DELIVERY OF DERMATOPATHOLOGIC HEALTH CARE IN THE TWENTY-FIRST CENTURY

DELIVERY OF DERMATOLOGIC HEALTH CARE

0733-8635100 $15.00

+

.OO

DELIVERY OF DERMATOPATHOLOGIC HEALTH CARE IN THE TWENTY-FIRST CENTURY Nicole Conrad, MD, Raashid Haque, MSIV, and Clay J. Cockerell, MD

Although dermatology as a field had its beginnings centuries ago, modern dermatology can be directly traced to 1798, when On Cutaneous Disease by Willan was published. In this classic work, Willan emphasized morphologic characteristics of skin diseases, stressing the importance of precise descriptions of color, shape, size, and patterns. By coupling precise, repeatable descriptions with historical and other physical signs, increasingly accurate diagnosis of this group of often mysterious and confounding disorders could be more readily accomplished.6Since Willan’s publication, the field of dermatology has progressed considerably. One of the most important developments has been the advent of dermatopathology. Dermatopathology formally began in the late nineteenth century with the publication of The Histopathology of the Diseases of the Skin by Unna. This became recognized as an important work, and as such, it was translated into English in 1896. Other works followed soon thereafter, and the first original English work, Practical Hand-

book of the Pathology of the Skin by MacLeod, was published in 1903.14Since its early beginnings, dermatopathology has continued to grow and flourish, especially with the advent of improved technology and basic science techniques. These improvements have led to discoveries in the pathogenesis and mechanisms of disease processes as well as exciting potential novel forms of therapy.6 The fields of dermatology and dermatopathology continue to expand exponentially at the beginning of the twenty-first century. Health care reform issues also continue to be important, and as new health care policies are instituted, the role and contribution of dermatopathology to health care must be addressed. SKIN DISEASES AND HEALTH CARE AS A WHOLE

It is only relatively recently that the skin has been recognized as a separate organ, having for years been considered only an integu-

From the Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern Medical Center, Dallas, Texas

DERMATOLOGIC CLINICS

-

VOLUME 18 NUMBER 2 APRIL 2000

241

242

CONRAD et a1

rnent overlying deeper, vital structures. Skin diseases occur in association with systemic disease processes or as independent phenomena. The importance of skin conditions is tremendous with regard to the effects they exert on physical and psychological well-being as well as their impact on an individual's overall quality of life. One study reveals that patients with psoriasis report a much poorer quality of life in comparison with patients with lifethreatening diseases, such as diabetes, asthma, and bron~hitis.~~ Dermatologic conditions make up a significant number of outpatient visits and constitute a significant percentage of diagnoses rendered in anatomic pathology laboratories. Finally, the incidence of skin diseases continues to rise, and as patients become better informed about them, the demand on dermatologists and dermatopathologists to diagnose and treat these conditions also grows.

CURRENT STATUS OF DERMATOPATHOLOGY IN DERMATOLOGIC HEALTH CARE DELIVERY

The art of dermatologic diagnosis is primarily a visual one, and the clinician must rely on his or her knowledge coupled with experience to recognize skin diseases correctly. Although much of dermatologic diagnosis is based on macroscopic findings, microscopic feabpes of a skin disease are often the most important ones, without which a precise diagnosis may not be able to be rendered. The renowned French dermatopathologist Civatte described the characteristic acantholysis seen in pemphigus vulgaris as early as 1943. Before this, there had been no distinction between pemphigus and bullous pemphigoid, a distinction that was soon thereafter delineated by Lever.Is Dermatopathology is integral and essential to the practice of dermatology. Without access to expertise in dermatopathology, dermatology simply cannot be practiced competently. Dermatopathology itself is based on the correlation of clinical features with the microscopic findings. Consequently the skilled,

