Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US

Access to Sudden Hearing Loss Care at Urgent Care Centers

OBJECTIVES

To compare patient access to urgent care centers (UCCs) with a diagnosis of sudden hearing loss based on insurance.

METHODS

One hundred twenty-five random UCCs in states with Medicaid expansion and 125 random UCCs in states without Medicaid expansion were contacted by a research assistant posing as a family member seeking care on behalf of a patient with a one-week history of sudden, unilateral hearing loss. Each clinic was called once as a Medicaid patient and once as a private insurance (PI) patient for 500 total calls. Each phone encounter was evaluated for insurance acceptance and self-pay price. Secondary outcomes included other measures of timely/accessible care. Chi-square/McNemar's tests and independent/paired sample t-tests were performed to determine whether there were statistically significant differences between expansion status and insurance type. Calls ended before answering questions were not included in the analysis.

RESULTS

Medicaid acceptance rate was significantly lower than PI (68.1% vs. 98.4%, p < 0.001). UCCs in Medicaid expansion states were significantly more likely to accept Medicaid (76.8% vs. 59.2%, p = 0.003). The mean wage-adjusted self-pay price was significantly greater in states with Medicaid expansion at $169.84 than in states without at $145.34 when called as a Medicaid patient (mean difference: $24.50, 95% Confidence Interval: $0.45-$48.54, p = 0.046). The rates of referral to an emergency department and self-pay price nondisclosure rates were greater for Medicaid calls than for private insurance calls (8.2% vs. 0.4% and 17.4% vs. 5.8%; p < 0.001 for both).

CONCLUSION

Medicaid patients with otologic emergencies face reduced access to care at UCCs.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:5066-5072, 2024.

Access to Healthcare for Appendicitis Patients in the United States Based on Insurance Coverage

INTRODUCTION

Health insurance plays a crucial role in ensuring access to healthcare services, addressing affordability concerns. Insurance options have varying wait times and acceptance challenges, which can greatly impact patients in emergency conditions, such as appendicitis. This study aims to find out the healthcare access disparities for appendicitis patients in states with low Medicaid coverage.

METHODS

A three-week virtual cross-sectional study (Oct 20-Nov 10, 2023) evaluated healthcare accessibility for appendicitis symptoms in North Dakota, Utah, Wyoming, and New Hampshire. Using www.healthgrades.com, data on general surgeons within 10 miles prioritizing new patients with three stars or above were collected and then analyzed with StataCorp 2023.

RESULTS

The study was done among 81 physicians among whom, 61 (75.31%) were male and 20 (24.69%) were female, mostly MD (76, 93.83%), DO (3, 3.70%), and APRN (2, 2.47%). Cigna (n=77) is mostly accepted by more physicians than Medicaid (n=33) across the states. The average waiting period for Cigna (9.45±10.54 days) is mostly longer than Medicaid (4.71± 9.63 days). Our findings of P-values >0.05 reveal no significant associations in insurance acceptance or waiting times.

CONCLUSIONS

Although varying wait times were observed across states, no significant disparities were found in appointment waiting periods based on insurance types.

Qualitative perspectives of Medicaid-insured patients on ambulatory care at an academic medical center: challenges and opportunities

BACKGROUND

Ambulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery.

METHODS

The authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity.

RESULTS

Twenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or "other" race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers.

CONCLUSIONS

The missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO)

INTRODUCTION

Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers' diagnostic and treatment tendencies and accuracy.

METHODS

This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis.

RESULTS

Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel.

DISCUSSION

Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.

Wait times for scheduling appointments with hospital affiliated dermatologists in New York City

