Use and Cost of Actinic Keratosis Destruction in the Medicare Part B Fee-for-Service Population, 2007 to 2015 | Dermatology | JAMA Dermatology | JAMA Network
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1.
Landis  ET, Davis  SA, Taheri  A, Feldman  SR.  Top dermatologic diagnoses by age.  Dermatol Online J. 2014;20(4):22368.PubMedGoogle Scholar
2.
Flohil  SC, van der Leest  RJ, Dowlatshahi  EA, Hofman  A, de Vries  E, Nijsten  T.  Prevalence of actinic keratosis and its risk factors in the general population: the Rotterdam Study.  J Invest Dermatol. 2013;133(8):1971-1978. doi:10.1038/jid.2013.134PubMedGoogle ScholarCrossref
3.
Tennvall  GR, Norlin  JM, Malmberg  I, Erlendsson  AM, Hædersdal  M.  Health related quality of life in patients with actinic keratosis—an observational study of patients treated in dermatology specialist care in Denmark.  Health Qual Life Outcomes. 2015;13:111. doi:10.1186/s12955-015-0295-4PubMedGoogle ScholarCrossref
4.
Weinstock  MA, Lee  KC, Chren  MM, Marcolivio  K; VATTC Trial Group.  Quality of life in the actinic neoplasia syndrome: the VA Topical Tretinoin Chemoprevention (VATTC) Trial.  J Am Acad Dermatol. 2009;61(2):207-215. doi:10.1016/j.jaad.2009.02.022PubMedGoogle ScholarCrossref
5.
Philipp-Dormston  WG, Müller  K, Novak  B,  et al; NMSC-QoL Study Group.  Patient-reported health outcomes in patients with non-melanoma skin cancer and actinic keratosis: results from a large-scale observational study analysing effects of diagnoses and disease progression.  J Eur Acad Dermatol Venereol. 2018;32(7):1138-1146. doi:10.1111/jdv.14703PubMedGoogle ScholarCrossref
6.
Drake  LA, Ceilley  RI, Cornelison  RL,  et al; Committee on Guidelines of Care.  Guidelines of care for actinic keratoses.  J Am Acad Dermatol. 1995;32(1):95-98. doi:10.1016/0190-9622(95)90191-4PubMedGoogle ScholarCrossref
7.
Siegel  JA, Korgavkar  K, Weinstock  MA.  Current perspective on actinic keratosis: a review.  Br J Dermatol. 2017;177(2):350-358. doi:10.1111/bjd.14852PubMedGoogle ScholarCrossref
8.
de Berker  D, McGregor  JM, Mohd Mustapa  MF, Exton  LS, Hughes  BR.  British Association of Dermatologists’ guidelines for the care of patients with actinic keratosis 2017.  Br J Dermatol. 2017;176(1):20-43. doi:10.1111/bjd.15107PubMedGoogle ScholarCrossref
9.
Atkins  D, Bang  RH, Sternberg  MR, Chen  SC.  Reliable methods to evaluate the burden of actinic keratoses.  J Invest Dermatol. 2006;126(3):591-594. doi:10.1038/sj.jid.5700110PubMedGoogle ScholarCrossref
10.
Bickers  DR, Lim  HW, Margolis  D,  et al; American Academy of Dermatology Association; Society for Investigative Dermatology.  The burden of skin diseases: 2004: a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology.  J Am Acad Dermatol. 2006;55(3):490-500. doi:10.1016/j.jaad.2006.05.048PubMedGoogle ScholarCrossref
11.
Lim  HW, Collins  SAB, Resneck  JS  Jr,  et al.  The burden of skin disease in the United States.  J Am Acad Dermatol. 2017;76(5):958-972.e2. doi:10.1016/j.jaad.2016.12.043PubMedGoogle ScholarCrossref
12.
Warino  L, Tusa  M, Camacho  F, Teuschler  H, Fleischer  AB  Jr, Feldman  SR.  Frequency and cost of actinic keratosis treatment.  Dermatol Surg. 2006;32(8):1045-1049.PubMedGoogle Scholar
13.
Umans  B, Nonnemaker  KL. The Medicare beneficiary population. https://www.aarp.org/health/medicare-insurance/info-01-2009/fs149_medicare.html. Published January 2009. Accessed January 20, 2018.
14.
Kirby  JS, Gregory  T, Liu  G, Leslie  DL, Miller  JJ.  Variation in the cost of managing actinic keratosis.  JAMA Dermatol. 2017;153(4):264-269. doi:10.1001/jamadermatol.2016.4733PubMedGoogle ScholarCrossref
15.
Berenson  RA, Goodson  JD.  Finding value in unexpected places—fixing the Medicare Physician Fee Schedule.  N Engl J Med. 2016;374(14):1306-1309. doi:10.1056/NEJMp1600999PubMedGoogle ScholarCrossref
16.