competent dermatopathologist must be well versed in clinical dermatology as well as aspects of anatomic pathology as they relate to the skin. Although dermatopathologists may be trained first as anatomic pathologists or dermatologists, the truly competent dermatopathologist must be intimately knowledgeable about dermatology and pathology. Although it is important that those trained in dermatology understand the principles of anatomic pathology, it is even more important for a pathology-trained dermatopathologist to understand dermatology because the clinical manifestations of skin diseases represent the gross pathology of the skin biopsy specimen that is received in the laboratory. Dermatopathologists are also often called on to render suggestions about therapy, so that the dermatopathologist must understand the dermatologic pharmacopeia and know when certain drugs would likely be effective. They must also understand principles of dermatologic surgery and the types of surgical procedures that are likely to be performed when a diagnosis of a neoplastic process is rendered. The future of dermatopathology is somewhat uncertain, largely as a byproduct of the advent of managed care systems in the delivery of health care (see later). In the setting of managed care, in many cases, the practice of dermatopathology is deemed a laboratory service and given no more consideration than other automated tests, such as urinalyses and automated blood tests performed by machine.I7As a consequence, skin biopsy specimens are often interpreted by individuals with or without expertise in dermatopathology who happen to be affiliated with a corporate laboratory. Such individuals may or may not have had special training in dermatopathology and likely lack any clinical dermatology experience. In effect, the histologic interpretation becomes trivialized to the level of a clinical laboratory test, which may lead to disastrous results, especially when the diagnosis of a cutaneous malignancy is missed.17 This situation was documented in a video news item aired on the American Broadcasting Corporation television show "20 / ~ C I . ' ' ~ Despite the increasing recognition by the lay public of the importance of having skin biopsy specimens interpreted by experts in der-

DELIVERY OF DERMATOPATHOLOGIC HEALTH CARE IN THE TWENTY-FIRST CENTURY

matopathology, the practice of capitation and restriction of access to these experts continues in many managed care settings. If this trend were to continue unchecked, dermatopathology as a specialty could erode significantly, possibly to the point of virtual disappearance.17 As problems associated with managed care continue to mount, physicians have begun to take action in efforts to combat them. These have taken a number of different venues. Some physicians have formed groups to compete with managed care organizations (MCOs) for patient populations. Others have associated to be able to negotiate more effectively. Medical associations, such as the College of American Pathologists, the American Medical Association, and the American Academy of Dermatology, have worked with legislators to form resolutions and legislation that would place the importance of patient care above cost-cutting measures. In some states, bills allowing direct access to dermatologists have been passed, and in others, such as Texas, physicians have been given the right to bargain collectively. The American Medical Association's House of Delegates voted to approve the formation of a union of physicians.l0 In pathology and dermatopathology, there has been a trend for consolidation with a number of practices joining or being acquired by physician management companies, some of which are publicly traded companies. As with other changes in medicine, this is largely a response to the negative effects of managed care on the practice of pathology and dermatopathology. Whether such companies will be successful and long-lasting and the effects that they will have on dermatopathology and dermatology are not yet k n 0 ~ n . l ~ There are significant changes that are ongoing in health care in general as well as in dermatology and dermatopathology. To ap-

preciate fully the importance of the role of dermatopathology in the health care delivery system, especially as it relates to dermatology, it is essential to understand the demographic factors that affect dermatologic health care delivery. These are discussed next with special emphasis as to how they relate to dermatopathology.

DERMATOLOGICAND DERMATOPATHOLOGIC HEALTH CARE NEEDS IN THE UNITED STATES In the United States, 31% of the population has significant skin disease requiring medical attention.12Approximately 7% of all ambulatory visits are relatedz4to skin disorders, and there are approximately 12,000 dermatologists for a population of 250 m i l l i ~ n Of .~ these, 767 are dermatopathologists with an additional 653 dermatopathologists trained as primarily pathologists. There are a total of 1420 practicing dermatopathologists. Of all dermatologists in the United States, 80% are based in private practice with others in large multispecialty group practices or in managed care settings (Table l).I There has been a significant decrease in the number of individuals who receive board certification in dermatopathology since the first board examination in dermatopathology was administered in 1974. This trend (Table 2) is primarily due to two reasons. Before 1983, any dermatologist was eligible to sit for this examination without having received formal fellowship training in dermatopathology. The number of fellowship positions in dermatopathology has declined, however, especially over the last 10 years, primarily as a consequence of managed care and cutbacks in funding available for fellowship positions. There has also been a shift in the demograph-

Table 1. DEMOGRAPHICSOF DERMATOPATHOLOGY IN THE UNITED STATES AND CANADA Background

United States

Canada

Elsewhere

Retired

Total

Dermatology Pathology

767 653

7 9

16 4

26 36

816

Data from American Board of Dermatology, August 1, 1998.

