Advocacy Opportunities in Dermatology

In this podcast episode, Larry Green, MD, and Bruce Brod, MD, MHCI, FAAD, share how dermatologists can get involved in advocacy efforts for the specialty.

Dr Green is a clinical professor of dermatology at George Washington University School of Medicine in Washington, DC. Dr Brod is a clinical professor of dermatology at the University of Pennsylvania in Philadelphia.

Transcript
Dr Larry Green: Hi, everyone. This is Larry Green. Welcome to our podcast for the dermatologist. I'm on the editorial board of The Dermatologist.

I am so happy here, today, to have with us Dr Bruce Brod who is clinical professor of dermatology at the University of Pennsylvania. He is also chair of the American Academy of Dermatology Association's Government Affairs, Health Policy, and Practice Committee.

Bruce has a long history in advocacy with the American Academy of Dermatology Association. With dermatology itself, he's a champion for dermatologists. We're very lucky to have him on this podcast talking about advocacy. Welcome, Bruce.

Dr Bruce Brod: Larry, thanks. Thanks for that introduction. It's great to be here with you today. Larry and I have worked together on a number of relevant AAD committees on advocacy, I think at the state and federal level. I'm happy to be here today talking about advocacy. Why it matters to the dermatologist, the issues that are important to us at the state and federal level.

What each and every one of us can do to advocate in some way for our specialty to ensure that we can practice, that we can provide the best care for our patients. That's what it's all about. That's why we do this.

We want to make sure we have the ability to practice in a setting that gives patients as many choices as possible in a safe environment, in a reasonable environment that's efficient, that provides the best value for patients. We're the experts. We know, we're the dermatologists, we know what's best for our patients, and it's important for policymakers to hear our voice.

Dr Green: Yes. Thanks, Bruce. You mentioned federal and state levels. I want to ask you the difference for that in a second, but I want to go back to something you said, I think it's very important is that we are the best voice for our patients. People may be asking, why is being an advocate important? What does it do for me as a dermatologist and for my patients? Because these are legislators...What do we have to do with changing their minds and why is that important to us in our business and us for our patients?

Dr Brod: Well, because they're hearing from a number of stakeholders. Legislators tend to focus a lot on the cost of care, but they don't understand what we do as dermatologists, they don't understand the importance of what we do as dermatologists. It's important for them to understand how the decisions they make could impact patients, could impact even jobs in their district, which is important to them and could impact them and their families. They're not physicians. One of our biggest roles as advocates is to serve as educators. We need to educate them and we need to have a seat at the table.

Dr Green: That's very well said, when you say seat at the table, because if we don't have a seat at the table for our business lives and our patients, someone else will take it for us. That's an important reason to be advocates, because if you're not there, someone will easily take your place.

Dr Brod: That's right. We're there advocating for our patients. We're advocating for our ability to provide care to our patients, but we're there advocating for our patients. They're all patients. A lot of them don't even understand initially, what a dermatologist does. One of the first things I do when I talk to a legislator is I try to open up a conversation with them, so that they understand what a dermatologist does. That we take care of serious skin diseases, both medical and surgical, and what we do is critically important for patients, because many of them don't understand the level of care that we deliver. That's first and foremost, one of the important things we do when we forge relationships with legislators.

Dr Green: We don't want other people to be telling legislators what we do. It's best that we do tell them and we tell them what we can do for our patients rather than someone else, because if we're not there, then someone else will tell them what we do and that isn't correct or accurate.

Dr Brod: That's right. One of the most valuable days I had is that, in my office, I had a little roundtable of legislators come into my office a few years ago and just showed them through the office, and educate them what we do as dermatologists. How we deliver care, how we do surgery, how we have pathology right there on the premises, and why it's important for us to be able to do that in an integrated fashion. How we provide efficient care for patients. Patients come to us for almost one-stop type shopping in dermatology. We do it all right then and there.

It's important for them to understand our flow and what works for us, because once they understand that, then they'll have a better understanding of why we're advocating for things that could potentially interrupt that flow or potentially harm patient safety.

Dr Green: Right and there's no other way to tell them except advocating on our own behalf. Thank you, Bruce. You were talking about state in which is local level. There's advocacy on a federal level and advocacy on a state level. Can you tell me some of the differences between them, what we advocate on each level for, and things like that?

