Practice patterns of dermatologists who have opted out of Medicare

Abstract

To the Editor: Since 1998, physicians have had the option of opting out of Medicare and entering into private contracts with Medicare beneficiaries.1Opt out affidavits - Centers for Medicare & Medicaid Services data. Center for Medicare and Medicaid Services.https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/opt-out-affidavitsDate accessed: November 10, 2021Google Scholar Given the paucity of data regarding dermatologists who have opted out of Medicare, we performed a cross-sectional analysis in order to compare their practice characteristics with those of dermatologists enrolled in Medicare.The Medicare Opt Out Affidavits database, which is a comprehensive list of physicians who have opted out of Medicare, was used to identify dermatologists who have opted out. The National Downloadable File was used to identify dermatologists enrolled in Medicare. The practices of all dermatologists who have opted out were successfully phoned in order to determine services offered and insurance acceptance. Medicare data from November 2021 were utilized in this study.We identified 168 practicing dermatologists who opted out of Medicare, which accounts for 1.34% of 12,516 active dermatologists.2Physician specialty data report. American Association of Medical Colleges.https://www.aamc.org/data-reports/workforce/report/physician-specialty-data-reportDate accessed: November 10, 2021Google Scholar We identified 12,172 dermatologists enrolled in Medicare. Compared with the dermatologists enrolled in Medicare, the dermatologists who have opted out were more likely to be women (70.2% vs 51.6%, respectively; P < .01) (Table I). A greater proportion of dermatologists who have opted out practice in counties where the median household income is at or above the national median (66.1% vs 54.7%, P < .01), and a smaller proportion practices in medically underserved areas (3.0% vs 18.3%, P = .02). Furthermore, 96.4% (n = 162) of the opt outs occurred after 2010 (Table II).Table IDemographic and practice characteristics of dermatologists who opted out of Medicare versus dermatologists enrolled in Medicare∗This table demonstrates the demographic and practice characteristics of dermatologists who have opted out of Medicare versus those enrolled in Medicare. Geographic regions were based on classifications from the US Census Bureau. Rural-Urban Continuum Codes were used to determine the rural-urban status. Practice locations were deemed to be in a medically underserved area according to the designations set forth by the Health Resources and Services Administration. County demographic data were obtained from the Census Bureau.CharacteristicsDermatologists who opted out of Medicare (n =168)Dermatologists enrolled in Medicare (n = 12,172)P valueSex, n (%)<.01 Male50 (29.8)5890 (48.4) Female118 (70.2)6282 (51.6)Age (y), n (%)†For the purpose of comparison, data regarding the age of all practicing dermatologists were obtained from the Association of American Medical Colleges.<.01 ≥55103 (61.3)5535 (44.3) <5555 (32.7)6970 (55.7)Geographic region, n (%)<.01 Northeast65 (38.7)2665 (21.9) Midwest11 (6.5)2254 (18.5) South47 (28.0)4274 (35.1) West45 (26.8)2979 (24.5)Practice setting, n (%)<.01 Private practice (solo practice or dermatology-only group)161 (95.8)8001 (65.7) Multispecialty group or nonacademic hospital4 (2.4)2280 (18.7) Academic hospital group3 (1.8)1891 (15.5)Practice urban-rural status, n (%).11 Metropolitan163 (97.0)11459 (94.1) Nonmetropolitan5 (3.0)713 (5.9)County household median income, n (%)<.01 ≥National median111 (66.1)6664 (54.7) <National median57 (33.9)5508 (45.3)Mean county racial demographic proportion (SD), n (%) Non-Hispanic White56.2 (20.1)57.7 (20.3).34 Other43.7 (17.4)42.3 (16.9).29Practice in medically underserved area, n (%) Yes5 (3.0)2229 (18.3).02 No163 (97.0)9943 (81.7)∗ This table demonstrates the demographic and practice characteristics of dermatologists who have opted out of Medicare versus those enrolled in Medicare. Geographic regions were based on classifications from the US Census Bureau. Rural-Urban Continuum Codes were used to determine the rural-urban status. Practice locations were deemed to be in a medically underserved area according to the designations set forth by the Health Resources and Services Administration. County demographic data were obtained from the Census Bureau.