243

702

244

CONRAD et a1

Table 2. NUMBER OF DERMATOPATHOLOGY CERTIFICATIONS Year

Dermatology Background

Pathology Background

1974 1995 1971-1995

108 38 823

44 49

665

Total 152 87 1488

From Weinstock MA, Boyle MM: Statistics of interest to the dermatologist. In Yearbook of Dermatology. St Louis, Mosby, 1997, pp 10-17; with permission.

ics of dermatopathology trainees because there are now more individuals trained first as pathologists than trained as dermatologists. Few data are yet available as to what the practice patterns of these individuals are in comparison to individuals trained initially as dermatologists, although it is expected that many of these will join large multispecialty pathology laboratories serving as the consultant dermatopathologist for these groups. Concerns have been raised that this shift in demographics may lead to the depletion of the ranks of academic dermatopathologists and directors of independent dermatopathology laboratories.

DELIVERY OF DERMATOLOGIC CARE IN THE MANAGED CARE ENVIRONMENT

In the United States, the health care system has been undergoing significant reorganization over the last 10 to 15 years. Strenuous efforts to decrease health care costs have been made primarily by increasing the use of primary care physicians and decreasing referrals to specialists, including dermatologists and dermatopathologists. Based on these efforts, the concept of managed care has emerged. Although there are a number of different models, the most common one assigns each patient a primary care physician who serves as a gatekeeper to monitor all the medical problems of the patient as well as the cost of the patient's health care. This physician is supposed to develop a close relationship with the patient.19 Referrals to specialists or requests for laboratory tests or procedures require the approval of the gatekeeper or the

MCO itself. Physicians' practices are monitored by MCOs, and the number of tests and referrals are periodically evaluated. Gatekeepers are encouraged to avoid referral of patients to specialists and often receive financial penalties for high numbers of referrals? Managed care has grown explosively over the last decade and today occupies a significant role in health care, including the practice of dermatology and dermatopathology. Managed care is already the dominant mechanism of payment for the treatment of skin diseases in many areas of the United States, and it has been predicted that by 2000, most patients seen by dermatologists will be seen under the auspices of managed care systems.28 Traditional fee-for-service medicine, in which payment is made for services rendered, is rarely encountered with the exception of cosmetic surgery. More detailed and restrictive guidelines for the diagnosis and management of patients are being constantly developed, with physicians experiencing diminished autonomy and being required to answer to nonmedical supervisors. The managed care system in the United States emphasizes preventive services, such as immunization, breast and cervical cancer screening, smoking cessation, counseling, and prenatal care." Although these services would seem to benefit patients and reduce costs, there have been accompanying decreases in payments for medical services, decreased specialty access, and increased pap e r ~ o r k . *The ~ modus operundi of MCOs in decreasing costs has been to lower fees paid to physicians and hospitals, capitation of laboratory services, discouragement of laboratory use, and cuts in payments for prescription medications. Gag clauses that prevent physicians from openly criticizing MCOs are often incorporated into contracts that physicians must sign if they choose to be a provider for the MC0F6 These practices have come under increasing fire from patients, physicians, and the media because they may result in compromise of care as patients are denied the opinions of specialists, emergent care is delayed while prior approval by the MCO is sought, or patients are discharged from hospitals ~rematurely.~ Additionally the gatekeeper model does not consider nonmed-

DELIVERY OF DERMATOPATHOLOGIC HEALTH CARE IN THE TWENTY-FIRST CENTURY

ical costs to patients, such as travel expenses, lost work time, inconvenience, and additional suffering.2O Generalists are faced with the task of diagnosing and managing multiple conditions, many of which they are not trained for.20Most Americans believe that quality of care is compromised by MCOs that are attempting to save money at the expense of patients.32 As with other specialties, these problems have affected the practices of dermatology and dermatopathology. In managed care settings, dermatologists are classified as specialists and are deemed to provide more expensive patient care. Although 7% of all ambulatory visits are related to skin conditions, only about one third of these patients are seen by a dermatologist initially.12 Feldman et a19 demonstrate that although managed care grew by 32% between 1990 and 1992 and the number of skin-related visits to all physicians increased from 56.5 million to 63.5 million, the proportionate share of this care delivered by dermatologists decreased from 40% to 38%. Although the total number of dermatologist visits increased from 1989 to 1992, the number of dermatologist visits within managed care actually shrunk during the same time period. A second study confirms these results, showing that the age-adjusted rates of visits for adults with managed care insurance to dermatologists are less than one third the rate for other adults without prepaid care.29 Despite these trends, repeated studies have demonstrated that dermatologists are far more qualified to care for patients with skin conditions than primary care physicians. A study by Ramsay and FoxZ4evaluated the ability of primary care physicians to diagnose the 20 most common skin conditions in comparison to dermatologists. Primary care physicians correctly diagnosed these disorders 54% of the time versus dermatologists who rendered correct diagnoses in 96% of cases. Another study evaluating the ability of dermatologists and nondermatologists to diagnose correctly cutaneous neoplasms found that dermatologists rendered the correct diagnosis 83% of the time versus 45% for nondermatologists.4 More than 25% of the primary care physicians tested could not identify a classic nodular-ulcerative basal cell carci-

