Questions Answered with Timothy G. Berger, MD

October 2015, Vol 3, No 10 - Inside Dermatology Care

In a recent interview with Inside Patient Care, Timothy G. Berger, MD, Vice President of the American Academy of Dermatology (AAD), discussed the role of the academy in patient care and the role of the interprofessional healthcare team in promoting dermatology care and wellness care.

What is your background?

A: I am the executive vice chair of the Department of Dermatology at the University of California San Francisco (UCSF). I became the vice president of AAD because I had been on the Board of Directors for the academy and had participated in many academy activities; I was nominated by the Nominating Committee, and elected by the membership. It is a democratic process, not an appointment system in dermatology.

My career was initially in the military. I trained in San Francisco and then served overseas, and was activated for Operation Desert Storm. After a military career, I came into academics, and have been at UCSF since 1987; in 2 years, I will have been with UCSF for 30 years.

The vice president has 2 important functions: (1) support the president, and (2) be the primary liaison for the Advisory Board. The Advisory Board is a structural part of our organization, our grassroots House of Representatives. They represent the concerns of the private physician to the leadership. It allows members, directly through their Advisory Board representative, to bring concerns to the Board of Directors.

The mission of AAD is multifold. We have an educational mission, which involves educating our members and making sure that they have the most up-to-date knowledge about all the new therapies and discoveries that have been made in dermatology. That is our primary mission, and how AAD began.

We realized that the educational mission had to be extended to the whole population, so we took on a public education arm as well that occurs throughout the year, but is most intense in the month of May (ie, Melanoma/Skin Cancer Detection and Prevention Month).

We also have a mission where we advocate for patients with skin diseases—we attempt to support government activities that improve the state of public health around skin cancer, sun safety, and skin disease. We have worked with legislation—with the government—regarding fair labeling of sunscreen, so that you can read a sunscreen label, and understand whether that product is adequate for you.

We got tanning beds declared as class II medical devices, rather than class I, which means they are considered to pose a greater risk to consumers than a class I medical device and are subject to greater oversight by the US Food and Drug Administration. We have worked with state societies to have laws passed that prevent teenagers from tanning because that leads to skin cancer. We have played this advocacy role to support our patients and the public’s health as they pertain to skin disease.

Over the past year or so, we have added another mission. As the healthcare system is restructured, access to dermatology care and medications has become substantially restricted for many patients; we are working with our patient counterparts to try to keep those channels of medication availability open.

How are healthcare providers working together to deliver dermatology care?

A: I think that we used to do this really well, because healthcare was a community activity. If you were the dermatologist in the community using the network of primary care physicians, you had your pharmacists who knew the dermatology medications as well as your practice style. For the patient, that became a pretty simple system. Unfortunately, healthcare has now become fragmented for several reasons.

More than half of dermatologists have other health practitioners within their practice, including nurse practitioners (NPs) and physician assistants (PAs). We have developed a concept called the DermCare Team, where all those staff members (eg, the medical assistant, the PA, the NP, the dermatologist) form a team, and work together as one.

I think our next mission—and we have a task force at the academy that’s beginning the process—is to reach out to primary care and internal medicine specialties and ask, “How can we structure ourselves to better interface with you?” We are going back to forming these networks that I think got lost—from the old-time, neighborhood healthcare system to the modern integrated healthcare system.

What changes in healthcare are contributing to its fragmentation?

A: We have 2 major problems from the dermatology perspective.

First, there aren’t enough dermatologists, and dermatology care providers in the United States. Second, we have a skin cancer epidemic, including a more educated population that understands, and has questions about, their skin, and an aging population that has lots of skin disease. We are left with a temporary deficit that is going to take a while for us to overcome.

Dermatologists are trying to stretch their resources during this time of inadequate supply, looking to reach out to primary care physicians, especially in rural areas, to think of new ways for care to be delivered. One of our major efforts is in using telemedicine as a way for primary care networks to access dermatologists, and, at the same time, not require that the patient drive long distances, because, as is the case with many specialties, we are concentrated in urban areas, and patients in rural areas are not as well-served.

How can community pharmacies and retail clinics support dermatologists?

A: We actually had a series of specialty pharmacists come to speak to the leadership of AAD, and to our industry partners, to help us better understand the role of pharmacy in helping to deliver care. I think we all kind of understood this, but didn’t register it in a conscious way, because, as I said, in the old days the dermatologist always knew the pharmacy that helped them make the compounded dermatology drugs, so we all had our go-to “derm-competent” pharmacies.

Although dermatology represents a fairly small percentage of the physician workforce, we disproportionately prescribe medications because many patients use combinations of medicines to reduce side effects. Pharmacists are used to understanding the interactions of those medicines, and helping to educate patients about how to use them, avoid problems, and comply with regimens.

As we have formed good alliances with pharmacies, we are attempting to navigate that same relationship with retail health clinics. On the one side, retail health clinics are clearly a mechanism by which patients can get easy access, but it goes against the patient medical home concept, where the patient’s primary care provider is overseeing their whole healthcare. Most of the retail pharmacies don’t share medical information; they are not connected via electronic health records, so care becomes fragmented and inefficient.

We are trying to understand the role that retail clinics play in dermatology care. For the first time this year, we conducted skin cancer screenings in a series of Target stores throughout the United States. These screenings did not occur in their retail clinics, but as a part of arranging this, we began a discussion with Target about how retail clinics and dermatology can interface, because for us it is a new frontier that has come on to the scene fairly quickly.