Patients' experience accessing dermatologic care is understudied. The purpose of this cross-sectional study was to examine current wait times for new patients to receive dermatological care in NYC. Websites at 58 accredited private and public hospitals in the five boroughs of NYC were reviewed to identify dermatology practices. Office telephone numbers listed on each website were called to collect information pertaining to whether the physician was accepting new patients, type of insurance accepted (public, private, both, or none), and the number of days until a new patient could be seen for an appointment. Data pertaining to the time kept on hold and availability of web-based booking were also collected. Mean waiting time for an appointment was 50 days [standard deviation, SD 66] - nearly 2 months, but the distribution was considerably skewed. The median waiting time was 19.5 days [Interquartile range, IQR 4-60]. The time kept on hold to make the appointment was negligible at about 1 min (63 s, SD = 77) but could take up to ~ 7 min. Two-thirds of dermatologists accepted private, Medicare, and Medicaid insurance (n = 228, 66%); a small number accepted only private insurance (n = 12, 4%) or no insurance at all (n = 16, 5%). The median waiting time for an appointment for the 228 providers that accepted Medicaid was 30.5 days (IQR = 5.0-73.25) while for providers who did not accept Medicaid (n = 116) the median wait time for an appointment was 13.0 days (IQR = 3.0-38.0). Just over half (56%) of the dermatologists allowed for appointments to be booked on their website (n = 193). This research highlights the necessity of incorporating new strategies into routine dermatology appointments in order to increase treatment availability and decrease healthcare inequality.

The performance of an artificial intelligence-based computer vision mobile application for the image diagnosis of genital dermatoses: a prospective cross-sectional study

BACKGROUND

There is a huge demand-supply gap between the incidence of genital dermatoses (including sexually transmitted infections and non-venereal genital dermatoses) and physicians trained to manage them.

OBJECTIVES

To find out the performance of an artificial intelligence (AI)-based mobile application in the image diagnosis of genital dermatoses, and to compare it with primary care physicians (PCPs) and dermatologists.

METHODS

Photos of the genital diseases of consecutive patients presenting to the STD and genital diseases clinic were included. The gold standard diagnosis was established by the consensus of two certified dermatologists after examination and one positive investigation. Image diagnoses by the DermaAId application, two PCPs, and two dermatologists were recorded and compared to the gold standard diagnosis and to each other.

RESULTS

A total of 257 genital disease images, including 95 (37.0%) anogenital warts, 60 (22.2%) lichen sclerosus, 20 (7.8%) anogenital herpes, 15 (5.8%) tinea cruris, 14 (5.4%) molluscum contagiosum, 9 (3.5%) candidiasis, 8 (3.1%) scabies, 6 (2.3%) squamous cell carcinomas, were included. The top-1 correct diagnosis rate of the application was 68.9%, compared to the 50.4% of the PCPs and 73.2% of the dermatologists. The application significantly outperformed PCPs with regard to the correlation with the gold standard diagnosis (P < 0.0001), and matched that of the dermatologists.

CONCLUSIONS

AI-based image diagnosis platforms can potentially be a low-cost rapid decision support tool for PCPs, integrated with syndromic management programs and direct-to-consumer services, and address healthcare inequities in managing genital dermatoses.

Access to Dermatological Appointments Based on Insurance Types in Hawai'i

Although there is evidence that Medicaid beneficiaries in the continental United States experience barriers to accessing dermatological care, limited data exists on whether these same barriers exist in Hawai'i. Using a secret shopper study design, a total of 46 dermatology offices were contacted, 41 (89%) of which were accepting new patients. Thirty (73%) offices were located on O'ahu, and the remaining 11 (27%) were distributed among the neighboring islands (Hawai'i Island, Kaua'i, Maui). Overall, the acceptance rate for Medicaid (n=14) was 34%, which was significantly lower (P<.0001) than private insurance (n=39 (95%)) and Medicare (n=38 (93%)). The acceptance rate for patients with Medicaid insurance was lower for O'ahu offices (27%) than for neighboring islands' offices (55%), but the difference was not statistically significant (P=.095). Differences in average wait times were not statistically significant among insurance types or between O'ahu and neighboring islands. Overall, these results suggest that Medicaid recipients compared to those with private insurance or Medicare might experience difficulty in accessing dermatological care in Hawai'i.