245

noma, the most common malignant neoplasm of humans. A comparable study by Clark and Rietsche15 found similar differences in diagnostic capabilities between family physicians and dermatologists. They also found that only 72% of the patients evaluated by family practitioners for skin conditions were being treated for the correct disease, likely a reflection of the high rate of misdiagnosis. Primary care physicians themselves often do not feel comfortable diagnosing and treating many dermatologic disorders with their limited experience. In one survey of family physicians, greater than 50% admitted to lacking confidence in their ability to recognize melanoma, an error that might potentially lead to a fatal outcome as well as medicolegal liability.5 The reasons that primary care physicians do not develop expertise in dermatology are legion and begin in medical school. In a study by Ramsay and Wearytz5it was found that during 4 years of medical school, medical students on average were exposed to only 21 hours of dermatology. Most of this exposure occurred during the first 2 years before clinical training. Only one third of students had the opportunity to rotate through dermatology on clinical electives. In addition, further evidence reveals that primary care physicians undergo only limited postgraduate training in dermatology compared with other specialties of medi~ine.'~ The value of continuing medical education in dermatology for primary care physicians is questionable, however, because one study demonstrated that it did not significantly improve their diagnostic skills in dermat~logy.~~ Probably the most important reason that primary care physicians do not develop significant competence in dermatology relates to lack of experience in practice. Although approximately 67% of all skin diseases are seen by nondermatologists at least initially, the total number of cases managed by a typical primary care physician averages approximately 100 per year.s, 9, 25 This number is in contrast to the practicing dermatologist, who may see 75 patients with skin disease each day. Because the primary care physician does not focus primarily on dermatology and must deal with disorders of other systems, expertise in dermatology is never gained.

246

CONRAD et a1

These results are cause for significant concern because patients typically do not have direct access to dermatologists in managed care settings. Feldman et ale studied the limitations of the gatekeeper model as it relates to dermatology and demonstrated conclusively that it erodes the quality of care of skin diseases and paradoxically makes inefficient use of medical resources. They noted that of all ambulatory office visits, those related to dermatology have the highest referral rate of 5.8%. Internists refer to dermatologists more often than pediatricians or family practitioners8 These referrals are usually for common skin conditions rather than unusual diagnoses or difficult management problems. This situation illustrates that simple skin problems are more complex than is generally appreciated by MCOs and that they are not consistently able to be managed well by primary care physicians. Initial visits to primary care physicians for skin diseases are not cost-effective for a number of reasons. In many cases, this initial visit does not provide enough information for the primary care physician to make an accurate diagnosis and to institute appropriate therapy so that multiple visits are necessary. When it becomes apparent that dermatology referral is necessary, there have already been significant costs incurred. Some of these include costs of medicines that are often ineffective; costs of procedures that are often not necessary; morbidity caused by delay in diagnosis and rendering of the incorrect therapy; adverse effects of medicines, which may make subsequent diagnosis difficult; and an additional new visit or consultation fee generated by the consultant. Other indirect costs include wasted time spent by patients, physicians, and ancillary personnel in physician offices and in MCOs as well as medicolegal costs if malpractice lawsuits are filed because of delay in diagnoses and treatment. Paradoxically, although referrals to dermatologists are restricted primarily to cut costs, such restriction actually increases costs to MCOs as well as to the health care system in general. Although dermatologists are displeased with the gatekeeper model for many of the aforementioned reasons, patients have also demonstrated their dissatisfaction with the

