As the 2016 US presidential election heats up, everyone is talking about what—or who—will make this country great “again,” and all of this discourse has a lot of dermatologists thinking about what’s wrong with dermatology today and more importantly, how to fix it.

Contributing editor Wendy Lewis asked three leading dermatologists what ticks them off, what they want to see go away, and what makes them want to shut down their practice and move to Tahiti permanently.

Not surprisingly, HIPAA, electronic medical records (EMR), Obamacare, Meaningful Use, recertification, and Yelp! made the list.

Seemal R. Desal, MD

Dermatologist

Innovative Dermatology

Plano, TX

“It’s not all roses and honey.That’s the plain truth.”

“Maintenance of certification needs to go away, along with all the other ridiculous bureaucracy that keeps me hidden behind my computer in between patients and rushing to get things done so I am not stuck at the office until who knows how long. For example, Meaningful Use, which was developed by the federal government to incentivize use of EMRs, is something I call ‘meaningful useless.’ Instead of spending time getting to know my patients even better, I now have to cram questions about all sorts of mundane information that has nothing to do with dermatology into my visits, and click a variety of buttons to show that I did that. I probably make 10-14 extra clicks in a patient’s chart than are actually needed or relevant to my patient’s skin disease. Let’s say those clicks take up 15-20 seconds per patient and I see 40-45 patients a day, that’s about 20 minutes per day of wasted time or 100 minutes per week, which equates to about 72 hours of wasted ‘meaningful’ clicks per year. Imagine how many more patients I could’ve gotten to see, diagnose and treat in those 72 hours. Sometimes, I say that seeing patients is the easy part; it’s all the other bureaucracy that makes practicing medicine so difficult these days.

Pricing is a continued issue. We need to advocate for our patients to make sure they get the drugs they need for their diseases at an affordable price. We talk about access to care for the uninsured, helping minorities, and eliminating health disparities—all of which are things I strongly believe in, practice, and fight for. But what good am I doing a patient who I finally do get see for little or no cost, but can’t treat effectively because their topical steroid cream costs a prohibitive $800 a tube? Even when you try to help, the system holds you back.

Yelp is a nightmare. I wish it didn’t exist, and I feel the same with other online review sites if I am being honest. I used to take the Yelp reviews personally, but in all honesty the vast majority of what I read is completely false, and the reviewer is just a miserable person, anyway. I am pretty sure I have come to terms with the fact that a person who wants to develop a long-lasting relationship with a prospective physician and does so based on believing Yelp reviews is actually not a patient I want in my practice.

What gets to me most overall is the stress of running a business. I love dermatology. I love treating skin disease. I love making people feel and look better. This gives me true joy and it is why I chose this specialty, but the stress of decreasing reimbursements, rising drug costs, threats of liability, patient beliefs that I am out there to take their money (even though it is part of their own insurance policy’s deductible), and retaining good employees, are some of the major challenges I face on a daily basis running two private offices. Would I quit? No. Will I leave dermatology? Never. Do I regret having my own practice? No, but it’s not all roses and honey. That’s the plain truth.”

Mary P. Lupo, MD

Dermatologist

Lupo Center for Aesthetic and General Dermatology

New Orleans, LA

“We have become marginalized in the equation, while pharmacies, big Pharma, insurance, and the government smile.”

“The adoption of EMRs is one reason the doctor-patient relationship has deteriorated. Looking at a computer is no way to interact with a patient. To remedy this, doctors have to hire scribes, and the costs of implementing an EMR system and the yearly service contracts are egregious. The upside? At least now I can read my own notes!

Anyone who thinks this government is concerned about our privacy is not paying attention. HIPPA is all about regulations that cost doctors money and generate money for the government via fines. No regulation ever improved patient care.

Another ‘stick it’ to the middle class move is the Affordable Care Act (ACA) also known as Obamacare. Before Obamacare, middle class workers had health insurance just as good as any CEO. Now, premiums are up, covered services are down, co-pays and deductibles are over the moon, few drugs are covered, and most of the time, the co-pay is higher than the cost of the drug. When you decide to feed everybody, you are going to be eating spam.

