Speakers advocate cost-conscious approach

Kevin Kia, MD, discusses the importance of physicians making diagnosis and treatment decisions that are cost-effective.

Kevin Kia, MD, discusses the importance of physicians making diagnosis and treatment decisions that are cost-effective.

As the cost of medicine continues to escalate dramatically, physicians must take responsibility for how best to cost-effectively evaluate and treat patients.

During a Friday morning Focus Session, “Cost Conscious Dermatology,” presenters offered an in-depth look at the cost-to-benefit ratio for the evaluation and management of several common clinical scenarios.

“We don’t set the costs of MRIs and prescriptions, but everything that gets done in medicine ends up with our signatures. Depending on how judicious and self-conscious you are, you can make a big footprint if you spend a lot of money. Or you can approach the same problem with a smaller footprint,” said Kevin Kia, MD, forum director.

Dr. Kia, clinical assistant professor of dermatology at the University of Texas Southwestern Medical Center, Dallas, noted that rates of uninsured Americans have gone down since the Affordable Care Act (ACA) rolled out. While numbers change each month and about 15 percent of the U.S. population is currently uninsured, about 30 to 35 percent of people age 25 to 35 are uninsured.

A number of the ACA health insurance programs have “insane deductibles,” he said. Individuals who sign up for the lowest plan incur a $5,000 yearly deductible.

While Medicaid was expanded to include adults with incomes below the 133 percent of the poverty level, 24 states, including Texas, where Dr. Kia lives, have not expanded Medicaid.

The number of underinsured in the U.S. — individuals who spend more than 10 percent of their income on health care expenses — has been increasing, and those people are more likely to go without access to care.

The treatment of dermatitis, for example, can range from $24 to $445, depending on the 60g topical steroid used.

“I like tacrolimus. It is a great drug, and I anticipate the cost will go down. It’s great for a lot of inflammatory conditions, but if it’s going to be cost-effective it should not be your go-to medicine,” Dr. Kia said. “The only time I prescribe tacrolimus is if a patient is still breaking through regularly, or when I inherit a patient who has atrophy all over the place.”

Ade Adamson, MD, MPP, a resident at the University of Texas Southwestern Medical Center, looked at several options beyond Mohs for the treatment of basal cell carcinoma.

“A lot of times we’re geared toward Mohs with skin cancers on the head and neck, but there are a lot of ways that we can treat these skin cancers,” Dr. Adamson said.

He pointed to data showing the long-term, five-year cure rates for primary BCC by treatment modality, which are: surgical excision, 91 to 95 percent; electrodessication and curettage (EDC), 74 to 92 percent; radiation, 91 percent; cryotherapy, 93 percent; all non-Mohs modalities, 91 percent; and Mohs surgery, 99 percent.

At Southwestern Medical Center, the costs for a 50-year old man with a skin cancer on his forehead are: Mohs with subsequent stages and intermediate repair, $854; imiquimod for six and 12 weeks, $814 and $1,628; respectively; 5-Fluorouracil 12 weeks, $750; excision with intermediate repair and pathology, $504; and EDC, $208. Not included in these charges are the costs of physician visits, associated management of treatment reactions, and recurrence.

“Health care costs are rising, and reform is eventually going to come,” Dr. Kia said. “We all want to do the best for our patients, but often the gold standard of care is expensive. If you make small adjustments you will have a huge impact over the course of a year.”

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