gatekeeper model through surveys.*O One of these demonstrated that of patients referred to dermatologists, only 24% were very satisfied with treatment by their previous physician, whereas 89% were very satisfied with the care administered by the dermatologist. Only 6% of patients surveyed believe that a generalist could adequately treat their skin disease. Of respondents, 87% considered direct access to dermatologists to be very important and felt confident that they could seek dermatology referral themselves for most skin disorders.20 Some of the reasons patients preferred direct access to dermatologists included dissatisfaction with shotgun therapy administered by primary care physicians, exacerbation of disease resulting from treatments prescribed by primary care physicians, the time spent in the extra visit to the primary care physician, and a general lack of confidence in the primary care physician’s medical decisions. Based on diagnostic acumen, management skills, patient satisfaction, and cost-effectiveness, dermatologists are the best choice to manage skin conditions and should be considered primary care physicians of the skin. Dermatologists are also willing to assume greater responsibility for dealing with more patients because 78% favor retaining direct patient access with cooperative work with primary care providers.33Presently, however, dermatologists are not recognized as primary care physicians in any sense. There are some indicators that this situation may be changing because some health maintenance organizations (HMOs) have developed dermatology divisions in which patients can directly seek dermatologic care. Open-access independent physician associations also permit direct access to dermatologi~ts.~~ Managed care plans that do offer direct access to specialists have shown the highest satisfaction ratings among their participants.21 The impact of managed care on dermatopathology is potentially even greater than that on dermatology. As noted earlier, dermatopathology is affected when MCOs, especially HMOs, establish capitation contracts for all pathology services with a corporate laboratory. This capitation restricts the access of dermatologists and other physicians who perform skin biopsies to dermatopathologists. In

DELIVERY OF DERMATOPATHOLOGIC HEALTH CARE IN THE TWENTY-FIRST CENTURY

addition to the fact that such corporate laboratories often do not offer dermatopathology expertise and often render incorrect diagnoses, the service provided by such laboratories is often substandard to that provided by independent dermatopathology laboratories. A study by Penneys22demonstrated that the diversion of skin biopsy specimens to corporate laboratories increased the turnaround time from 1.3 days when interpreted by a private laboratory to between 6.1 and 7.8 days. The number of outside dermatopathology consultations sought by corporate laboratories is greater than that generated by private dermatopathology laboratories, further increasing cost and delaying final diagnosis. Such delays are significant, especially when dealing with potentially life-threatening malignancies or severe inflammatory disorders. Because of such data as well as the experience of dermatologists in dealing with corporate managed care laboratories, many dermatologists write pointed letters to MCOs as well as state insurance boards and congresspersons in efforts to reduce this practice. Some MCOs have allowed dermatologists to send biopsy specimens to independent dermatopathologists. Paradoxically, however, they have not opened the access to dermatopathologists for nondermatologists who perform skin biopsies. Although a dermatologist with greater diagnostic skill than a primary care physician might be able to detect where a problem might lie.with a histologic diagnosis of a skin disorder and be able to request a second opinion or evaluate sections himself or herself, the primary care physician is much less likely to do so, and an erroneous diagnosis is more likely to go undetected. MCOs should especially mandate that all skin biopsies performed by PCPs be evaluated by a dermatopathologist, a standard that dermatologists maintain routinely.

TELEMEDICINE IN DERMATOLOGY AND DERMATOPATHOLOGY As managed care companies attempt to find ways to decrease the cost and increase access methods, advancing technology has been incorporated into the medical setting.

