Checking for and Preventing Skin Cancer

By Jon R. Ward, MD, Robert Calcote, MD, John H. Phillips III, MD, John L. Ratz, MD

Each year in the U.S. over 5.4 million cases of nonmelanoma skin cancer are treated in more than 3.3 million people. And, it is estimated that over 140,000 more will be diagnosed with melanoma in 2016. Because we know that ultraviolet radiation causes 90% of skin cancers, the key is to limit exposure, especially in those at highest risk for skin cancer. The majority of these types of skin cancers is highly curable. Basal cell carcinoma, the most common form of skin cancer, and squamous cell carcinoma, the second most common form, rarely spread beyond the skin. Melanoma is the most lethal form of skin cancer and is fortunately the least common of the three main types of skin cancer. The rates of melanoma continue to rise, largely affecting young women, and it is now the most common cause of cancer death in young adults ages 25 to 29.

Who is at greatest risk for skin cancer?
The greatest risk factors for melanoma are a personal or family history of melanoma and the presence of atypical or numerous (>50) moles. Other risk factors for all forms of skin cancer include fair skin, a history of blistering sunburns (especially in childhood), excessive sun exposure, UV tanning booth usage, personal or family history of skin cancer, a weakened immune system, and advanced age.

How can you prevent skin cancer? 
The best way to prevent skin cancer is to avoid exposure to ultraviolet radiation. Ultraviolet radiation from either the sun or other sources causes DNA damage to the skin. Cells with damaged DNA are the ones that form cancer. Wear protective clothing when outdoors and consider avoiding outdoor exposure from 10 AM to 4 PM when the ultraviolet light is strongest. On exposed skin, wear a sunscreen with SPF 30 or greater. Apply it prior to sun exposure and reapply every two hours, especially if swimming or with excessive sweating. And, avoid indoor tanning beds altogether.

What are the signs of skin cancer? 
Melanoma, the most lethal form of skin cancer, either develops new or within a pre-existing mole. It is normal to develop new moles into young adulthood. Any person over age 40 who develops a new mole should be evaluated by a Board-Certified dermatologist. An existing mole that exhibits any of the ABCDE features should also be referred for expert consultation. Asymmetry, Border Irregularity, Color Change, Diameter > 6mm, and Evolution/Elevation are all signs that a previously benign mole has changed and now needs further scrutiny. Basal cell and squamous cell carcinomas appear as non-healing pearly or scaly bumps that bleed easily and are sometimes tender to the touch.

How is skin cancer diagnosed? 
All three types of skin cancer are best diagnosed by biopsy. A small sample of the skin can be taken with almost no pain. A small needle is used to numb the skin and the straight blade can be used to shave a small portion of the skin for evaluation and diagnosis. This technique requires no suture and when performed properly on a small tumor leaves no perceivable scar.

How is skin cancer treated?
Early forms of basal cell and squamous cell skin cancer may be treated non-surgically using liquid nitrogen (cryosurgery), electrocautery, currettage, light-based treatments, laser treatments and topical creams. Surgical removal is also used to eliminate these cancers, by excision or by performing Mohs micrographic surgery. For patients who are poor surgical candidates, superficial radiation therapy may be recommended. If melanoma is diagnosed, and is in its earliest stages, a dermatologist may choose to surgically remove it in their office. However, if the melanoma has spread beyond the top layer of the skin, more extensive treatment will be needed. This often requires having the melanoma removed by a general surgeon or surgical oncologist, and may also include radiation, chemotherapy and/or immunotherapy treatments.

Where can you learn more about skin cancer and its prevention? 
Visit www.skincancer.org, the website of the Skin Cancer Foundation, or visit www.aad.org, the website of the American Academy of Dermatology. Or, schedule a visit with a Board-Certified dermatologist for a skin screening and more information.

Scheduling a comprehensive skin screening with Dermatology Specialists?
We encourage you to take the time, not the risk, and schedule your appointment for a comprehensive skin screening by calling us at 877-231-3376.

Managing the cost-value equation

BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR, DERMATOLOGY WORLD

As featured in the Answers in Practice column of Dermatology World, the following is an interview with Jon Ward, MD, Founder and President of Dermatology Specialists of Florida, about managing and thriving in a value-based payment system.

UNDERSTANDING THE VBM

The value-based modifier (VBM) was created through the Affordable Care Act and assigns value-based payments to providers for Medicare services.Under MACRA it will be replaced by the resource use, or cost, category, which will not count toward a provider’s MIPS score during the first year of the program (2017, with bonuses and penalties applied in 2019).


Q: Tell me about your practice.

Dr. Ward: I am the president of an 11-physician and 13-midlevel dermatology group practice located in Florida, Alabama, and Mississippi.

Q. Tell me about your experience with the value-based modifier program.

Dr. Ward: We received an exciting notification from the Centers for Medicare and Medicaid Services (CMS) in June that we were one of 128 group practices nationwide to receive a value-based modifier [VBM] bonus. The VBM award is a 15.92 percent increase in Medicare payments. According to our Quality Resource Use Report, we achieved the bonus based on the low cost of our services. We achieved greater than one standard deviation of the mean in the cost analysis. This is the first year the VBM became available for our group’s size. In 2015, it was only for groups with more than 100 providers and this year it opened up to groups with 10 to 99 providers. There were more than 13,000 eligible groups of that size who could have received the award, placing our quality reporting in the top 1 percent nationwide. A total of 58 of the 128 groups — both primary care and various specialties — were awarded the 15.92 percent increase.