Inpatient prevalence and factors associated with Merkel Cell Carcinoma inpatient hospitalization in the United States

Merkel Cell Carcinoma is a rare and aggressive cutaneous carcinoma with a propensity for metastasis and death. Our study describes the prevalence, sociodemographics and inpatient mortality of Merkel Cell Carcinoma related hospitalizations in the United States from 2011 to 2020. We conducted an observational study using the Nationwide Inpatient Sample database, which captures a 20% sample of all hospitalizations in the United States. We utilized the International Classification of Disease Clinical Modification codes from the ninth and tenth revision to identify Merkel Cell Carcinoma and demographic factors. There was a total of 28,809 cases of Merkel Cell Carcinoma in the United States from 2011 to 2020. Merkel Cell Carcinoma was associated with white race (11.4 per 100,000) and disposition of death (26.8 per 100,000). It was most prevalent in the highest quartile income (12.5 per 100,000) and Medicare as primary payer (13.0 per 100,000). Hospitalization was lowest in nonwhite races, particularly NH-Blacks and NH-Others. Inpatient mortality was significantly associated with NH-Others (odds ratio 2.18, 95% confidence interval = 1.38-3.45) and self-pay patients (odds ratio = 2.93, 95% confidence interval 1.84-4.67).This study contributes to reported socio-demographic factors related to Merkel Cell Carcinomas and brings awareness to factors associated with increased hospitalization and inpatient mortality.

Access to Sudden Sensorineural Hearing Loss Care at Private Equity-Owned Otolaryngology Clinics

OBJECTIVE

Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models.

STUDY DESIGN

Cross-sectional prospective review.

SETTING

Private practice otolaryngology clinics.

METHODS

We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type.

RESULTS

Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004).

CONCLUSIONS

Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options.

Uncovering the burden of hidradenitis suppurativa misdiagnosis and underdiagnosis: a machine learning approach

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular skin condition that is associated with significant psychosocial and economic burden and a diminished quality of life and work productivity. Accurate diagnosis of HS is challenging due to its unknown etiology, which can lead to underdiagnosis or misdiagnosis that results in increased patient and healthcare system burden. We applied machine learning (ML) to a medical and pharmacy claims database using data from 2000 through 2018 to develop a novel model to better understand HS underdiagnosis on a healthcare system level. The primary results demonstrated that high-performing models for predicting HS diagnosis can be constructed using claims data, with an area under the curve (AUC) of 81%-82% observed among the top-performing models. The results of the models developed in this study could be input into the development of an impact of inaction model that determines the cost implications of HS diagnosis and treatment delay to the healthcare system.

The United States dermatology inpatient workforce between 2013 and 2019: a Medicare analysis reveals contraction of the workforce and vast access deserts-a cross-sectional analysis

While time spent practicing inpatient dermatology has decreased since the 1990s, less is known about the current state of inpatient dermatology. We describe the distribution and frequency of inpatient dermatology encounters servicing the United States Medicare population between 2013 and 2019. Cross-sectional analysis of publicly available inpatient Medicare Part B claims data from 2013 to 2019 was conducted. Main outcomes and measures were characteristics and trends of dermatologists performing inpatient encounters. Categorical variables were compared using χ2 analysis. Trends were analyzed for linearity using Pearson correlation coefficient. 782 physicians met inclusion criteria for inclusion. Dermatologists were more often male (56.5%), possessing allopathic Medical Doctorate (MD) (86.3%), and in metropolitan settings (98.2%). However, proportion of female inpatient dermatologists increased significantly (37.9% to 46.2%). Across rural and metropolitan practices, number of inpatient physicians (2013: 356; 2019: 281) and number of medical centers in which dermatology encounters occurred (2013: 239; 2019: 157) decreased, more significantly in non-residency-associated institutions. Spatial analysis revealed wide regions lacking dermatologists meeting defined criteria. Limitations included the need for ten Medicare inpatient encounters for inclusion, counties without reported data. In conclusion, the number of dermatologists performing > 10 inpatient encounters per year is decreasing, and large variations exist in the number of U.S. inpatient dermatology visits.

Implementation of a postgraduate dermatology fellowship program for nurse practitioners

ABSTRACT

Transition to practice programs (also referred to as fellowship, residency, or postgraduate training programs) for nurse practitioners (NPs) are becoming more popular, especially in specialties such as dermatology. A nationwide shortage of dermatology clinicians, which had led to long appointment wait times and inadequate patient access to care, has led to more NPs practicing dermatology to help meet the demand for care. New graduate NPs may struggle in their transition to practice, and fellowship programs have been shown to support NPs as they transition from novice to expert. In this article, the University of Rochester Medical Center shares its experience in developing, implementing, and managing a postgraduate dermatology fellowship program for NPs.

