More Than Skin-deep
Newcastle Herald
Saturday July 30, 2005
THERE'S money in moles.
And not just moles, but all kinds of skin spots and blemishes.According to the director of the Newcastle Melanoma Unit, surgeon Dr Bob Sillar, the average Australian has 25 moles of various kinds. Across the nation every year hundreds of thousands of skin cancers are diagnosed, ranging from the benign to the very, very malignant.For those on whose skin these cancers grow they are a source of great worry. For some of those who cut them off, however, they can be a very significant cash crop. That helps explain why there's a bitter fight going on between doctors about who should be treating skin cancers and how they should be doing it.Traditionally the work has belonged to family general practitioners and to specialist doctors, with the GPs typically dealing with "simpler" skin lesions and referring more difficult or uncertain cases to specialists.In recent years, however, they've been joined by a new and very effective competitor: the skin cancer clinic.As publicly funded publicity campaigns have done their work, demand for skin cancer checks and treatments has mushroomed, creating a perfect niche for specialised clinics.Similar clinics, dealing with sports health, impotence, travel medicine and other narrow niches, have also emerged, leading to uneasiness from more traditional GPs and specialists.Family GPs are troubled by the specialised clinics, saying they are creaming off the more profitable cases and leaving behind the hard, unprofitable patients. Specialists are unhappy too, arguing that the clinics are presenting themselves as having a special expertise when often they do not. The specialists assert with some evidence on their side that some clinic doctors are producing poor results for patients. They also argue that some clinics are maximising their incomes by performing very large numbers of highly profitable, but unnecessary surgical procedures. And while the specialists plastic surgeons and dermatologists deny they are fighting a turf war over money, it is clear one of their major concerns is the impact the clinics are having on Medicare.THERE'S profit in flaps."Flap" repairs are surgical procedures done to repair holes in skin, usually done when the holes are bigger than a couple of centimetres. According to a past president of the Australian Society of Plastic Surgeons, Dr Norm Olbourne, claims on Medicare for surgical flap repairs following skin cancer removal have jumped six-fold since the advent of skin cancer clinics. On the Medicare Benefits Schedule the list of medical procedures that taxpayers fund flap procedures are lucrative, returning between $240 and $340 a throw. Specialists say the blowout in flap payments is due to skin cancer clinics targeting the high-paying procedure. The same applies, they allege, to the even more profitable area of skin grafts.Legitimate or illegitimate, the surge in claims has reportedly prompted the Health Insurance Commission (HIC), which administers Medicare, to contemplate cutting the rebate for the procedure, or restricting its use, a prospect that has greatly alarmed plastic surgeons and dermatologists.Dr Peter Callan, the chairman of the plastic surgeons' fees committee, denies a rebate reduction would cut the incomes of plastic surgeons."It won't cut our incomes, we are all flat out," Dr Callan said. "But it will reduce the amount our patients will get back from Medicare."He says flaps are not easy to do and take years to learn how to do well. "When they are poorly designed or poorly done they can look terrible."According to Dr Callan, some doctors in some skin cancer clinics are doing flaps and grafts in cases which don't warrant such extensive surgery.Instead of cutting the rebate, the colleges want the HIC to investigate this alleged overservicing."There are two factors in our minds that make this a huge issue," he says. "One is that we know some people are doing complicated flaps and grafts after doing two-week courses. That's crazy when you consider that surgeons spend six years learning to do it properly."The other factor is the impact on Medicare. Many patients go to clinics because they will be bulk-billed. They think they are getting a good deal because they aren't out of pocket. They don't realise they may have undergone a range of procedures that were completely unnecessary and for which the taxpayer will pay a handsome sum."Dr Callan said he had personally reviewed patients who had had flap repairs done for very small lesions on their backs when these could have been far more easily and cheaply repaired with a simple straight closure."One woman I saw had a tiny lesion cut from her nose and repaired with a flap when the whole thing could have been frozen off. The cost for the job was $400 and that was all rebate."Plastic surgeons are worried that such practices might induce the Government to reduce access to rebates for the procedure by those who need it.Newcastle surgeon Dr Chris Howe said this would amount to "throwing out the baby with the bathwater".THERE'S cash in cancer.On the Medicare Benefits Schedule it matters a lot whether that spot on your nose is cancer or not.The doctor who cuts it off will get $220 if the spot turns out to be benign. But if it's malignant that figure jumps straight to $333. Elsewhere on the body the rebate for cutting out a benign spot is $104, compared to $180 if it's cancer.As a result, it is alleged, some practitioners prefer to send their biopsy samples to laboratories with a record of making "soft" assessments.A lab that returns a finding of "pre-cancerous" or "possibly cancer" or "recommend excision" is effectively boosting the income of the doctor who sent the sample.Professor Bill McCarthy, of the Sydney Melanoma Unit, believes these soft terms and recommendations from pathology labs ought to be outlawed. "It's cancer or it's not," he said.As far as the skin cancer clinics are concerned, everybody familiar with the area agrees that many are ethically and professionally run. But every clinic doctor interviewed by The Herald, on and off the record, agreed the area was being badly affected by "cowboy" operators who were either not well-trained or were chasing cash.Some skin clinic doctors are racing to clean up their industry before the authorities step in. The greatest push is coming from Toowoomba GP and skin clinic operator Dr Peter Bourne, who has helped found the Skin Cancer Society of Australia and who is trying hard to establish formal qualifications and accreditation for clinic doctors.Dr Bourne agrees that all the allegations levelled against the clinics by their enemies and critics have some foundation in fact. "Yes, it is happening but it is a minority who are making the whole industry sound dishonest," he said. "That's why we are trying to set up accreditation and organise better education. But you should report that the specialists aren't falling over themselves to help and that is a real shame. We are no threat to the specialists. There is so much skin cancer in Australia that the specialists can't possibly deal with it all."Everybody knows how long it takes to get an appointment with a specialist and that is part of the problem." Dr Bourne's prescription is to force the clinics to become accredited, force the doctors to become qualified and to ban the sort of advertising that might imply a clinic has specialist expertise unless it actually obtains accreditation.He also believes the Government should audit the claims records of skin cancer doctors, weeding out any who might be shown to be farming the system for illegitimate profit.Every skin cancer doctor interviewed by The Herald agreed that such audits would be a good thing.But one GP at a skin cancer clinic said the audits, if they occurred, should not just single out clinics."They should also have a good hard look at the specialists if they want to be fair," said the doctor, who declined to be named. "I firmly believe that some specialists are indulging in the same over-servicing they are accusing the clinics of doing," he said.
© 2005 Newcastle Herald