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From: "Howard McCollister" <>
Subject: Re: Just what is the difference anyway?
Date: 5 May 2004 17:46:05 -0500
Message-ID: <40996dbb$0$32816$>

"Cheerful Pickle" <cheerfulpickle@net-venture.compostheap> wrote in message
> Hi, gang,
> I just got back from my dermatologist's office and I have a question (not
> involving any specifics as to my case though I will refer to it solely for
> illustrative purposes).
> On his wall was a letter from my HMO's Chief of Dermatology apologizing for
> the long waits in getting appointments for dermatologists.  It seems there
> is a worldwide shortage of general dermatologists.  Part of the reason is
> an aging population requires dermatologists more.  Part is that many
> dermatologists are older and retiring.  The letter noted that, for
> instance, in the UK, they expect to lose half of their dermatologists
> within the next five years.  The third reason puzzles me.  It seems that
> many general dermatologists are abandoning their specialty for one called
> "cosmetic dermatology."
> Wait a minute.  We are dealing with the skin here.  All skin conditions of
> which I am aware involve in their cluster of symptoms things like pimples,
> scaling, flaking, blemishes, dandruff, the skin turning strange colors,
> etc.  I remember the first time I saw a dermatologist twenty one years ago.
> It was for cosmetic reasons.  The diagnosis was basal cell skin cancer.
> After eleven years of either being not diagnosed or misdiagnosed by family
> doctors (one crazy doctor actually thought it was asthma), I finally knew
> what it was.  Later basal cell cancers did not concern me since the first
> one never became life threatening.  I simply had them removed for cosmetic
> reasons.  The only time I was at the dermatologist for noncosmetic reasons
> (though it started out as being for cosmetic reasons) was for melanoma.
> Once that diagnosis was made, my concern switched from cosmetics to
> survival.  That was seven years ago and I am still here.
> Besides melanoma, some skin conditions might cause people to seek a
> dermatologist for noncosmetic reasons, such as itching, but I suspect most
> conditions concern the patient mostly for cosmetic reasons.  That leads to
> the question (finally):  Just what is the difference between general
> dermatology and cosmetic dermatology anyway, since it would seem that most
> dermatological problems manifest themselves cosmetically?

Cosmetic dermatology addresses aging/damaged skin and includes chemical
peels, botox, laser wrinkle removing and other laser treatments, and a wide
variety of other treatments that aren't medically necessary, but desired by
the large baby boomer patient base. It is cosmetic in nature and not aimed
at treating skin cancers, rashes etc. Even liposuction is part of many
cosmetic dermatology training programs.

Cosmetic dermatologic treatments are generally not covered by insurance
since they are cosmetic and it is the insurance company that determines
whether or not the procedure is cosmetic. As a result, these treatments are,
for the most part, strictly cash-on-the-barrelhead and they have patients
standing in line anxious to pay the fee. This represents a much more
financially productive use of the dermatologists time given the extremely
poor Medicare and third-party insurance reimbursements for a standard
dermatology office visit. Few dermatologists these days want to spend their
days treating rashes at $15 per office visit gross reimbursement. At the
rate they are reimbursed, it's very difficult to make a dermatology practice
financially viable. Reimbursements are going down rapidly and
government-imposed expenses are going up, not to mention malpractice

In many or most cases, even private physicians are forced to contract with
insurance companies for what's called "negotiated fee-for-service"
reimbursement contracts. A key feature of these contracts is that the
physician cannot balance-bill the patient for a covered service - has to
accept what the insurance company decides to pay. By declaring one's
practice limited to "cosmetic dermatology" the dermatologist takes
him/herself out of the third party arena altogether and eliminates the
financially disadvantageous situation of treating rashes all day for

It's a sign of the times. The same thing is happening in other specialties
as well, and is likely to increase. Insurance companies are really changing
the landscape of doctor availability and distribution.


From: "Howard McCollister" <>
Subject: Re: Just what is the difference anyway?
Date: 5 May 2004 18:52:13 -0500
Message-ID: <40997d84$0$6219$>

"Cheerful Pickle" <cheerfulpickle@net-venture.compostheap> wrote in message
> However, that makes me wonder.  If I were not signed up with a group plan
> through my NONPROFIT HMO, then I would be charged $450 a month with a $1000
> a year deductable.  They say they are paying their doctors a competitive
> rate, which I assume would be your $15 an hour.   Few people would go
> through about a dozen years of higher education for $15 an hour.  As I
> said, high premiums and low payments has to spell high profits, even for a
> nonprofit HMO.  That does not sound right.
> Even in a group (Medicare) I still have to fork out an additional $90 a
> month to my HMO for their services, besides whatever Medicare pays them.
> I don't know.  Something simply does not sound right with your scenario.

First of all, it's $15 for an office visit, figure 30-50 office vistis per
day. And of course that's not all they do - they might do procedures such as
removing basal cell skin cancers or mole removals which reimburse higher. As
to your HMO, they equalize by cost-shifting. Their surgeons, who generate
more revenue for the HMO, get paid less so that the dermatologists can get
paid more.

You asked who'd do all of that for such low reimbursement. The answer is:
fewer and fewer every year.

By the way, see if you can find out how much the CEO of your HMO gets paid.


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