Centers for Medicare & Medicaid Services. Physician/Supplier Procedure Summary. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary/index.html. Accessed August 11, 2018.
17.
Rosenkrantz  AB, Hughes  DR, Duszak  R  Jr.  Medicare claims data resources: a primer for policy-focused radiology health services researchers.  J Am Coll Radiol. 2017;14(12):1538-1544. doi:10.1016/j.jacr.2017.04.005PubMedGoogle ScholarCrossref
18.
American Medical Association.  Current Procedural Terminology. 2016 Professional Edition. Chicago, IL: American Medical Association; 2015.
19.
Centers for Medicare & Medicaid Services. Physician fee schedule search. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx. Updated July 6, 2018. Accessed August 11, 2018.
20.
Centers for Medicare & Medicaid Services. Part B National Summary Data File (previously known as BESS). https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Part-B-National-Summary-Data-File/Overview.html. Updated October 19, 2017. Accessed January 15, 2018.
21.
Centers for Medicare & Medicaid Services. Medicare utilization for Part B. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/MedicareUtilizationforPartB.html. Accessed January 20, 2018.
22.
Dunn  A, Grosse  SD, Zuvekas  SH.  Adjusting health expenditures for inflation: a review of measures for health services research in the United States.  Health Serv Res. 2018;53(1):175-196. doi:10.1111/1475-6773.12612PubMedGoogle ScholarCrossref
23.
Agency for Healthcare Research and Quality, US Dept of Health & Human Services. Medical expenditure panel survey: using appropriate price indices for analyses of health care expenditures or income across multiple years. https://meps.ahrq.gov/about_meps/Price_Index.shtml. Accessed August 11, 2018.
24.
Ringel  JS, Hosek  SD, Vollaard  BA, Mahnovski  S.  The Elasticity of Demand for Health Care: A Review of the Literature and Its Application to the Military Health System. Santa Monica, CA: RAND Corp; 2002.
25.
Liu  S, Chollet  D. Price and income elasticity of the demand for health insurance and health care services: a critical review of the literature. final report. Published March 24, 2006. Accessed January 23, 2018.
26.
Shen  J, Andersen  R, Brook  R, Kominski  G, Albert  PS, Wenger  N.  The effects of payment method on clinical decision-making: physician responses to clinical scenarios.  Med Care. 2004;42(3):297-302. doi:10.1097/01.mlr.0000114918.50088.1cPubMedGoogle ScholarCrossref
27.
Criscione  VD, Weinstock  MA, Naylor  MF, Luque  C, Eide  MJ, Bingham  SF; Department of Veteran Affairs Topical Tretinoin Chemoprevention Trial Group.  Actinic keratoses: natural history and risk of malignant transformation in the Veterans Affairs Topical Tretinoin Chemoprevention Trial.  Cancer. 2009;115(11):2523-2530. doi:10.1002/cncr.24284PubMedGoogle ScholarCrossref
28.
Werner  RN, Sammain  A, Erdmann  R, Hartmann  V, Stockfleth  E, Nast  A.  The natural history of actinic keratosis: a systematic review.  Br J Dermatol. 2013;169(3):502-518. doi:10.1111/bjd.12420PubMedGoogle ScholarCrossref
29.
Tan  SY, Tsoucas  D, Mostaghimi  A.  Association of dermatologist density with the volume and costs of dermatology procedures among Medicare beneficiaries.  JAMA Dermatol. 2018;154(1):73-76. doi:10.1001/jamadermatol.2017.4546PubMedGoogle ScholarCrossref
30.
Song  H, Adamson  AS, Mostaghimi  A.  Trends in Medicare spending on topical immunomodulators and chemotherapies.  J Am Acad Dermatol. 2018;78(1):173-175. doi:10.1016/j.jaad.2017.07.056PubMedGoogle ScholarCrossref
31.
Wang  DM, Morgan  FC, Besaw  RJ, Schmults  CD.  An ecological study of skin biopsies and skin cancer treatment procedures in the United States Medicare population, 2000 to 2015.  J Am Acad Dermatol. 2018;78(1):47-53. doi:10.1016/j.jaad.2017.09.031PubMedGoogle ScholarCrossref
32.