Dr Brod: There is some overlap between state and federal advocacy. Where the rubber meets the road is oftentimes at the state level. However, the two can work in tandem. I'll give you an example. For instance, the way I got involved in advocacy initially was I was very passionate many years ago about indoor tanning. I was appalled by the fact that there were no laws to limit minors from going into tanning salons. That was my entryway into advocacy in my state of Pennsylvania. Since that time, there've been a number of state laws that had been passed, most of this has been spearheaded by dermatologists at the state level, that have banned tanning for minors under the age of 18.

However, there are opportunities at the federal level as well. The academy, other stakeholders have worked with the FDA in the past to help to regulate the devices. That's at a federal level. There's also opportunities there at the federal level to issue a ban on minors using these devices because FDA regulates devices.

There's a lot of overlapping territory there. The two work very synergistically with one another. Another area at the state level where most of the action occurs is on scope of practice, expansion, and therein there's a concern there with patient safety. We've seen a tremendous expansion of scope of practice attempt at the state level. Half the states in the country now have nurse practitioners practicing independently. Most of those battles are fought at the state level. However, there are also federal expansion moves as well, not as robust, but that also potentially send a clear message.

We see, even in some of the administrative regs that come down from Medicare, attempts there to reduce supervision or reduce on-site supervision when physicians are supervising nurse practitioners, PAs, and things like that. We sure do have to keep our eye on the ball in both courts.

Dr Green: Well said. You mentioned, Bruce, some of the issues facing us that are mostly state issues. You mentioned indoor tanning ban and scope of practice. I can add truth in advertising. Even sunscreen access is mainly a state issue that these dermatologists are facing. Do you think those are the main issues on the state level that we can influence legislators about?

Dr Brod: Those are some of the key issues. We could talk about any one of them probably for an hour. Drug pricing also is another issue and perhaps maybe one of the best examples where there's a lot of parallel work being done at both the federal and the state level as well.

Dr Green:  When it comes to the AADA and people saying that the AADA's not doing enough for us. They'll ask for the AADA's help on the state level, can you explain the difference with how our dermatology organizations, AADA and ASDSA, can help us on the state level versus the federal level?

Dr Brod: Access to drugs and the burdens that physicians have to go through for their patients to access needed medications might be the best example to compare and contrast what goes on at the state level and what goes on at the federal level.

Dermatology is uniquely impacted, perhaps more than any other specialty. Dermatologists, we're living in an age now where we have amazing ability to treat debilitating diseases. The listeners know that. Psoriasis is a good example. We see a whole pipeline of drugs coming down the pike with atopic dermatitis as well. However, insurance companies, payers, and perhaps this is where legislators don't understand, they view us as low-hanging fruit. With dermatology perhaps more than any other specialty, they put tools in to try to limit our access to drugs, things like prior auth and step therapy.

The Academy is working really hard at both the state level and the federal level to help at least develop some work around to that process, reduce the burden. Step therapy or fail first therapy is a good example. The AADA, our state policy staff, has worked very, very closely with a number of state medical societies and dermatologists on the ground as well as coalitions where we have strong leadership roles in their coalitions to pass laws at the state level to streamline step therapy. There's an exception process so that the insurer has to address it so that patients who are stable on their drug who aren't candidates for the drug don't have to go through these onerous step therapy process.

Also, at the federal level, we're part of coalitions there as well, pushing very hard along with other medical organizations for a step therapy bill at the federal level. You may ask, "Why do we need both?" Well, the reason is because some insurance payers are regulated at the state level, like private insurers. Some insurers, like plans under ERISA and large group plans, they're regulated at the federal level and so is Medicare. Medicaid is kind of a federal/state combination.

To me, that's a really good example of where we need to put our fingers in all of our holes in the dyke. One feeds on the other. One sets precedent. If we have good and strong policies about drug access and that's important, we promote that through legislation at the state level, that helps influence federal policy and vice versa.

Dr Green: Very true. It really shows how you can't one without the other. The AADA and the ASDSA needs to be involved in both. It's an avenue. If any of the listeners have an issue that's particularly facing them, whether it be scope of practice or drug access and affordability, you're suggesting it'd be great to contact the AADA or ASDSA, whichever organization they're more closely involved with and ask them, what's the best way to approach your issue? Is it working with the state? Is it working on the federal level because they can help direct us.

Dr Brod: They do. The staffs are amazing at both of these organizations and in other sister societies as well. The majority of dermatologists belong to the AAD though. It's important for the listeners to realize, works in close conjunction with some of our important sister societies, like the Mohs society, like the ASDS.

