relationship between the Colorado Dermatologic Society and the American Academy of Dermatology continues to play a pivotal role in advocacy affairs at the state level,” said Geoffrey Lim, MD, FAAD, legislative trustee of the Colorado Dermatological Society. “When faced with legislation that jeopardizes the physician-led health care team and allows the independent practice of physician assistants, the CDS has benefited from a truly grassroots effort by its membership and its ties to the Academy, which consistently provides guidance and resources for the betterment of patient care in Colorado.” 

Partnering with others

Building strength and visibility through partnering with other state specialty societies on issues that impact more than just dermatologists is another effective way to move the needle on state issues, Dr. Haas said. Several years ago, she was on her way to the California Medical Association (CMA) meeting when she was made aware via the AAD/A’s Advisory Board communications (which are shared with state societies via their AAD/A Advisory Board representative) that Anthem was considering cutting payments for claims using modifier 25 on the East Coast, and the action was also being considered for California. Having been made aware of that fact as it had been shared with CalDerm, Dr. Haas, who was representing CalDerm in the specialty delegation at the CMA, had the opportunity to explain to the other specialty delegates why this could be a potential problem for the entire California house of medicine. The specialty delegation wrote a resolution — mirroring the one the Academy had already submitted to the AMA — which was then carried back to the AMA by the CMA delegates as well. Those delegates supported the Academy’s AMA resolution and as a result of both AMA and CMA pressure, Anthem backed away from their attempt to cut reimbursement for modifier 25 on the West Coast and elsewhere, she said. “Because these relationships and processes were in place, we were able to take a national issue which was potentially affecting many states including ours and we were able to make a difference for our specialty and other specialties,” Dr. Haas said, adding, “The whole circular process was very instructive and showed how much influence a well-integrated state society can have.”

Looking ahead, the SSRC will be expanding its efforts by working to engage and integrate patient advocate voices. The Academy’s Patient Advocate Task Force is currently responsible for serving as a point of coordination on educational, legislative, and research issues of shared concern between patients, patient advocacy groups, and the Academy, Ring said. The shared goal is to promote, advance, and sustain the highest medical care for all patients with dermatologic disorders. Oftentimes, having a patient advocate there to speak to the very real dangers inherent in some of the current legislation can facilitate a rich discussion that may ultimately impact the outcome, Dr. Haas said.

From scope of practice to compounding

The most significant advocacy issue at the state level today is scope of practice, said Jill I. Allbritton, MD, FAAD, chair of the Academy’s State Policy Committee. It is being driven by COVID-19 because proponents claim that allowing physician assistants (PAs) and/or nurse practitioners (NPs) to practice independently will expand access to medical care, which is an area of interest for many legislators. 

In 2021, the Academy was tracking scope of practice legislation in 30 states. Bills are being introduced in virtually every state where PAs and/or NPs haven’t gained independent practice, said Lisa Albany, JD, director of state policy at the Academy. “They’re chipping away to expand their scope of practice by expanding the physician-to-PA ratio, not requiring a physician to sign off on their charts, or allowing PAs/NPs to practice independently,” she said. 

“We work closely with state societies and state medical societies because we want to make sure that our positions align,” Albany noted. “We don’t want to communicate inaccurate information or contradict local politics.” The local groups can also help determine in which states the bills are moving, enabling the Academy to concentrate its efforts and resources. The AADA also serves on the AMA Scope of Practice Partnership (SOPP) to combat scope of practice expansion for non-physician clinicians. 

Last year, the AADA worked with the Louisiana Dermatological Society, Louisiana State Medical Society, and the AMA SOPP to stop several pieces of legislation that would have authorized PAs and NPs to practice independently. The Academy partnered with the Mississippi Dermatology Association and AMA SOPP to defeat a bill that would have authorized advanced practice registered nurses to practice independently after completing only 3,600 transition-to-practice hours. The AADA also collaborated with the South Dakota State Medical Association and AMA to successfully defeat legislation that would have expanded the scope of practice of PAs, allowing them to practice without physician involvement after only 520 practice hours. A similar bill is expected to be introduced this year, Albany said. 

Education is critical when tackling state policy issues. Legislators don’t understand the difference in training between a dermatologist and a PA or NP, Dr. Allbritton said. The Academy emphasizes the additional training dermatologists obtain to reach their level of expertise. It also highlights study outcomes, such as those demonstrating that NPs perform more biopsies and require more visits to make a correct diagnosis than dermatologists, which increases costs and subjects patients to lower-quality care and potentially higher morbidity, she said. Furthermore, people don’t know that NPs don’t always carry the same medical liability coverage as physicians. If an adverse event occurs, an NP may not have sufficient liability insurance to cover the patient’s losses. An educational campaign created by state and medical societies — used to explain to legislators the importance of physician-led, team-based care — has played an important role in thwarting independent practice for NPs for many years in Mississippi, Albany added.

Blurring the lines of scope of practice and truth in advertising, PAs are campaigning to call themselves ‘physician associates’ instead of physician assistants, Dr. Allbritton said. Most people are confused about the level of education or credentials of the individuals treating them. “The title of ‘physician associate’ intimates that they are on equal footing with a physician and not being supervised,” she added. Legislators want their constituents to be able to choose who provides their care and not to be misled.  