Yoon  J, Phibbs  CS, Chow  A, Pomerantz  H, Weinstock  MA.  Costs of keratinocyte carcinoma (nonmelanoma skin cancer) and actinic keratosis treatment in the Veterans Health Administration.  Dermatol Surg. 2016;42(9):1041-1047. doi:10.1097/DSS.0000000000000820PubMedGoogle ScholarCrossref
33.
Kirby  JS, Delikat  A, Leslie  D, Miller  JJ.  Bundled payment models for actinic keratosis management.  JAMA Dermatol. 2016;152(7):789-797. doi:10.1001/jamadermatol.2016.0502PubMedGoogle ScholarCrossref
34.
Sutton  A, Crew  A, Wysong  A.  Redefinition of skin cancer as a chronic disease.  JAMA Dermatol. 2016;152(3):255-256. doi:10.1001/jamadermatol.2015.4215PubMedGoogle ScholarCrossref
35.
Stacey  D, Légaré  F, Col  NF,  et al.  Decision aids for people facing health treatment or screening decisions.  Cochrane Database Syst Rev. 2014;(1):CD001431.PubMedGoogle Scholar
36.
Tan  J, Wolfe  B.  A patient decision aid for psoriasis based on current clinical practice guidelines.  Arch Dermatol. 2012;148(6):718-723. doi:10.1001/archdermatol.2012.36PubMedGoogle ScholarCrossref
37.
Gupta  AK, Paquet  M, Villanueva  E, Brintnell  W.  Interventions for actinic keratoses.  Cochrane Database Syst Rev. 2012;12:CD004415.PubMedGoogle Scholar
38.
Walker  JL, Siegel  JA, Sachar  M,  et al.  5-Fluorouracil for actinic keratosis treatment and chemoprevention: a randomized controlled trial.  J Invest Dermatol. 2017;137(6):1367-1370. doi:10.1016/j.jid.2016.12.029PubMedGoogle ScholarCrossref
39.
Fleming  P, Zhou  S, Bobotsis  R, Lynde  C.  Comparison of the treatment guidelines for actinic keratosis: a critical appraisal and review.  J Cutan Med Surg. 2017;21(5):408-417. doi:10.1177/1203475417708166PubMedGoogle ScholarCrossref
40.
Kirby  JS, Scharnitz  T, Seiverling  EV, Ahrns  H, Ferguson  S.  Actinic keratosis clinical practice guidelines: an appraisal of quality.  Dermatol Res Pract. 2015;2015:456071. doi:10.1155/2015/456071PubMedGoogle ScholarCrossref
41.
Gupta  AK, Cooper  EA, Feldman  SR, Fleischer  AB  Jr.  A survey of office visits for actinic keratosis as reported by NAMCS, 1990-1999: National Ambulatory Medical Care Survey.  Cutis. 2002;70(2)(suppl):8-13.PubMedGoogle Scholar
42.
Resneck  JS  Jr, Kimball  AB.  Who else is providing care in dermatology practices? trends in the use of nonphysician clinicians.  J Am Acad Dermatol. 2008;58(2):211-216. doi:10.1016/j.jaad.2007.09.032PubMedGoogle ScholarCrossref
43.
Coldiron  B, Ratnarathorn  M.  Scope of physician procedures independently billed by mid-level providers in the office setting.  JAMA Dermatol. 2014;150(11):1153-1159. doi:10.1001/jamadermatol.2014.1773PubMedGoogle ScholarCrossref
44.
Adamson  AS, Suarez  EA, McDaniel  P, Leiphart  PA, Zeitany  A, Kirby  JS.  Geographic distribution of nonphysician clinicians who independently billed Medicare for common dermatologic services in 2014.  JAMA Dermatol. 2018;154(1):30-36. doi:10.1001/jamadermatol.2017.5039PubMedGoogle ScholarCrossref
45.
Hafner  K, Palmer  G. Skin cancers rise, along with questionable treatments. New York Times. November 20, 2017.
46.
Bae  GH, Hartman  RI, Joyce  C, Mostaghimi  A.  Comparing dermatology referral patterns and diagnostic accuracy between nonphysician providers, physician trainees, and attending physicians.  J Am Acad Dermatol. 2016;75(1):226-227. doi:10.1016/j.jaad.2016.02.1213PubMedGoogle ScholarCrossref
47.
Jacobson  G, Damico  A, Neuman  T, Gold  M. Medicare Advantage 2017 spotlight: enrollment market update. https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/. Published June 6, 2017. Accessed January 20, 2018.
48.
Lee  KC, Lew  R, Weinstock  MA.  Improvement in precision of counting actinic keratoses.  Br J Dermatol. 2014;170(1):188-191. doi:10.1111/bjd.12629PubMedGoogle ScholarCrossref
49.
Chen  SC, Hill  ND, Veledar  E, Swetter  SM, Weinstock  MA.  Reliability of quantification measures of actinic keratosis.  Br J Dermatol. 2013;169(6):1219-1222. doi:10.1111/bjd.12591PubMedGoogle ScholarCrossref
Original Investigation
November 2018

