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.
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.”
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.
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.
Originally Posted On: https://www.nytimes.com/2017/11/20/health/dermatology-skin-cancer.html?_r=0