What opportunities do you see ahead for dermatologists?

A: One of the things we are going to work on in the next 5 years is the relationships with primary care specialties, especially in underserved areas—whether that is an underserved inner city or rural America—and working with primary care colleagues who practice in those areas to figure out how to serve patient needs, and how we can more effectively deliver care.

The concept of telemedicine, for instance, holds promise if it’s done in a thoughtful, physician-led manner. On the one side, a person can pay $40 to have someone give them a consultation, but that doesn’t occur through their medical home, and is completely unregulated and undocumented. The alternative is to have a structured system where that telemedicine consultation occurs as a part of that patient’s medical care, where it is documented in a chart, and requires structure.

You need to have someone trained at the practice to take the photographs, download them, and send the photographs; at the receiving end, you need a dermatologist interpreting them, sending diagnosis and treatment back. We have several ongoing test programs, some here at UCSF and some at other areas, where we are doing telemedicine projects to learn how to most efficiently use the resource. From the public health perspective, I think we need a better knowledge of the population, and better integration with primary care networks, especially in rural areas.

How do you think the model for team-based care will evolve in the next 5 to 10 years?

A: I have been watching this model unfold for about 30 years because Fresno, CA, is a part of the UCSF system. We never had a dermatologist there, but we do have a dermatology clinic operating there now that is affiliated with us, and with the Fresno medical community.

I think that, with most specialty care, there is going to be evolution in 2 directions. One direction is that primary care physicians will learn more about dermatology so that they will be better able to partner with dermatologists. The other thing we need to do is figure out how to deliver care in areas that are underserved.

One of the things I realized is that 30% of patients who come for a medical visit have a skin problem; that’s 1 of 3 patients. In medical school, physicians receive, on average, 1 to 10 hours of dermatology education. Although it could represent as much as 10% to 20% of all primary care physician healthcare visits, it represents an infinitesimal amount of their medical education, and that education is not standardized. AAD actually built a standardized curriculum, which is public access and posted on the AAD website. It has dermatology basics so that every medical student throughout the world can go on and learn the terminology and the basic principles of managing the 20 most common skin diseases, in addition to learning how to effectively communicate with dermatologists. These modules all talk about diagnosis. They somewhat discuss treatment, but do talk about when and how to refer patients.

Currently, what is happening is, if I went to medical school and I only had 1 hour of training in something, I’m not going to feel very confident in treating a patient who has a problem relevant to that training. We realized that there was this need for a dermatology course, and that schools couldn’t put it into the curriculum because the curricula were expanding. It has approximately 30 hours of content. That 1 to 10 hours of exposure has now been, we hope, expanded. With all those efforts, we are attempting to partner better with our primary care colleagues through education.

How do you think the healthcare system will evolve?

A: I actually think that what will happen will do so over time. Currently, most of dermatology operates on a fee-for-service system where dermatologists are in their offices delivering care, and they are not tightly integrated with a larger system.

Primary care is moving toward medical homes, accountable care organizations, and other large groups. They will probably not initially hire dermatologists into those groups, but, rather, make relationships with dermatologists in the community who are willing and able to manage patients in an evolving fee-for-service, value-based care system.

I think that value-based care, the medical home, and a coordinated management process similar to the Kaiser Permanente system is where we are going to end up. I have trained many physicians and dermatologists who practice in the Northern California Kaiser Permanente system.

The way the Kaiser Permanente system works for dermatology is that the patients can opt to go directly to their dermatologist. They don’t actually go to their primary care provider; their dermatologist works within the network and coordinates the care of that patient with the primary care provider. I think we will evolve to a model where the dermatologist is going to, for some years, still operate their practice with that patient a little independently, but in a system where all care is visible and coordinated with the medical home.

The payment system will then evolve over time to include more alternative payment models. How quickly that’s going to happen, none of us know. I think dermatologists are going to be the last ones completely captured inside these medical homes as employees because of the problems with patients accessing them. If you try to stick a dermatologist in a busy primary care clinic, the patients and the dermatologist can’t make that work efficiently.

The dermatologist is much better served in their own practice and running it highly efficiently, just like in ophthalmology. We have to figure out how to have that independent dermatologist efficiently and cost-effectively continue to deliver good care, but under the umbrella of a system of value-based care. AAD has several initiatives trying to look ahead and decide how dermatologists can best serve the population amid the evolving model of healthcare delivery. As it turns out, in the Kaiser Permanente system, the reason patients are allowed direct access to dermatology and don’t go to a managed-care model is because it costs less and the patient gets better faster.

Kaiser Permanente learn­ed many years ago that the best thing to do is to allow the patient, who clearly understands they have a skin disease, to go directly to that specialist, and for that physician to be a part of the healthcare team so that the care can be coordinated. I think that’s the model that we’re going to evolve to; dermatologists will be independent practitioners reimbursed for their services; important contributors offering cost-efficient ways to deliver skin care; and, at the same time, be integrated into these systems. I think that is the model that we’re going to end up with.

Do you have any concluding remarks that you would like to share?

A: AAD is very interested in having relationships that will be mutually beneficial to dermatologists and primary care. The delivery of dermatologic care, especially to rural areas or community health clinics, exists. We are going to have to work together. AAD and its members are very interested in helping primary care physicians prevent and treat skin diseases.

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