A good example of that is on compounding. That's an area that was really due to unintended consequences, due to an unfortunate incident that occurred in 2012, we're still dealing with the fallout now where there are cases of fungal meningitis because of interstate transport of a corticosteroid injected into the back.

That triggered a whole cascade. Federal legislation was passed in about 2015 or '16, I could be a little bit off there, called the Drug Safety and Quality Act, that trickled down to affect dermatology in many different ways, both at the state level and at the federal level.

The Academy's working closely now to try to overcome one of the barriers of something we do very commonly in our office, which is buffering lidocaine so that we can treat patients with Mohs and the excisions we do in a much more kind and gentle way using buffered lidocaine.

The Academy's been collaborating with the Mohs College with the ASDS on actually developing a monograph, an approved way. We have to do this through stability testing and sterility testing. We're working with those groups in collaboration to get the necessary data so that we can safely compound in our office.

Dr Green: You're saying, if the AADA and all our sister organizations weren't involved in something as simple as buffering lidocaine, that we do every day, we would no longer be able to do it. Going through all this regulatory work, which the AADA is doing with sister organizations to try and get around it, it's for us. It's not for necessarily other medical specialties. If we weren't doing this, we wouldn't be able to buffer lidocaine?

Dr Brod: Yes, that's true. We could buffer it. We basically have to get into a space suit to do it. Build laminar hoods in our offices and be equipped like a sterile pharmacy that might compound pharmaceutical products for a sterile injection. We all know that that's not necessary. The track record for what we do in our office is pretty nearly impeccable. Working with other groups, pooling our resources, there's a good chance we're going to be able to overcome this.

Dr Green: It's interesting, Bruce. What seems obvious us, something as simple as buffering lidocaine, we know how safe it is. The rest of the world doesn't know that. If we weren't here to advocate for ourselves, the regulatory agencies would say, "OK, buffering lidocaine has to be done in a hood and in space suit," like you said.

Dr Brod: Yes, because state pharmacy boards oversee drugs. There's a lot of murkiness between where the pharmacy boards can creep into our offices and the way we practice. By creating this monograph and doing the necessary testing, we're pretty optimistic that will justify to the pharmacy boards that at least we can do that.

We also work very, very hard at the federal level to change the guidance that the FDA issues for compounding drugs in our office as well. We were very successful in changing that.

After this Drug Quality Security Act was passed, because somebody got fungal meningitis from a steroid injected into their back, basically the FDA came out with guidelines, called insanitary guidelines. In those initial guidelines, the language that was written, and they were just guidelines, indicated that now we shouldn't be compounding things. We shouldn't be sterilely mixing things in our office. Because of our relationships with our legislative contacts, our congressmen, we were able to get up in front of a committee and make our case before that committee. That resulted in the FDA changing their guidelines, which basically say, "If you're a dermatologist and you're doing your normal compounding, the way you do, it's OK."

Dr Green: Interesting because it shows right there the value of belonging to and participating with national organizations to change our livelihood, to directly affect something we do every single day. It's as simple as that.

Dr Brod: No question about it.

Dr Green: Let me move to something that's more federal that also has affected us. I know the AADA and our sister organizations, like the ASDSA and Mohs, have been advocating for years, there's a constant battle, is the 10-day global periods.

That's something that's coming up again. I know we worked really hard a few years ago to get it staved off for a few more years now. It's coming up again for eliminating the 10-day globals. Basically, for our listeners who don't know, when we freeze something, like in an actinic keratosis, there's a 10-day global. Built in to that 10-day global period is an office visit in terms of our payment for our actinic keratosis.

When we freeze something simple as an actinic keratosis or a wart, we are receiving payment for an office visit as well within those next 10 days that shows that Medicare, CMS, and insurers are paying for a patient to come back within those 10 days for an office visit after we freeze an AK or a wart. We've been able to keep that and keep the payment steady for those, but this is something up for elimination again. This is another example of the national organization doing what it can to help ourselves. If we don't advocate for a ourselves, no one else will.

Can you give us an update on what's going on with the 10-day global elimination?

Dr Brod: Yeah. The Academy and organized medicine have done a really good job in at least delaying that. In 2015, the 10- and 90-day global codes came under threat to be eliminated. Basically, if that occurred and those office visit value was taken out of the codes, it would significantly cut the reimbursement for those codes. It's still under threat now. CMS has been trying to gather data and evidence for many, many years.