Use and Cost of Actinic Keratosis Destruction in the Medicare Part B Fee-for-Service Population, 2007 to 2015

Author Affiliations
  • 1Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
  • 2Division of Dermatology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia
  • 3Harvey L. Neiman Health Policy Institute, Reston, Virginia
  • 4School of Economics, Georgia Institute of Technology Ivan Allen College of Liberal Arts, Atlanta
  • 5Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
JAMA Dermatol. 2018;154(11):1281-1285. doi:10.1001/jamadermatol.2018.3086
Key Points

Question  How is the use and cost of actinic keratosis destruction changing in the aging population?

Findings  This billing claims analysis found that, in the Medicare Part B fee-for-service population, the estimated number of actinic keratosis lesions treated per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments decreased from $11 749 to $10 942 per 1000 beneficiaries owing to successive reimbursement cuts. In 2015, a total of 13.5% of actinic keratosis lesions were treated by independently billing nurse practitioners and physician assistants.

Meaning  Actinic keratosis appears to impose high and increasing levels of treatment burden in the aging population.

Abstract

Importance  Actinic keratosis is prevalent and has the potential to progress to keratinocyte carcinoma. Changes in the use and costs of actinic keratosis treatment are not well understood in the aging population.

Objective  To evaluate trends in the use and costs of actinic keratosis destruction in Medicare patients.

Design, Setting, and Participants  A billing claims analysis was performed of the Medicare Part B Physician/Supplier Procedure Summary Master Files and National Summary Data of premalignant skin lesion destructions performed from 2007 to 2015 among Medicare Part B fee-for-service beneficiaries.

Main Outcomes and Measures  Mean number of actinic keratosis lesions destroyed and associated treatment payments in 2015 US dollars estimated per 1000 Medicare Part B fee-for-service beneficiaries. Data analysis was performed from November 2017 to July 2018.

Results  More than 35.6 million actinic keratosis lesions were treated in 2015, increasing from 29.7 million in 2007. Treated actinic keratosis lesions per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments per 1000 patients decreased from $11 749 to $10 942 owing to reimbursement cuts. The proportion of actinic keratosis lesions treated by independently billing nurse practitioners and physician assistants increased from 4.0% in 2007 to 13.5% in 2015.

Conclusions and Relevance  This study’s findings suggest that actinic keratosis imposes continuously increasing levels of treatment burden in the Medicare fee-for-service population. Reimbursement decreases have been used to control rising costs of actinic keratosis treatment. Critical research may be warranted to optimize access to actinic keratosis treatment and value for prevention of keratinocyte carcinoma.

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