247

One of these techniques is telemedicine. This concept involves the transmittal of visual and other information across telephone lines or via satellite between a referral center and another site, usually one in a remote location. Images can be transmitted in a store-andfirward fashion, or the exchange can be interactive, making use of video conferencing or interactive television. The former is usually the most efficient because of time constraints of having all parties available simultaneously for interactive sessions.16 The concept of telemedicine in dermatology has significant potential because it can strengthen the association between the primary care physician and the dermatologist as well as offer medical care in rural areas, nursing homes, and pris0ns.3~A prominent concern has been the accuracy of telemedicine diagnoses compared with in-office diagnosis. In one study, accurate diagnoses were generated 83% of the time via telemedicine versus 88% in the office.16,35 Some enhancements that have been noted to be necessary include the use of angled images to enhance the elevation and scale pattern of the lesion and a polarization to decrease glare and reflection.16 Five factors have been stated as being necessary for the success of telemedicine: distance, data, telecommunications, availability of an expert to interpret the findings, and ability to administer care as a result of the interpretati~n.~~ Telemedicine in dermatopathology has less potential than in dermatology because of the ease of transport of glass slides. Slides can be packaged and sent to virtually any site in the world within 24 to 48 hours using air freight. Dermatopathology images are able to be transmitted electronically, however, and the quality can be sufficient to allow a diagnosis to be made. One limiting factor in the use of the store-and-forward method is that the images are made by the one seeking the consultation rather than the consultant, which introduces another source of sampling error. If sections are not well prepared and well stained, there is an even greater potential for misinterpretation with the inevitable loss of resolution attendant with creation and transmission of digital images. Although telemedicine does offer the potential to supplement dermatology and dermatopathology, it does

248

CONRAD et a1

not have the potential to replace conventional

IMPROVING COST-EFFECTIVENESS OF DERMATOLOGIC HEALTH CARE DELIVERY

As discussed earlier, primary caregivers and generalists are often ill equipped to deal with skin conditions primarily and do not deliver care as cost-efficiently or as effectively as dermatologists. The most reasonable goal is for dermatologists to be given direct access to patients with skin disease. Even if dermatologists do become recognized as primary care physicians of the skin, however, and direct access to dermatologists becomes the norm in managed care plans, primary care physicians will still encounter a significant number of patients who present with complaints related to the skin. At the very least, there should be more time in the medical curriculum devoted to dermatology, and primary care physicians should be required to take a certain number of continuing medical education hours. The emphasis should be on diagnosis and treatment of the 20 most common skin disorders and knowledge of when to refer to a dermatologist. Education about how to perform skin biopsies, the importance of having expert dermatopathology interpretation, and how to interpret the results of skin biopsy should be incorporated into any educational curriculum. In addition to increasing the competence of primary care physicians in dermatology, another potential for improved efficiency and cost containment lies in the use of physician extenders, such as physician assistants and nurse-practitioners. Dermatology-specific physician assistants and nurse-practitioners receive more specific and more intensive training in dermatology and often have a greater knowledge of dermatology than primary care physicians. Most of these individuals are employed by dermatologists and function to care for routine cases and perform certain procedures, such as patch testing and phototherapy. This function allows the dermatologist to devote more time to dealing with challenging cases or to performing sur-

gical procedures. They are not a replacement for the physician and cannot practice without supervision. Nevertheless, physician assistants and nurse-practitioners are becoming more common in dermatology practices, and as these practices become busier with greater access to dermatologists by patients, they will assume a more important role.

CONCLUSION

Although current trends in health care are undermining the essence of dermatology and dermatopathology, with proper modifications and reorientation of managed care toward patient-centered medicine, the quality of health care delivery as it relates to dermatology can be enhanced. Responsibilities of dermatologists, dermatopathologists, primary care physicians, and physician extenders can all be integrated in a synergistic fashion, such that the ethical principles of medicine are followed. Until such changes are implemented, however, patients and providers as well as MCOs all remain at risk. It is recommended that patients be given direct access to dermatologists and that dermatologists and primary care physicians who perform skin biopsies be given free and necessary access to dermatopathologists as the standard of care.

References 1. American Board of Dermatology, Direct Communica-

tion, 1998 2. American Broadcast Corporation: Melanoma: The Deadly Surprise. 20/20 Sunday, April 18, 1999 3. Anders G: Health Against Wealth. Seattle, Mariner Books, 1996 4. Brodkin RH, Rickert R, Machler BC: The dermatologist and managed care. Cutis 58:352, 1996 5. Clark RAF, Rietschel RL: The cost of initiating appropriate therapy for skin diseases: A comparison of dermatologists and family practicioners [sig]. J Am Acad Dermatol 9:787-796, 1983 6. Crissy JT, Parish LC: Two hundred years of dermatology. J Am Acad Dermatol 39:1002-1006, 1998 7. Cunliffe WJ: Dermatology in England. Arch Dermato1 130:1305-1307, 1994 8. Feldman SR, Fleischer AB, Chen JG: The gatekeeper model is inefficient for the delivery of dermatologic services. J Am Acad Dermatol 40:42&432, 1999 9. Feldman SR, Williford PM, Fleischer AB Jr: Lower utilization of dermatologists in managed care: Despite growth in managed care, visits to dermatolo-