"Check Your Vulva"-A Patient Education and Virtual Vulva Care Pilot Project

OBJECTIVE

The aim of the study is to identify whether vulvar self-examination learned from a web site could lead to a self-identification of vulvar lesions and the feasibility of virtual vulvar care with patient submitted photos.

MATERIALS AND METHODS

The study used a prospective cohort design in a tertiary academic hospital over a 1-year period. Eligible participants who self-identified a vulvar lesion/skin changes were invited to send vulvar photos through a secure patient portal and schedule a phone consult to discuss diagnosis/management. Clinical data, photo interpretability, and patient satisfaction measures were collected. Self-referral patients versus vulva clinic waitlist patients were analyzed separately.

RESULTS

Few people were interested in submitting vulvar photos online. Twenty-eight participants directly contacted the study, 8 consented, and 6 sent in vulvar photos. Forty four of 476 on the waitlist consented but only 24 of 44 sent in photos (5% of waitlist patients). The median time for a virtual assessment was 7 days for study participants while it was 18 months for the in-person usual care pathway. Most patient submitted photos were assessable. However, 60% participants needed help from another person to take the photos. More than 90% of patients required an in-person visit for their vulvar condition/concerns. While most patients were happy with the virtual process, 58% rated their satisfaction with the ease of taking photos of the genital region as "fair" or "poor."

CONCLUSIONS

Virtual care with photos/phone calls might be feasible, although most patients are unlikely to participate. Because of patient discomfort, unease with taking photos, and patient privacy concerns, vulvar care should continue to be in-person for most new consults.

Private Equity: The Bad and the Ugly

Private equity's (PE) presence has grown within dermatology over the last decade, creating a new landscape for dermatologists to navigate. Although dermatology PE-backed groups (DPEGs) claim to partner with physicians and improve health care delivery, their actions show that investment returns and profits are prioritized. The history of PE in medicine, the corporate practice of medicine, maturation of the dermatology market, monopolistic practices, overleveraging of nonphysician practitioners, dependence on debt, training under PE, and professional and lifestyle considerations are discussed. Dermatologists should be wary of DPEGs in order to protect the profession and patients.

Trends in Private Equity Acquisitions of US Otolaryngology Practices

With the increasing consolidation of physician practices, private equity (PE) firms have been playing a growing role in healthcare delivery and recently began entering the otolaryngology-head and neck surgery space. To date, no studies have examined the extent of PE investment in otolaryngology. We assessed trends and geographic distribution of US otolaryngology practices acquired by PE using Pitchbook (Seattle, WA), a comprehensive market database. From 2015 to 2021, 23 otolaryngology practices were acquired by PE. The number of PE acquisitions increased over time: 1 practice was acquired in 2015 versus 4 practices in 2019 versus 8 practices in 2021. Nearly half (43.5%, n = 10) of acquired practices were in the South Atlantic region. The median number of otolaryngologists at these practices was 5 (interquartile range: 3-7). As PE investment in otolaryngology continues to grow, further research is needed to assess its impact on clinical decision-making, healthcare costs, physician job satisfaction, clinical efficiency, and patient outcomes.

Economics of a Dermatology Practice

Understanding the economics behind any medical practice comes down to one basic concept: Profit = Revenue - Expenses. This article aims to demystify the details that underlie this simple formula and to provide the budding dermatologist the information and the tools needed to determine their own profitability in the "real world."

Patterns and determinants of pediatric dermatologic care in the United States: An evaluation of the National Ambulatory Medical Care Survey from 2009 to 2015

BACKGROUND

Dermatologists and other providers play essential roles in managing the dermatologic care of pediatric patients. This study aims to identify patterns and elucidate factors associated with receiving dermatologic care in the United States.

METHODS

The National Ambulatory Medical Care Survey (NAMCS) was used to identify pediatric patients with dermatologic diagnoses from 2009 to 2015. Clinical and demographic information were evaluated, and visit diagnoses were stratified based on provider type (dermatologists vs. non-dermatologists). Multivariate logistic regression analysis was used to identify key predictors of outpatient dermatology care for pediatric patients. National estimates of diagnoses were procured using weights provided within the NAMCS database to project disease incidence.

