Cold Iron Truth

Melanoma in situ: It’s hard to know what you don’t know


Now a knowledgeable friend of mine thinks this study is biased because 17% more patients with prior melanomas were seen by a dermatologist rather than by a PA. While it’s true that patients with prior melanomas are more likely to develop new melanomas, the counterargument is that the bar for a biopsy in a patient with a prior melanoma is much lower. Patients with a history of melanoma should have more skin biopsies, but the dermatologists in this study still took many fewer biopsies to diagnose melanomas in situ.

Why do these findings matter for patients and for the health care system?

PAs billed independently for 12% of skin biopsies (including lip, ear, ear canal, vulva, penis, and eyelid) in Medicare Fee for Service in 2016. Skin biopsies paid for by Medicare have been increasing at a very rapid rate, about twice as fast as the rate reflected in the current skin cancer epidemic.

Every skin biopsy results in a pathology charge, for which Medicare pays about $70. A level 3 new patient visit pays $110. If PAs bill independently, they are paid at 85% of the fee schedule, which often is touted as a great savings. Therefore, if only 24.2% of skin biopsies by PAs were unnecessary, even at a reduced 85% reimbursement, it costs Medicare more than having these visits and biopsies provided by a dermatologist. The cost savings decrease even more with additional skin biopsies, because they pay so little ($33 for a doctor, $28 for a PA), yet the pathology charge is unchanged.


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