DELIVERY OF DERMATOPATHOLOGIC HEALTH CARE IN THE TWENTY-FIRST CENTURY gists did not decrease: An analysis of National Ambulatory Medical Care Survey data, 1990-1992. J Investig Dermatol 107860-864, 1996 10. Gianelli D M Delegates: AMA must do more to foster collectivebargaining. American Medical News 423031,,1999 11. Gonen JS: Women’s primary care in managed care: Clinical and provider issues. Womens Health Issues 9(suppl):5S14S, 1999 12. Health Maintenance Organization Review Committee: An analysis of the potential impact of health maintenance organizations upon the practice of dermatology. J Am Acad Dermatol2346-353, 1980 13. Jacoby RA: The marketplace for pathology services or how it looks from here. Dermatopathology Practical and Conceptual 5:75-79, 1999 14. King D F J.M.H. MacLeod and British dermatopathology. Am J Dermatopathol 7433-435, 1985 15. Kirsner RS, Federman DG: Lack of correlation between internists’ ability in dermatology and their patterns of treating patients with skin disease. Arch Dermatol 1321043-1046, 1996 16. Kvedar JC, Edwards RA, Menn ER, et al: The substitution of digital images for dermatologic physical examination. Arch Dermatol 133:161-167, 1997 17. LeBoit PE, Cockerell CJ: The effort to decapitate American dermatopathology through laboratory capitation: An urgent and dire warning to dermatologists and dermatopathologists. J Am Acad Dermatol 31:9%100, 1994 18. Lever WF: From ”descriptive” to “dynamic” dermatopathology. J Cutan Pathol 11:467-470, 1984 19. Nestor M S Dermatology independent practice associations. Arch Dermatol 132:1099-1101, 1996 20. Owen SA, Maeyend E Jr, Weary PE: Patients’ opinions regarding direct access to dermatologic specialty care. J Am Acad Dermatol36:250-256, 1997 21. Page L: HMO growth tied to customer service. Am Med News 9, Nov 20 1995 22. Penneys NS: Log-in/log out time: A quality factor

249

for a reference laboratory-prolonged times for skin pathology processing in managed care-authorized laboratories. J Am Acad Dermatol36995998, 1997 23. Perednia DA: Fear, loathing, dermatology, and telemedicine. Arch Dermatol 133:151-155, 1997 24. Ramsay DL, Fox AB: The ability of primary care physicians to recognize the common dermatoses. Arch Dermatol 117620-622, 1981 25. Ramsay DL, Weary P: Primary care in dermatology: Whose role should it be? J Am Acad Dermatol 35:1005-1008, 1996 26. Russell PS, Kaplan LJ: The American Academy of Dermatology’s response to managed care and capitation. Arch Dermatol 132:11251127, 1996 27. Stephenson A, From L, Cohen A, et al: Family physicians’ knowledge of malignant melanoma. J Am Acad Dermatol37953-957, 1997 28. Stem RS: Managed care and the treatment of skin disease, 1995: Continued growth and emerging dominance. Arch Dermatol 1341089-1091, 1998 29. Stem Rs: Managed care and the treatment of skin diseases: Dermatologists do it less often. Arch Dermatol 132:1039-1042, 1996 30. Van Onselen J: Dermatology care: The next role for primary care nurses. Commun Nurse 4:28-30, 1998 31. Wagner RF, Wagner D, Tomich JM, et al: Residents’ comer: Diagnoses of skin disease: Dermatologists vs. nondermatologists. J Dermatol Surg Oncol 11:476479, 1985 32. Weary PE: Quality safeguards for managed care. Arch Dermatol 133:139%1401, 1997 33. Weinberg, DJ, Engasser PG: Dermatologists in Kaiser Permanente-northern California: Satisfaction, perceived constraints, and policy options. Arch Dermato1 1321057-1056, 1996 34. Weinstock MA, Boyle M M Statistics of interest to the dermatologist. In Yearbook of Dermatology. St Louis, Mosby, 1997, pp 10-17 35. Zelickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 133:171-174, 1997

Address reprint requests to Clay J. Cockerell, MD 2330 Butler Street, Suite 115 Dallas, TX 75235 e-mail: ccockerellQskincancer.com