RESULTS

A total of 85,217,557 pediatric patients (survey-weighted) were observed during the study period. Of the sampled patients, 29.3% were evaluated by dermatologists, while 70.7% were seen by non-dermatology providers. Atopic dermatitis was the most common diagnosis encountered by dermatologists in ages 0-3 years, while unspecified contact dermatitis was the most common diagnosis reported by non-dermatologists in all age groups. On multivariable logistic regression, ≥1 year of age, Caucasian race, private insurance versus Medicaid, residence in a metropolitan area, referral from another provider, and longer appointment wait time were associated with an increased likelihood of being evaluated by a dermatologist compared to a non-dermatologist.

CONCLUSIONS

Non-dermatologists are responsible for the majority of pediatric dermatologic care. For pediatric patients, health disparities by race, insurance status, and rurality present significant challenges to being evaluated by a dermatologist.

Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review

OBJECTIVE

To review the evidence on trends and impacts of private equity (PE) ownership of healthcare operators.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Web of Science, Embase, Scopus, and SSRN.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Empirical research studies of any design that evaluated PE owned healthcare operators.

MAIN OUTCOME MEASURES

The main outcome measures were impact of PE ownership on health outcomes, costs to patients or payers, costs to operators, and quality. The secondary outcome measures were trends and prevalence of PE ownership of healthcare operators.

DATA SYNTHESIS

Studies were classified as finding either beneficial, harmful, mixed, or neutral impacts of PE ownership on main outcome measures. Results across studies were narratively synthesized and reported. Risk of bias was evaluated using ROBINS-I (Risk Of Bias In Non-randomised Studies of Interventions).

RESULTS

The electronic search identified 1778 studies, with 55 meeting the inclusion criteria. Studies spanned eight countries, with most (n=47) analyzing PE ownership of healthcare operators in the US. Nursing homes were the most commonly studied healthcare setting (n=17), followed by hospitals and dermatology settings (n=9 each); ophthalmology (n=7); multiple specialties or general physician groups (n=5); urology (n=4); gastroenterology and orthopedics (n=3 each); surgical centers, fertility, and obstetrics and gynecology (n=2 each); and anesthesia, hospice care, oral or maxillofacial surgery, otolaryngology, and plastics (n=1 each). Across the outcome measures, PE ownership was most consistently associated with increases in costs to patients or payers. Additionally, PE ownership was associated with mixed to harmful impacts on quality. These outcomes held in sensitivity analyses in which only studies with moderate risk of bias were included. Health outcomes showed both beneficial and harmful results, as did costs to operators, but the volume of studies for these outcomes was too low for conclusive interpretation. In some instances, PE ownership was associated with reduced nurse staffing levels or a shift towards lower nursing skill mix. No consistently beneficial impacts of PE ownership were identified.

CONCLUSIONS

Trends in PE ownership rapidly increased across almost all healthcare settings studied. Such ownership is often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality. Owing to risk of bias and frequent geographic focus on the US, conclusions might not be generalizable internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022329857.

Obstacles to Early Diagnosis and Treatment of Hidradenitis Suppurativa: Current Perspectives on Improving Clinical Management

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that can progress to significant tunnels and scars that affect quality of life, especially if diagnosis and treatment are delayed. Average delay after initial presentation of HS symptoms can range from 3 to 10 years in adults and 1 to 2 years in children. Factors associated with diagnostic delay include female gender, non-white race, and greater disease severity at diagnosis. Contributing factors include misdiagnoses, difficulty accessing a dermatologist, hesitation in seeking care due to the stigmatizing nature of the disease, and lack of awareness among providers and patients. While efforts to increase awareness include academic talks at conferences and by foundations geared toward HS, social media offers the opportunity to reach young audiences. Many patients report dissatisfaction with their HS treatments. Better understanding of HS pathophysiology and implementation of clinically focused phenotypes and endotypes can lead to development of more targeted and efficacious therapies. FDA approval of medications for HS beyond adalimumab will increase access to a wider selection of therapies, and implementation of therapeutic drug monitoring may maximize the use of biologics for HS.

History of Race in America

Racial and ethnic disparities exist across a wide range of disease areas and clinical services. Becoming familiar with the history of race in America, and how it has been used to structure laws or policies that drive inequities in the social determinants of health, even today, is necessary to mitigate these disparities across medicine.