Q: How does your practice manage the administrative workload associated with reporting for this program?

Dr. Ward: We use a certified registry through our EHR vendor. This registry allows us to see how we are performing on our chosen metrics against the national benchmark. We are able to handle the administrative workflow because we spent extensive time researching the implications of the Physician Quality Reporting System (PQRS) and the VBM programs prior to 2014. As a result, we adjusted our clinical workflows to assure we implemented the necessary steps to satisfy the requirements on the measures we were reporting throughout the year. By building this into our workflow, we did not have a huge administrative burden playing “catch up.”

Q: How much time is spent on reporting for programs like the VBM?

Dr. Ward: We put a great deal of emphasis on continually educating our staff on our reporting programs. We have a small team — made up of our chief information officer, our director of practice operations, and a consultant who specializes in PQRS and meaningful use — that monitors our reporting numbers on a monthly basis and constantly provides feedback to our clinical staff on how we are doing and of any improvements that need to be made. Each month, we send our reporting numbers out to our office administrators and providers so they can see where we are throughout the year. If one of our offices is not meeting their measures, we can track that performance down to the group and individual provider.

Q: Can you describe one or two quality measures that you report on and the protocol you have in place to ensure that the practice is consistently performing at the highest level?

Dr. Ward: PQRS 138 — Melanoma: Coordination of Care — looks at the “percentage of patients, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physicians providing continuing care within one month of diagnosis.” This is all about workflow and proper tracking within our EHR software. We ensure that all of our treatment plans are thoroughly documented within the progress note and we have a strict policy ensuring that our treatment plans are promptly sent to the primary care physician. In order to make sure no patients fall through the cracks, we are able to track all of our melanoma patients by ICD-10 code within our EHR system to follow up and make sure that we have communicated treatment plans in a timely manner. PQRS 130 — Documentation of Current Medications in the Medical Record — looks at the “percentage of visits for patients age 18 and older for which the eligible professional attests to documenting a list of current medications in the patient’s medical record.” Again, this comes back to making sure you have the proper workflows and tracking measures in place. It is standard procedure for our clinical staff to verify all patient medications on every patient encounter. We leverage technology through our EHR system to notify a clinician at the time of service to remind them to “verify” all medications.

Q: What can you tell us about how your practice manages cost?

Dr. Ward: The cost composite is based on the cost of the physician, the medications, and any ordered ancillaries, so we have significant control over our costs and try to be mindful of the resources we use. Cost management is attained through our quality-control processes implemented through our practice’s Medical Advisory Committee which is made up of five of our physicians and one non-physician clinician. We educate all of our physicians and non-physician clinicians — in person annually and by phone quarterly — about high-cost procedures and medications and make sure we select less-expensive options when appropriate.

Q: What standards do you have in place to control costs?

Dr. Ward: Since the inception of the AAD’s Mohs Micrographic Surgery Appropriate Use Criteria (AUC), we have encouraged all of our providers to download the app and adhere firmly to the guidelines. We educate our providers on the importance of prescribing generic drugs first, and only selecting branded drugs when less-expensive options are unavailable. We also have an in-house dermatopathologist who is judicious in his use of immunohistochemistry and special stains. We disseminate information about the practices we have put in place through the physician and physician assistant email and we send out various memos.

Q: How does your practice ensure that patients receive the best possible treatment rather than the least expensive available option?

Dr. Ward: I think there are flaws in the cost and value metrics. The general idea is that by being compared to your peers, judicious use of branded drugs and biologics will be advantageous. It truly does penalize practices with higher acuity cancer surgery and complex patients with high-cost medicine, such as the psoriasis patients on biologics. Our practice manages with the best outcomes in mind, but does factor cost into the equation when selecting the best therapy. We aren’t able to truly track medication expense through our EMR, but we are able to track every provider’s charges per patient to identify potential over-utilizers of services.

Q. Even though the VBM will transition to the ‘resource use’ and ‘quality’ requirements under the new Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization (MACRA) law, what advice do you have for other practices to ensure that they are performing these cost and quality standards at the highest level?

Dr. Ward: Be proactive. A lot of practices are aware of the 4 percent penalty for noncompliance but were unaware of the potential positive financial impact with the VBM program. Invest the time to get a good understanding of the MIPS program so your practice can meet the desired measures. You have flexibility on the measures you can attest to so take the time to get familiar and decide what measures work for you. Above all, educate and train your clinical staff on proper workflows and give them insight on how meeting these measures has a positive impact on the practice but also on patient care.

Q: What advice do you have for a small or solo practice that may not have the resources available to manage the administrative workload associated with these types of requirements?

