News Release

Medicare Policy Contradicts Preferred Treatment For Precancerous Skin Conditions, Westwood Squibb Center For Dermatology Research Reports

Peer-Reviewed Publication

Atrium Health Wake Forest Baptist

WINSTON-SALEM, N.C. -- A Medicare policy designed to reduce the cost of treating precancerous skin lesions contradicts standard medical practice in the vast majority of cases, according to a study by researchers at the Westwood Squibb Center for Dermatology Research at Wake Forest University School of Medicine.

The policy can leave patients in pain and increase the risk that the lesions, called actinic keratoses, can develop into a form of skin cancer called squamous cell carcinoma, which can be fatal.

In a paper published today by the Journal of the American Academy of Dermatology, Steve Feldman, M.D., and others reported that dermatologists overwhelmingly prefer to treat such lesions by removing them immediately. Yet, Medicare policies give states the right to induce doctors into using other treatments first.

"In states such as Florida, Medicare will not reimburse doctors who remove lesions on the first visit, with a few exceptions," said Feldman, who is the center's director, and associate professor of dermatology at Wake Forest University. "They require that all actinic keratoses initially be treated with topical creams.

"But when you look at the data of how doctors typically treat actinic keratoses, we found that in almost 80 percent of the cases, doctors chose to remove the lesion on the initial visit."

In comparison, doctors chose to do nothing in 19 percent of initial visits. In 1.5 percent of the cases, doctors chose to use both topical creams and removal. Not once -- never -- did doctors apply topical creams only, as mandated under Medicare's rules in Florida.

Medicare policy leaves it up to the Medicare insurance carriers in individual states to decide whether to implement the rule, said William O'Neill, the director of practice issues for the American Academy of Dermatology. "What causes frustration is this crazy quilt of states deciding this issue at their own discretion," he said.

So while a doctor in Tallahassee may not remove a lesion on the first visit, his colleague a few miles over the state line in Georgia may. Texas, Maryland and New Mexico also have adopted the Florida policy. Colorado limits the number of procedures a physician can perform on the first visit.

Members of the Academy are meeting in Washington, D.C. later this month to review the data about actinic keratosis and squamous cell carcinoma to assess the impact of the rules.

Dr. Alan Fleischer, a co-author of the Westwood Squibb Center study, pointed out that technically, Medicare is not prohibiting doctors from removing lesions on the first visit if that is called for. "But the fact that they will not reimburse you makes it reality," he said. "If Medicare stopped paying for all gall bladder removals, how many gall bladder removals would there be." The researchers based their study on an analysis of all initial visits to doctors for actinic keratosis in 1993 and 1994, collected as part of the National Ambulatory Medical Care Survey.

In recent years, Medicare has been making it harder for doctors to perform certain medical procedures in order to reduce Medicare costs. The policy is intended to reduce the instances in which doctors perform unnecessary procedures.

To see if this might be the case with actinic keratosis, the study looked at how doctors treat other skin conditions for which minor surgery and other procedures are available, such as warts, psoriasis and acne. It found that medical procedures were used far less frequently, said Fleischer, associate professor of dermatology at Wake Forest. .

"We wanted to see if it's just 'greedy doctors' charging for procedures because they can," he said. "We found that the other conditions had procedures available but they were not used as much, and this goes to the point that there really is something beneficial to removing lesions over using creams."

Dr. Clifford W. Lober, a dermatologist in Kissimmee, Fla., and the chairman of the Academy's section on health policy practice and research, says the Medicare policy has no scientific basis and endangers patients. "We have an epidemic of skin cancer and with it we've seen a tremendous rise in the incidence of actinic keratosis.

"Many of these actinic keratoses can progress to invasive squamous cell carcinoma. More than 2,000 Americans die each year from this kind of cancer, so it's a very significant problem."

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Contact: Robert Conn, Jim Steele or Mark Wright at 336-716-4587



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