The AADA is working closely with the Indiana Academy of Dermatology and state medical association, which is leading the effort in Indiana on a truth-in-advertising bill that would limit who can call themselves a dermatologist to an MD or DO. A study demonstrating that Indiana residents are confused about who is providing their care strengthens the argument for state legislators, Albany said. The AADA, working with the Virginia Dermatology Society, killed legislation that would have licensed naturopaths and allowed them to use numerous misleading terms that included ‘doctor’ to identify themselves. 

Another advocacy issue — compounding — may take center stage at the state level this year. After the FDA restricted physician in-office compounding and office-use compounding, the agency issued a draft guidance that threatened dermatologists’ ability to prepare medications, such as buffered lidocaine and reconstituted botulinum toxin, in the clinical setting. This issue was addressed primarily at the federal level when the Academy, backed by the house of medicine, began working with the United States Pharmacopeia (USP) to carve out a permanent exemption for physicians conducting in-office preparations from meeting the same onerous equipment and process requirements as large compounding facilities. To that end, the AADA hired an independent laboratory to demonstrate that lidocaine can be buffered in a physician’s office safely and effectively and plans to release a monograph to support this exemption. Once the monograph is approved and adopted by the USP, states will have to adopt it, Albany explained. The Academy is gearing up to work with state societies and medical associations to educate state pharmacy boards about the importance of adopting the monograph. 

Private payer policies

One of the most pressing payer issues today is carriers trying to inappropriately decrease payment for modifier 25.

Last year, the Massachusetts Academy of Dermatology informed the AADA of Blue Cross Blue Shield of Massachusetts’ attempt to decrease payment for claims using modifier 25 and built a coalition with the state medical society and other specialty societies to work with the carrier, Dr. Moody said. When that didn’t work, the AADA helped the state society draft language using model legislation. Before introducing a stand-alone bill, it’s important to learn what the existing state statutes say on the subject, Albany said. “Massachusetts had an entire section of the law explaining that the physician’s role is to make clinical decisions and the carrier’s role is to pay for them,” she said. “We took the existing language and amended it.” 

The Massachusetts Academy of Dermatology hired a lobbyist who assisted the dermatologists’ effort to introduce the legislation prohibiting payers from reducing modifier 25 payments at a hearing in December 2021. The state society also coordinated and submitted testimony before the legislative committee. “There was great turnout at the hearing,” Albany said. Dermatologists, along with ophthalmologists, gastroenterologists, and orthopedic surgeons spoke about the impact this payment policy had on their practice and patients. The proposed legislation received a favorable report from the committee, which allows it to move forward during the second year of Massachusetts’ two-year legislative cycle. “If appropriate, we would love to work with other states to replicate that effort,” Albany said. “But it’s important to build a coalition with local physicians because you need a local voice and guide to know if this strategy would work in a particular state.” 

Similarly, following a joint advocacy effort with the Oregon Dermatology Society, the AADA was notified that the HealthNet Medicare Advantage plan in Oregon would halt its current policy limiting payment when evaluation and management services are billed with a procedure.

The Academy also recently collaborated with the Pennsylvania Academy of Dermatology and Dermatologic Surgery to change a very restrictive lab policy issued by a health plan impacting dermatopathologists and worked with the Rhode Island Dermatology Society to resolve an issue with commercial carriers that were limiting the number of patch tests that could be performed for the diagnosis of contact dermatitis. 

Other collaborative efforts

While the Academy relies on state societies for their local insight and advocacy power, it offers them numerous resources to assist in their advocacy efforts and beyond. Regarding advocacy support, the Academy offers legislative and regulatory analysis, payer issue guidance, legislative hearing preparation, grassroots support, and proactive policy planning. Ring shared, “It is exciting to see so many state and local dermatology societies who have designated a representative to the Academy Advisory Board. By bringing forward questions and concerns from members nationwide, the Advisory Board better understands the issues impacting Academy members and brings their voice to the Academy Board of Directors.”

“After all, stronger state societies mean a stronger Academy.”

From a leadership-development perspective, the Academy hosts the State Society Executive Director Conference and the State Society President Summit. Both are opportunities to network, share best practices, collaborate around issues that impact multiple state societies, and brainstorm to solve specific challenges. The program covers a variety of topics including membership engagement, communication tips and strategies, and policy updates. The Academy also responds to requests for Strategic Leadership Retreats where state society boards meet with members of the SSRC and AAD staff members to explore growth opportunities and learn about best practices from other societies. The agenda varies based on the needs of the individual society, but often includes bylaws and organizational structure review, advocacy planning, membership communication and engagement strategies, and strategic planning. This year, the AAD will begin offering a comprehensive onboarding for new state society presidents and periodic topic-specific virtual town halls.

Additionally, the Academy offers resources for state societies to address other endeavors, such as community outreach and education. The Academy has toolkits and guidelines to engage communities in creating shade structures, conducting skin cancer screenings, providing sun safety education, and volunteering for Camp Discovery. “Publicity around these community events highlights the role of a dermatologist and the importance of sun safety and skin care education,” Ring said. 

In recent years, the SSRC has made great strides to strengthen the relationship between the Academy and state societies, Dr. Haas said, adding, “After all, stronger state societies mean a stronger Academy.”

Additional DermWorld Resources