Dr. Ward: Leverage EHR technology as much as possible and consider bringing in an outside consultant to perform an analysis. While the MIPS program will start small with a 4 percent penalty, it will only increase before topping out at a 9 percent payment adjustment. The other reason to take quality measures seriously is the high likelihood that commercial payers will adopt the MIPS standards, so investing now and getting ahead of this will pay dividends in the future. By being proactive and meeting the quality of care and cost metrics, you will be able to demonstrate high quality which could help in commercial payer negotiations. These requirements can be managed and it’s important to remember that there’s more than just a stick to these programs. There’s a carrot for you if you do it right.

Posted in FL

Performance. Quality. Cost Efficiency.

These three key indicators are what every medical practice aspires to deliver on when it comes to providing an exceptional patient experience. Individually, each aspect takes care and thought to achieve, day in and day out. But, when taken together, the weight of delivering on all three of these key indicators is greatly multiplied and no small feat.  This is especially true when it comes to the stringent standards CMS (Centers for Medicare & Medicaid Services) uses to measure the delivery of each of these important aspects in our practice.

“Our ability to deliver on all three of these measurement standards is truly what sets us apart in the region.  It’s the commitment to our patients that comes from our entire team that ultimately enabled us to receive CMS’s VBM award. The distinction of being in the top 1% of group medical practices in the nation, when it comes to providing quality health care services, is a great honor. It’s an achievement that carries with it the responsibility of continuing to deliver on it every day – to be better for our patients,” says Dr. Jon Ward.

 

 

Posted in FL

Local Dermatology Group Taming Transplants with Technology

Local Dermatology Group Taming Transplants with Technology
“Medicine is constantly changing, constantly being upgraded and advanced, which is a good thing, but one of the important thing that we need to do as physicians is to stay on top of the technology and use it to our advantage,” said Dr. Angel Ayar of Dematology Specialists of Florida.

Read the story from ABC 27 WTXL.

Posted in FL

Leprosy Diagnosed

Early this year a patient in our Panama City clinic was diagnosed with Leprosy.  This is the first known diagnosis of this disease in Bay County, Florida.

Although rare, there has been a spike in leprosy cases in the Southeast over the past 2 years, with cases almost tripling in Florida from 10 to 27. Scientists believe contact with armadillos is the reason, citing that 16.5% of armadillos tested in FL, GA, AL and MS are known to be carriers of the bacteria, Mycobacterium leprae. It is estimated that more than 100,000 armadillos are infected in the southeastern U.S. alone.

Although leprosy is contagious, only 5% of the population is able to contract the disease.  There is no test to determine if you are at risk.  Leprosy is diagnosed through a clinical biopsy.

This infectious disease has a lengthy incubation period, from 2 years to a decade.  Our patient had contact with an armadillo between 5 and 7 years ago when he shot it and then handled it as he disposed of the animal.  His symptoms presented as a rash on his elbows and feet that would not resolve.

The treatment for leprosy is antimicrobial drug therapy, a series of common antibiotics, which must be taken for an extended period of time, 6 months to 2 years.  Within a week of beginning the treatment the patient is no longer contagious.

The disease presents first on the skin but, if undiagnosed and treated, can progress to cause underlying nerve damage, damage to the eyes and bones.  Leprosy can be fatal if allowed to grow untreated.

The primary lesson here is not to touch an armadillo or its habitat.  And, if you have an unexplained rash, schedule an appointment with a dermatologist.

Content sources and related links:
Centers for Disease Control and Prevention
University of Florida, Emerging Pathogens Institute
Health Resource and Services Administration
National Hansen’s Disease Program: U.S. Data and Statistics
World Health Organization (WHO): Leprosy Fact Sheet

Posted in FL

Gulf Coast Dermatology Changes Name

Tallahassee, FL Gulf Coast Dermatology recently announced that, after almost a decade of providing advanced treatments and care to the communities they serve, including Tallahassee, they are changing their name to Dermatology Specialists of Florida. The practice began in 2006 in Panama City, and opened the Tallahassee location on Market Street in April of 2012. The group’s ten dermatologists and clinical teams now see patients in more than twenty locations. Clinics now span northern Florida, from Gulf Breeze to Ponte Vedra Beach, with additional locations in Alabama and Mississippi also undergoing name changes.

“We’ve outgrown the name ‘Gulf Coast’, as we are now seeing patients in cities like Tallahassee and Ponte Vedra Beach on the east coast, but our commitment remains the same. We are dedicated to the prevention, detection and treatment of skin cancer.

Ayar adds, “In Leon County, where most of us lead active lives, enjoying college football and recreation outdoors in the sun, it is especially important to have regular skin exams with a specialist. If we can diagnose skin cancer in its earliest stages we have a great chance of eliminating it. ”

CEO Chris Brooks states, “Dermatology Specialists of Florida is honored to serve the capital city community. When we came to Tallahassee over 4 years ago, there were long wait times to get an appointment with a dermatologist. But understanding that early detection leads to an easier cure for skin cancer, we believe patients should never have to wait more than a few days to see a specialist. And, with the addition of Dr. Ayar to the Tallahassee team, we are accommodating that schedule. Dr. Ayar is an outstanding provider who sincerely cares for his patients.”

Posted in FL