Proposed solutions by the American College of Allergy, Asthma, and Immunology and advocacy experts to address racial disparities in atopic dermatitis and food allergy

Atopic dermatitis (AD) and food allergies are more prevalent and more severe in people with skin of color than White individuals. The American College of Allergy, Asthma, and Immunology (ACAAI) sought to understand the effects of racial disparities among patients with skin of color with AD and food allergies. The ACAAI surveyed its members (N = 200 completed), conducted interviews with health care providers and advocacy leaders, and hosted a roundtable to explore the challenges of diagnosis and management of AD and food allergies in people with skin of color and to discuss potential solutions. Most of the survey respondents (68%) agreed that racial disparities make it difficult for people with skin of color to receive adequate treatment for AD and food allergies. The interviews and roundtable identified access to care, burden of costs, policies and infrastructure that limit access to safe foods and patient education, and inadequate research involving people with skin of color as obstacles to care. Proposed solutions included identifying ways to recruit more people with skin of color into clinical trials and medical school, educating health care providers about diagnosis and treating AD and food allergy in people with skin of color, improving access to safe foods, creating and disseminating culturally appropriate materials for patients, and working toward longer appointment times for patients who need them. Challenges in AD and food allergy in persons with skin of color were identified by the ACAAI members. Solutions to these challenges were proposed to inspire actions to mitigate racial disparities in AD and food allergy.

Improving migrant health in the USA: opportunities for dermatologists to participate in care delivery, asylum medicine and community partnership

With an increase in migrant patients in the U.S. who are facing legal and health barriers, dermatologists can engage in opportunities to improve migrant health. These include: providing trauma-informed, culturally competent dermatologic care to migrants; partnering with human rights clinics to provide dermatologic consultations for asylum seekers with skin conditions or unique scars; and engaging with community organizations to collaborate and advocate for the health and well-being of migrants.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Importance

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated.

Objective

To assess the interventions and patient factors associated with ED return following an initial ED visit for HS.

Design, Setting, and Participants

This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022.

Exposures

Factors analyzed included those associated with the ED visit and patient characteristics.

Main Outcomes and Measures

Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit.

Results

This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days).

Conclusions and Relevance

This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Access to pediatric dermatology

PURPOSE OF REVIEW

To identify factors that impact accessibility to pediatric dermatology and review healthcare delivery models that improve access and address these barriers.

RECENT FINDINGS

Up to one-third of pediatric primary care visits include a skin-related problem, yet pediatric dermatology subspecialist services are highly inaccessible. Workforce shortages and geographic, sociocultural, and economic barriers perpetuate inaccessibility. Teledermatology expands care, particularly to underserved or geographically remote communities, and reduces healthcare-related costs. Federal legislation to support telehealth services with adequate reimbursement for providers with parity between live, video, and phone visits will dictate the continued feasibility of virtual visits. Innovative care delivery models, such as language-based clinics, multidisciplinary teleconferencing, or embedded dermatology services within primary care are other promising alternatives.

SUMMARY

Despite efforts to expand access, dermatology still ranks among the most underserved pediatric subspecialties. Improving access requires a multipronged approach. Efforts to expand exposure and mentorship within pediatric dermatology, diversify the workforce and clinical curriculum, recruit and retain clinicians in geographically underserved areas, and collaborate with policymakers to ensure adequate reimbursement for teledermatology services are necessary.

Dermatology Workforce in the United States - Part 1: Overview, Transformations, and Implications

The dermatology workforce continues to evolve to meet the growing and diversified demands of the United States population. Part 1 of this continuing medical education (CME) series is designed to provide an overview of the dermatology workforce as well as delineate the motivators and socio-economic implications of significant workforce transformations which are impacting dermatologic health care. Part 2 of the series will consider the impact of workforce challenges on patient outcomes and discuss potential actions that may help to optimize workforce organization and care delivery.

Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis

IMPORTANCE

Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known.

OBJECTIVE

To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer.

EXPOSURES

Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database.

RESULTS

A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access.

CONCLUSIONS AND RELEVANCE

This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.

Disparities in access for melanoma screening by region, specialty, and insurance: A cross-sectional audit study

Background

Early detection of melanoma is critical for positive outcomes. However, access for the diagnosis of melanoma remains problematic for segments of the general population.

Objective

To compare the rates of dermatology and family medicine practitioner acceptances for a public insurance (Medicaid) versus private insurance (Anthem Blue Cross) and clinic wait times for an appointment for a changing pigmented skin lesion concerning melanoma in rural and urban regions in California.