† For the purpose of comparison, data regarding the age of all practicing dermatologists were obtained from the Association of American Medical Colleges. Open table in a new tab Table IIServices offered, insurance acceptance, and timing of Medicare opt outCharacteristicn (%)Services Offered Cosmetic dermatology155 (92.3%) Medical dermatology136 (81.0%) Dermatologic surgery104 (61.9%) Mohs micrographic surgery13 (7.7%)Insurance Acceptance No insurance122 (72.6%) Private insurance46 (27.4%)Year of Opt Out∗The year of opt out was determined from the Medicare Opt Out Affidavits database. 2001-20053 (1.8%) 2006-20103 (1.8%) 2011-201562 (36.9%) 2016-202092 (54.8%) 20218 (4.8%)Age at the Time of Opt Out (y) 30-3922 (13.1%) 40-4947 (28.0%) 50-5951 (30.4%) 60-6942 (25.0%) 70-796 (3.6%)Years of Practice before Opt Out (y)†Years of practice before opt out was determined by calculating the difference between a dermatologist’s year of opt out and dermatology residency or fellowship graduation year. 1-934 (20.2%) 10-1949 (29.2%) 20-2949 (29.2%) 30-3930 (17.9%) 40-496 (3.6%)∗ The year of opt out was determined from the Medicare Opt Out Affidavits database.† Years of practice before opt out was determined by calculating the difference between a dermatologist’s year of opt out and dermatology residency or fellowship graduation year. Open table in a new tab Kaiser Family Foundation data from 2020 indicate that the overall opt-out rate of dermatologists is comparable with that of all physicians (1.1% vs 1.0%, respectively).3How many physicians have opted-out of the Medicare program? Kaiser Family Foundation.https://www.kff.org/medicare/issue-brief/how-many-physicians-have-opted-out-of-the-medicare-programDate accessed: November 10, 2021Google Scholar Of note, many dermatologists who have not opted out do not treat Medicare patients, including those working for the military or Veteran’s Administration, pediatric dermatologists, researchers, and consultants. Additionally, dermatologists who perform noncovered services, such as cosmetics, on Medicare patients are not required to opt out. If these groups of dermatologists were factored out, the calculated opt-out percentage would be even higher. These nuances, however, may be applicable to other specialties also.Follow-up research is needed to explain why dermatologists who opt out are significantly more likely to be women. Although dermatologists who opt out of practice in higher-income counties are less likely to work in underserved areas, they do not practice in counties that are less racially diverse. The implications of these findings are unclear, and further research is required to ascertain whether dermatologists located in higher-income areas treat wealthier patients.The greater number of opt outs over the last decade may be indicative of changes associated with the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act. Such legislation has affected administrative tasks and reimbursement.4Ginsburg P.B. Patel K.K. Physician payment reform—progress to date.N Engl J Med. 2017; 377: 285-292Crossref PubMed Scopus (17) Google Scholar In fact, the inflation-adjusted dermatologic Medicare reimbursement decreased by 4.8% from 2007 to 2021.5Mazmudar R.S. Sheth A. Tripathi R. Bordeaux J.S. Scott J.F. Inflation-adjusted trends in Medicare reimbursement for common dermatologic procedures, 2007-2021.JAMA Dermatol. 2021; 157: 1355-1358Crossref PubMed Scopus (3) Google Scholar Thus, health care changes may be one of the multiple factors that affect opt-out rates.A limitation of this study is that dermatologists who previously opted out and are no longer practicing are not listed in the Opt Out Affidavits database, which may have increased the observed proportion of opt outs that have occurred in recent years. Additional investigation is required to elucidate how opt outs affect patient care. To the Editor: Since 1998, physicians have had the option of opting out of Medicare and entering into private contracts with Medicare beneficiaries.1Opt out affidavits - Centers for Medicare & Medicaid Services data. Center for Medicare and Medicaid Services.https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/opt-out-affidavitsDate accessed: November 10, 2021Google Scholar Given the paucity of data regarding dermatologists who have opted out of Medicare, we performed