Did I mention that they are paying doctors less and expecting us to be data gatherers for the government and insurance companies via new ICD-10 codes? These are not fun times for patients and doctors. We have become marginalized in the equation, while pharmacies, big Pharma, insurance, and the government smile.

We need to go back to cash pay for most doctor-patient interactions. Prices would go down. Patients don’t even know what their insurance covers.

Insurance should be a safety net for catastrophes, not a means to get your wart frozen and an annual skin check. Doctors would be able to lower prices and let the market and competition drive price, and then price would be driven by value and results.

Being 90 percent cosmetic keeps me sane, and I am planning to practice for at least another 10 years, well into my 70s. I am not hassled as much by insurance. In 2015, I opted out of Medicare. Best decision I ever made. The data and details were making me lose money. . .Insurance filing increases business costs for doctors.

Now I charge a nominal cash fee. I lost only about 20 percent of the practice’s Medicare patients, and my profits increased because of improved efficiency.

Insurance hassles are my number one complaint, and especially prior authorization delays. Drugs should be available in free market and not via what deal your insurance company cut with Walgreens.

Patients should wise up and stop shopping price and research a doctor’s qualifications more closely than they research their car, cell phone, or camera. If you want a bargain, go to Target, not Saks. It is your face, for God’s sake!

Yelp is extortion. They post bad reviews first and bury all your good ones if you don’t pay them. It feels like we are dealing with Al Capone.”

J. Matthew Knight, MD

Dermatologist

Knight Dermatology Institute

Orlando, FL

“No wonder only about five percent of current US medical students anticipate opening up their own practice upon graduation.”

“Dermatology is unique in that most of us remain in independent small practice. Ceaseless federal bureaucracy affects us more than most.

We’re not alone; bureaucracy and red tape are killing small businesses across our country. It shouldn’t be surprising that an emerging occupation, compliance officer, has experienced exponential growth.

The total federal regulatory burden stands at $1.8 trillion per year—exceeding half the size of the entire federal budget.

We must fight bureaucracy and federal government overreach at every opportunity, before we are regulated out of business. 

We must simultaneously demand healthcare transparency and a vigorous free-market for our services.

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New York dermatologist Heidi Waldorf, MD discusses the onerous MOC requirements and her efforts to fight them.

Consider this: if the Government says that it costs 49 cents to send a letter, why are you letting private insurers pay you 40 cents to do the same job? Sub-Medicare contracts, $10,000 deductibles, and $150 copays are now the norm. We’re not banks, yet we now extend almost as much credit, interest free. No wonder only about five percent of current US medical students anticipate opening up their own practice upon graduation.

It’s inexcusable that, in our government or insurance-brokered system, the best physician in town gets paid the same as the most incompetent. The only way to grow your business in this landscape is to see more patients than most of us are comfortable with—decreasing quality and increasing burn-out. Take a stand!

Start by slowly and methodically terminating your worst-acting insurance contracts. At the same time, begin acting like a practice that welcomes cash-paying private patients that value your time and expertise. Disclose your fees to your patients, and make sure they’re reasonable. Publish these fees on your website and social media. Make it easy for your patients and—unlike your local hospital—don’t fleece patients who carry insurance you no longer accept. Nurture your private patients, and help them find value in your services at every turn. Make it simple and straightforward. Show them that you’re on their side in an era of bureaucratic confusion and ACA-fueled anxiety.

We must help educate our patients on the forces that are driving up the costs of their care while simultaneously pushing good hard-working doctors out of business. Demand transparency. Defend the free market that should set the fees for your hard-earned knowledge and abilities. It’s a leap of faith; but, if you’re a competent and compassionate physician, you can do it!” n

Wendy Lewis is President of Wendy Lewis & CO Ltd, a marketing and social media boutique in New York City, and Founder/Editor in Chief of beautyinthebag.com. Reach her at WL@wendylewisco.com.