Anticipated Versus Unanticipated Incomplete Mohs Micrographic Surgery for Keratinocyte Carcinomas: Impact on Treatment Delays and Final Margin Status.

BACKGROUND: Mohs micrographic surgery may be discontinued with positive margins as an anticipated strategy for multidisciplinary care or as an unanticipated occurrence. Management of primary tumors has not been compared after anticipated versus unanticipated incomplete Mohs micrographic surgery (iMMS). OBJECTIVE: To compare rates and timing of adjuvant surgery after iMMS and final margin status when iMMS is anticipated versus unanticipated. Secondary outcomes were preoperative and intraoperative clinicopathologic factors associated with iMMS. METHODS: Cases of iMMS of keratinocyte carcinomas at a tertiary academic center between 2005 and 2022 were classified as anticipated (preoperative assembly of multidisciplinary teams) or unanticipated (ad hoc management of positive margins). Rate, timing, and final margin status of adjuvant surgery was compared between anticipated and unanticipated iMMS cohorts using χ2/Fisher exact test for categorical variables and t-test for continuous variables. RESULTS: Of 127 iMMS cases, 51.2% (65/127) were anticipated. Anticipated iMMS cases were more likely to undergo additional resection (98.5% vs 72.6%, p < .001), with fewer delays (3.9 vs 13.2 days, p < .001) and higher rates of final margin clearance (84.6% vs 59.7%, p < .001). CONCLUSION: When iMMS is anticipated as part of multidisciplinary care, patients are more likely to undergo additional resection, with fewer delays to next surgery and higher final margin clearance rates.

Evolving teledermatology policy and reimbursement landscape in the United States.

Background: Policymakers and payers are reevaluating the temporary telehealth flexibilities granted during the COVID-19 public health emergency, which will shape future teledermatology utilization. Objective: To summarize the recently expanded telehealth flexibilities in the United States, projected changes, and corresponding implications for dermatologists. Methods: Narrative review of the literature, United States policies and regulations, and white paper reports. Results: Key telehealth flexibilities included expansion of payment parity, relaxation of originating site requirements, loosening of state licensure requirements, and HIPAA (Health Insurance Portability and Accountability Act of 1996) enforcement discretion. These changes enabled widespread accessibility and adoption of teledermatology, which enhanced high-quality and cost-effective dermatologic care. Most waivers will end 151 days following the end of the public health emergency declaration. Notably, asynchronous telehealth was not included in the reimbursement expansion. Limitations: Only policies and regulations through December 2022 are included. Conclusion: It will be important for the field of dermatology to stay abreast of the upcoming changes in telemedicine policies and reimbursement, to demonstrate teledermatology's value through evidence-based studies and to advocate for enduring policies that will promote the accessibility of teledermatology for patients.

Giant pigmented apocrine hidrocystoma of the scalp.

Hidrocystomas are benign cysts of sweat duct epithelium that can present as single or multiple lesions, with or without pigmentation. The size is typically 1-3mm in diameter. Although hidrocystomas commonly occur in most parts of the head and neck region, occurrence on the scalp is rare. Herein, we present a 29-year-old woman with a giant pigmented apocrine hidrocystoma of the scalp, which, to our knowledge, represents the largest of its kind reported to date.

Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.

Primary cutaneous Hodgkin-like polymorphic post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder (PTLD) is an uncommon complication after solid-organ transplants and hematopoietic stem cell transplants. Isolated involvement of the skin without systemic involvement in PTLD is extremely rare. Primary cutaneous PTLD is generally categorized as either cutaneous T-cell lymphoma or cutaneous B-cell lymphoma, with variable Epstein-Barr virus (EBV) positivity. Herein, we describe an exceedingly uncommon case of a primary cutaneous Hodgkin-like polymorphic PTLD. A man in his 60s, with a history of kidney transplant, presented with a 5-week history of two indurated plaques. Clinical, histologic and immunohistochemical findings were consistent with primary cutaneous Hodgkin-like polymorphic PTLD. Reduction in immunosuppression led to resolution of his lesions. This case highlights a rare case of primary cutaneous Hodgkin-like PTLD and increases awareness of this uncommon post-transplant complication. It also underscores the importance of collaboration between dermatology, hematology, dermatopathology and hematopathology in order to diagnose challenging cases.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Relative Value Scale Update Committee.

The American Medical Association-Specialty Society Relative Value Scale Update Committee, also known as the RUC, plays a critical role in assessing the relative value of physician services and procedures. This committee provides access for all physicians, including dermatologists, to the reimbursement process. Since the introduction of the Resource-Based Relative Value Scale by Medicare, the RUC has done important work to evaluate and refine reimbursement for physician services. The RUC recommendations have also led the Current Procedural Terminology (CPT) Editorial Panel to develop additional reimbursement codes as new procedures and services are developed. In this article (from the series Future Considerations for Clinical Dermatology in the Setting of 21st Century American Policy Reform), we will review the RUC, including its history and membership, the RUC update process, and a brief discussion of a few issues of particular importance to dermatologists.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Accountable Care Organizations.

An Accountable Care Organization (ACO) is a network of providers that collaborates to manage care and is financially incentivized to realize cost savings while also optimizing standards of care. Since its introduction as part of the 2010 Patient Protection and Affordable Care Act, ACOs have grown to include 16% of Medicare beneficiaries and currently represent Medicare's largest payment initiative. Although ACOs are still in the pilot phase with multiple structural models being assessed, incentives are being introduced to encourage specialist participation, and dermatologists will have the opportunity to influence both the cost savings and quality standard aspects of these organizations. In this article, part of a health care policy series targeted to dermatologists, we review what an ACO is, its relevance to dermatologists, and essential factors to consider when joining and negotiating with an ACO.