a cross-sectional analysis in order to compare their practice characteristics with those of dermatologists enrolled in Medicare. The Medicare Opt Out Affidavits database, which is a comprehensive list of physicians who have opted out of Medicare, was used to identify dermatologists who have opted out. The National Downloadable File was used to identify dermatologists enrolled in Medicare. The practices of all dermatologists who have opted out were successfully phoned in order to determine services offered and insurance acceptance. Medicare data from November 2021 were utilized in this study. We identified 168 practicing dermatologists who opted out of Medicare, which accounts for 1.34% of 12,516 active dermatologists.2Physician specialty data report. American Association of Medical Colleges.https://www.aamc.org/data-reports/workforce/report/physician-specialty-data-reportDate accessed: November 10, 2021Google Scholar We identified 12,172 dermatologists enrolled in Medicare. Compared with the dermatologists enrolled in Medicare, the dermatologists who have opted out were more likely to be women (70.2% vs 51.6%, respectively; P < .01) (Table I). A greater proportion of dermatologists who have opted out practice in counties where the median household income is at or above the national median (66.1% vs 54.7%, P < .01), and a smaller proportion practices in medically underserved areas (3.0% vs 18.3%, P = .02). Furthermore, 96.4% (n = 162) of the opt outs occurred after 2010 (Table II). Kaiser Family Foundation data from 2020 indicate that the overall opt-out rate of dermatologists is comparable with that of all physicians (1.1% vs 1.0%, respectively).3How many physicians have opted-out of the Medicare program? Kaiser Family Foundation.https://www.kff.org/medicare/issue-brief/how-many-physicians-have-opted-out-of-the-medicare-programDate accessed: November 10, 2021Google Scholar Of note, many dermatologists who have not opted out do not treat Medicare patients, including those working for the military or Veteran’s Administration, pediatric dermatologists, researchers, and consultants. Additionally, dermatologists who perform noncovered services, such as cosmetics, on Medicare patients are not required to opt out. If these groups of dermatologists were factored out, the calculated opt-out percentage would be even higher. These nuances, however, may be applicable to other specialties also. Follow-up research is needed to explain why dermatologists who opt out are significantly more likely to be women. Although dermatologists who opt out of practice in higher-income counties are less likely to work in underserved areas, they do not practice in counties that are less racially diverse. The implications of these findings are unclear, and further research is required to ascertain whether dermatologists located in higher-income areas treat wealthier patients. The greater number of opt outs over the last decade may be indicative of changes associated with the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act. Such legislation has affected administrative tasks and reimbursement.4Ginsburg P.B. Patel K.K. Physician payment reform—progress to date.N Engl J Med. 2017; 377: 285-292Crossref PubMed Scopus (17) Google Scholar In fact, the inflation-adjusted dermatologic Medicare reimbursement decreased by 4.8% from 2007 to 2021.5Mazmudar R.S. Sheth A. Tripathi R. Bordeaux J.S. Scott J.F. Inflation-adjusted trends in Medicare reimbursement for common dermatologic procedures, 2007-2021.JAMA Dermatol. 2021; 157: 1355-1358Crossref PubMed Scopus (3) Google Scholar Thus, health care changes may be one of the multiple factors that affect opt-out rates. A limitation of this study is that dermatologists who previously opted out and are no longer practicing are not listed in the Opt Out Affidavits database, which may have increased the observed proportion of opt outs that have occurred in recent years. Additional investigation is required to elucidate how opt outs affect patient care. Dr Grant-Kels serves as Deputy Editor of Journal of the American Journal Academy of Dermatology; is Chief Medical Officer and member of the Board and stockholder of VeraDermics, Inc; and is a consultant and stock holder for DermaSensor, Inc. Dr Feng is a consultant for Cytrellis Biosystems, Inc and Soliton, Inc. Dr Kodumudi has no conflicts of interest to declare.