We got an unfavorable, perhaps, bad shake in the RAND report. The CMS Commissions ran studies that look at the way we handle codes, like 10-day global codes with the actinic keratosis. We didn't get a lot of support from other specialties. I would say it's a concern that that 10-day global code will go away.

The Academy, however, has responded extremely vigorously and is working really hard to come up with some other creative and appealing solutions to perhaps make sure that dermatologists are providing value care and to maybe chafe off some of the fat in the system but still preserve the value and the reimbursement for the work that we do. It's a really complex issue, but the Academy is definitely working very hard on that.

Another concern, which the Academy is taking a huge lead role on, is something really important for reimbursement for dermatologists. That's the use of the 25 modifier. That also has come under attack. Again, we've seen that both at the state level, and then there's concern always at the federal level.

The academy and other groups were able to turn that back a couple years ago with CMS and Medicare. We've seen a number of states and states' insurance companies, some of the Blue's plans impose reductions with the use of the 25 modifier. That totally goes against the grain of what dermatologists do. We're a one-stop shop operation. We don't want anything to disincentivize dermatologists from taking care of whatever they can when that patient comes through the door.

Dr Green: Going back to 10-day global, I want to summarize for the listeners that basically CMS says they have evidence that we don't see patients back within the 10 days after we freeze an actinic keratosis or a wart, so we don't deserve getting paid for that. That's what we're fighting against. We're fighting alternative payment ways to try and lessen that.

The 25 modifier, if we're doing a biopsy on the same day of service when someone comes in for two unrelated things, that's something we should be paid for because they're unrelated things. That's where insurers are not allowing that to happen for various reasons, basically to save themselves money, most likely. That's something, like you mentioned, the AADA's actively fighting against, to preserve the 25 modifier the way it's meant to be used.

Dr Brod: It's very true, Larry, and very well stated. The other important thing is that the AADA has friends. We have respect, and we have influence even in the larger house of medicine.

One of the largest insurance companies, nonprofit Blue's Anthem was about to impose a huge 25 modifier cut. This would have affected dermatologists in many, many, many states. In large part because of the AADA's influence at the AMA level and, in large, thanks to the AMA itself, those cuts were diverted.

We're seeing them pop up again in other states and even entertaining the possibility. This is again where Academy takes the lead of introducing specific state legislation that would try to perhaps inhibit use of the 25 modifier at the state level.

Dr Green: Let me summarize these for everybody on this. We talked about main issues facing us, elimination of the 10-day global periods and some of our codes, the 25 modifier, not letting us use that the way it's meant to be used.

We talked about compounding something simple, like buffering lidocaine, which we do in our everyday practice many, many times a day not being allowed; talked about the cost of medications that are rising and rising and making it completely unaffordable for our patients.

One thing I don't think we talked enough about, but I'll bring up again, is scope of practice. We have nurse practitioners who are practicing independently more and more and physician assistants who want to be more physician associates and move up and also practice independently. That's on a state-by-state level. That leads to truth of advertising so the public will learn the difference between a doctor and a nurse practitioner and a PA because the education is completely different. The public doesn't understand that, and the legislators don't understand that as well.

All those things directly reflect the way we practice, the way we can help our patients, and our income. Without the AADA and our sister organizations like you mentioned, we would be nowhere.

Dr Green: Absolutely. We don't win all the battles. This has become particularly urgent because of the pandemic. A lot of the supervision requirements were waived in a number of states or lessened in many states, both supervision and collaboration.

Now, the non-physician clinician groups are trying to really leverage that and push hard to continue, and march towards an independent practice. Or march towards going from supervision, which is, at least, more stringent, to collaboration, which is a looser association, which many of the nurse practitioners have in those states. The AAD has been front and center on this. They're a lead member of the AMA's very powerful, influential, and resourceful scope of practice partnership. We have a really strong voice there.

That's really important because it influences where some of the funding goes to states, like grant resources, where there are huge scope of practice battles being fought. Some of our leaders and members in the Academy are some of the hugest, most outspoken, eloquent, and articulate people when it comes to scope of practice, and fighting those battles in their states.

It's a matter of patient safety. We value the physician assistants and the nurse practitioners that work as part of our team, but we also realize it really comes down to training. We realize there's a huge difference in training and the type of training that we have. It needs to be a physician-led team. We rely on our non-physician clinicians, but it's important that the care is delivered in a safe team-type environment. That's where it's really important for us to educate the policymakers on that.

Dr Green: Thanks. It was very well said. Us, the dermatologists, as part of the physician-led team is so key. The policymakers...it may be obvious to us, just like buffered lidocaine, but it's not obvious to the rest of the world, and especially policymakers. That's the importance of us.