Methods

Cross-sectional audit study between June 2017 and March 2019; scripted phone calls were made to dermatology and family medicine practices (FMPs).

Results

Family medicine and dermatology practices in both regions had significantly decreased acceptance of Medicaid. Dermatology practices had 11.3% to 13.0% Medicaid acceptance rates that were less than FMP rates of 28% to 36%. In both regions, FMP wait times were 2.4- to 3.2-fold longer for public versus private insurance; there were little differences in wait times for the 2 insurance types in dermatology practices, in both regions.

Limitations

Assessment of only 2 regions in the state of California.

Conclusion

Delays at FMPs and insurance types limit access to melanoma screening in California for underserved segments of the general population, which has implications for melanoma outcomes and health policy.

Trends in Debt Valuations of Private Equity-Backed Dermatology Groups Before and During the COVID-19 Pandemic

Importance

Private equity (PE) firms have invested in and consolidated dermatology practices. Private equity firms typically operate by conducting leveraged buyouts, which occur when target companies are acquired with capital from PE firms and a combination of debt, which may include debt instruments held in business development corporations (BDCs).

Objective

To investigate the valuations of dermatology PE-backed group (DPEG) debt instruments in BDCs' portfolios both before and during the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional study, conducted from August 1, 2016, to August 31, 2021, examined public financial statements filed by BDCs lending to DPEGs. The public filings of BDCs were searched from inception of the DPEG's debt instrument in a BDC's portfolio, and the amortized cost and fair value of each debt instrument were tabulated.

Main Outcomes and Measures

The premium or discount at which each debt instrument was valued at a given time was calculated by dividing the difference between the fair value and the amortized cost by the amortized cost. Different testing methods were conducted for normal or nonnormal data to test differences in debt valuations across all DPEGs between 2 consecutive or nonconsecutive quarters.

Results

The search of the public filings found 10 BDCs containing data on 9 unique DPEGs. Overall, there were 15 trackable DPEG debt instruments because multiple BDCs can hold debt instruments for a given DPEG. Data were available from August 2016 through August 2021. During the study time frame, the amortized cost of the loans for an individual DPEG ranged from a low of $1.7 million to a high of $100 million. The valuation of debt instruments was stable for many DPEGs until some were discounted starting in May 2018, with a significant decrease from May 2019 to August 2019 (-1.4%; 95% CI, not applicable; P = .04), prior to the COVID-19 pandemic. Another significant decrease occurred during the pandemic from February to June 2020 (-9.0%; 95% CI, -13.6% to -4.4%; P = .002). US Dermatology Partners decreased to the lowest valuation (Golub BDC, -39.7%; TCG BDC Inc, -48.8%; TCG BDC II, -48.8%) of the DPEGs examined in November 2020 even after receiving a $10 million forgivable Small Business Administration Paycheck Protection Program loan in May 2020. After pharmaceutical companies announced effective COVID-19 vaccine candidates in November 2020, there was a modest and significant improvement in debt valuations (2.3%; 95% CI, 0.2%-0.4%; P = .03); however, they remained discounted. Only PhyNet Dermatology's debt instruments improved to a premium valuation by August 2021.

Conclusions and Relevance

Debt valuations of some DPEGs found in this cross-sectional study suggest a lower probability that their loans will be repaid in full. This could be a signal that some DPEGs are not performing well financially.

Access to Urological Care for Medicaid-Insured Patients at Urology Practices Acquired by Private Equity Firms

OBJECTIVE

To characterize appointment access for Medicaid-insured patients seeking care at urology practices affiliated with private equity firms in light of the recent national trends in practice consolidation.

METHODS

We identified 214 urology offices affiliated with private equity firms that were geographically matched with 231 non-private equity affiliated urology offices. Using a standardized script, researchers posed as an adult patient with either Medicaid or commercial insurance in the clinical setting of new onset, painless hematuria. The primary outcome was whether the patient's insurance was accepted for an appointment. The secondary outcome was appointment wait time.

