MANAGED CARE, CANCER AND MOHS MICROGRAPHIC SURGERY
The advent of managed care has led to increasingly restricted referrals to specialists and subspecialists such as dermatologists and dermatologic surgeons. This is usually done via a gatekeeper mechanism where a primary care physician such as a family practitioner restricts access to specialist care based upon his or her judgment as to the need for this specialty or subspecialty care. Many of these gatekeeper arrangements are structured so that there is a financial disincentive for primary care physicians to refer patients. An extreme variant provides financial incentives for such physicians not to refer patients out of their practices. This clearly is a recipe for misdiagnosis and mismanagement and will lead to potential disasters particularly in the treatment of nonmelanoma skin cancers of the central face. There have been cases of central facial tumors which directly resulted from delayed access to dermatologists and dermatologic surgeons and previous inadequate treatment by relatively inexperienced physicians.
Training in dermatology varies greatly in primary care residency programs. In general it is relatively inadequate when compared to the three to five years of training in dermatology and dermatologic surgery by physicians expert in the care of cutaneous carcinoma. An increased in the incidence of misdiagnosed and mistreated nonmelanoma skin cancer of the central face is anticipated as primary caretakers embark upon treatment of such lesions in their offices with much less experience than the average dermatologist.
Recurrence of Disease:
Recurrence rates for basal and squamous cell carcinoma vary depending on a number of important histologic and clinical parameters but, clearly, they are significantly higher for lesions of the central face, i.e., periorbital, periocular, periauricular and perinasal locations. These are also the areas which lend themselves to more complex reconstructive efforts after clearance of such tumors often requiring flaps and grafts. Inadequately excised basal and squamous cell carcinoma, particularly if repaired with flaps or grafts, leads to delayed recurrences, often not detected for three to ten years after the original surgery. This delay allows subclinical extension of tumor, sometimes with disastrous consequences when they involve the central face. They can invade the perineural space and even become life-threatening in these high-risk locations due to direct extension to the central nervous system.
Mohs Micrographic Surgery:
Mohs micrographic surgery, when performed correctly by well-trained and experienced physicians expert in this technique yields up to 99% cure rates. Clearly this modality allows superior clearance of tumor while at the same time minimizes the morbidity of the procedure by ensuring the smallest defect possible. This is well documented with extensive literature to support such claims. A recent article points out that if Mohs surgery is done in an ideal setting with nearly error-free technique, cure rates, even for high-risk tumors, should approach 99.7%. Mohs micrographic surgery is particularly useful for recurrent neoplams of the central face since it provides better clearance rates while minimizing the size of the defect and minimizing the extent of the reconstructive effort needed to repair such defects. This combination of advantages makes this technique cost-effective for central facial tumors.
Issues in Managed Care:
Another confounding factor in the setting of managed care is the delivery of dermatopathology services by general pathologists less experienced in skin pathology than a board certified dermatopathologist. Managed care often discounts pathologists' fees to the extent that careful sectioning of elliptical excisions becomes costly for them. Even a moderately-sized ellipse requires more than one block of tissue to provide adequate sections which still only allows review of less than 1% of surgical margins. Given the poor reimbursement for surgical pathology with managed care and large capitated contracts there is little incentive to systematically and exhaustively examine surgical margins of skin ellipses for basal cell carcinoma and squamous cell carcinoma. This will likely lead to higher recurrence rates in the treatment of nonmelanoma skin cancer of the central face due to under-reporting of inadequately excised diseased.
These factors suggest that there will be a rising need and demand for Mohs micrographic surgery as performed by expert and well-trained physicians. Unfortunately this exacting and time-consuming technique when done properly is also labor intensive and expensive. Managed care minimizes reimbursement for all surgical procedures and little attention is given to quality of care when contrasted with the cost of such care. Mohs surgery is cost-effective for recurrent disease of the central face due to its high cure rates and tissue-sparing nature. It may, in fact, be cost-effective for many primary skin cancers of the central face when compared to the high cost and morbidity of advanced recurrent disease.
Mohs micrographic surgery is cost-effective because it prevents recurrences, minimizes the size of any needed reconstruction and is, for the most part, performed in an outpatient setting. There is growing concern amoung dermatologists about the relative lack of emphasis on quality of care in the managed care setting. General dermatologists are likely to see increased numbers of previously treated cutaneous carcinomata referred at a later stage by general practitioners and be expected to manage these patients within the confines of their ofter restrictive contracts with various insurance companies particularly in a capitated care setting. Mohs micrographic surgery should be eliminated from any capitated contract. This avoids the treating dermatologist from being placed in the same quandary the gatekeepers are in where financial disincentives exist to refer such patients for Mohs micrographic surgery. Such disincentives interrupt referral patterns and will ultimately adversely effect the quality of care and negatively impact the patient's outcome. With managed care restrictions legal professionals can anticipate an increasing number of dermatologic issues that will need to be investigated.