Dr Brod: We need to keep the message simple. There's so much confusion out there. The AAPA, the national physician assistance group just decided that at their house of delegates meeting to change their name from physician assistant to physician associate.

That's just going to add to the confusion out there. Patients don't always understand the distinction between physicians and non-physicians, as well. One of the great endeavors that the Academy is undertaking now is branding us as what we call "FAADs," that's Fellows of the American Academy of Dermatology. This is really important. I encourage most of the listeners here, and they're members of other great sister societies of the Academy, as well. But most of the members are probably members of the Academy. I urge everybody to really start using the FAAD, because that's what we're going to use as the signal and the flashing light for the public to understand that person, they have training. They're a physician. They did a residency. That's who you want to see as the leader of your derm care.

Dr Green: All this, Dr Brod, takes all of us, not just our national organizations, we're part of that. We can't just have people like you up there, we need everybody because you can only do so much. A small amount of people can only do so much. Let me ask you, what is the best way for our listeners to get involved? What can they do? We need all their help, because this is constant and it's everywhere.

Dr Brod: There are so many ways, but you're so right, Larry. Dermatologists, to me, are the greatest colleagues in the world, kind, compassionate, caring type of people.

I'll often be at a meeting when we used to go to live meetings, and people who know or recognize me will come up very politely and say, "Hey, Bruce. Thanks for doing all that advocacy stuff that you're doing." To me, that opens up a conversation. I say, "I appreciate the thanks, but it's not my thing. It's for all of us to get involved." There are so many different ways. A great way to start is at the state level, the county level. Get involved with your county medical society. Be the voice of dermatology there. That can lead to getting involved in your state medical society. Everybody should be involved and support their state dermatology societies out there. If you're not a member of the advocacy team, still join the society, pay your dues, go to their meetings, and things of that nature. That's how I got involved at the Academy level in leadership. I came up through the state level. Larry, you probably did the same.

Then there's the group where we're all busy. Not everybody's going to jump in and engage. Not everybody has the time. There's one way that every single dermatologist can get involved in advocacy. That's at least to open up their checkbooks or pull out their credit cards and donate to their PAC. SKINPAC, I would say, first and foremost, that's our dermatology PAC. I'm not going to say it's bipartisan. It's nonpartisan, equal opportunity. PACs donate money to campaigns. That gives us access. SKINPAC is nonpartisan. It's pretty much 50/50 Dems and Republicans. Some years, it's a little more Dem. Some years, a little more Republican. I encourage everybody to give to their PAC.

Give to your state PACs as well, your state medical society PACs. They have influence at the state level with state legislators, if you're an AMA member, AM PAC as well because they advocate for the broader house of medicine.

Dr Green: Thanks, Bruce. Thank you for that insight, very well said. I'm going to summarize for everybody. It's, first case, if you can get involved on the state level, again, that's how I got involved. You mentioned that Bruce, and you got involved.

That's the easiest way to get involved. Be there in your county medical society, state medical society, and on the issues like scope of practice, sunscreen access, and indoor tanning. I got involved through indoor tanning. That's so key.

If no one has the time, the checkbook is the best way. SKINPAC can make a huge, huge different. SKINPAC's more federal, like you mentioned, Bruce. On a state level, it's very important to open up our checkbooks. It takes much less money on a state level than the federal level to affect change and to donate to that.

Do you have any other advice you want to give before we close? I want to thank you so much for your time and all the great advice you've given by talking about all the issues we face, and why it's so important to have a national organization helping us out.

Dr Brod: No, it's a great conversation, Larry. Advocacy isn't just for the advocates that you know. It's for all of us. We should all get involved. I also encourage dermatologists to get involved in leadership outside of the medical profession.

I was on the medical board in my state. We have dermatologists now who are in state legislatures. We have a dermatologist in congress now. That's perhaps the ultimate voice.

Dermatologists can also get involved in insurance panels as well to be advisers for formulary boards and things like that so that they understand the importance of what we do so that we have that voice there.

Dr Green: Thank you, Dr Brod. Thank you for everything you've talked about in terms of advocacy. Thank you what you've done for our Academy and on behalf of all the dermatologists here in the US. Thank you for the advice you've given. I hope you guys have all enjoyed this podcast on dermatologists. You're welcome to listen to it again to re-glean the points that we've talked about.

Dr Brod: Thank you, Larry.