RESULTS

We conducted 815 appointment inquiry calls to 214 PE and 231 non-PE-affiliated urology offices across 12 states. Appointment availability was higher for commercially-insured patients (99.0%; 95% CI: 98.1%-99.9%) versus Medicaid-insured patients (59.8%; 95% CI: 55.0%-64.6%) (p<0.0001). Medicaid acceptance was higher at non-PE affiliated (66.8%; CI 60.4%-73.2%) than PE-affiliated practices (52.1%; 95% CI 45.0%-59.2%) (p=0.003). On multivariable logistic regression analysis, state Medicaid expansion status (OR 2.20; CI 1.14-4.28; p=0.020) was independently associated with Medicaid appointment availability, whereas PE-affiliation (OR 0.55; CI 0.37-0.83; p=0.004) was independently associated with lower Medicaid access. Appointment wait times did not differ significantly for commercially-insured versus Medicaid patients (19.2 vs 20.1 days; p=0.59), but PE-affiliated practices offered shorter mean wait times than non-PE offices (17.5 vs 21.4 days; p=0.017).

CONCLUSIONS

Access disparities for urologic evaluation in patients with Medicaid insurance at urology practices and were more pronounced at private equity acquired practices.

Surgical Dermatology and Private Equity: A Review of the Literature and Discussion

BACKGROUND

While there has been substantial investment in dermatology by private equity (PE), the relevance of this trend to the dermatologic surgeon has not been assessed.

OBJECTIVE

The literature on PE investment in medicine was reviewed to provide interdisciplinary data relevant to the dermatologic surgeon.

MATERIALS AND METHODS

The PubMed database was queried for all peer-reviewed articles containing the term "private equity" and identified 70 unique articles across 18 medical specialties, comprising 20 original research articles and 50 commentary articles.

RESULTS

Significant PE growth across multiple medical specialties occurred in the 2010s. Private equity ownership was associated with higher levels of nonphysician providers relative to physicians. Pooled data suggest that PE ownership is associated with lower staffing levels, particularly for non-revenue-generating staff, as well as potentially lower levels of medical supplies on hand. Data on financial performance suggests that PE-ownership results in higher profits, revenues, and costs. Surveys of physicians demonstrate concern about autonomy, ethics, and career prospects.

CONCLUSION

For the dermatologic surgeon, issues related to consolidation, provider scope of practice, support staff availability, and supply management are important due to the nature of procedural intervention and the increased risk of adverse events.

Prevalence of Misrepresentation of Nonphysician Clinicians at Dermatology Clinics

INTRODUCTION

To evaluate the use of inaccurate terminology used by dermatology practices to describe the training and qualifications of their nonphysician clinicians (NPCs) when new patients are booking appointments.

METHODS

Clinics were randomly selected and called to determine the first available appointment for a new patient with a new and changing mole. If the receptionist confirmed the first-offered appointment was with an NPC, the encounter was included in this study. If receptionists used inaccurate terminology to describe the NPCs and their qualifications, this instance was recorded along with the specific language that they used.

RESULTS

A total of 344 unique dermatology clinics were contacted on February 27, 2020, in 25 states. Phone calls at 128 clinics (37.2%) met our inclusion criterion. Inaccurate language was used to describe NPCs at 23 (18%) unique clinic locations across 12 states, with "dermatologist," "doctor," "physician," and "board-certified" being used to describe NPCs as the most common inaccurate terms.

CONCLUSION

These findings demonstrate that front office staff at dermatology clinics use inaccurate and potentially misleading terminology to refer to NPCs working in their clinics. While we cannot establish whether this is intentional or due to a lack of training, additional focus should be placed on accurately representing provider qualifications to patients.

Barriers to healthcare access in pediatric dermatology: A systematic review

Barriers to healthcare access are healthcare inequities that have been widely studied across different medical specialties. No studies have previously evaluated the state of barriers to healthcare access research in pediatric dermatology. A systematic review was conducted to examine the types of barriers identified within pediatric dermatology literature. Relevant information was extracted and categorized into the themes of systemic, sociocultural, or individual barriers. The systemic barriers we found include finances, wait times, and geography. The sociocultural barriers included culture beliefs and communication. Patient beliefs and health knowledge were found as individual barriers. The small number and limited scope of studies we identified suggest that barriers to healthcare access in pediatric dermatology remain an understudied topic. Additional research is needed to further characterize these barriers to dermatologic care, as well as the impact of any interventions designed to overcome them.