Derm Appeal Blog

Combinations in Aesthetics
Susan H. Weinkle, MD

Dr. Weinkle shared some of her favorite combinations in aesthetics during the aesthetic innovation symposium.  First, Dr. Weinkle encouraged symposium attendees to address the outer envelope of patients, in that all patients should use a retinoid or retinol and a daily sunscreen to protect against both ultraviolet and visible light.  When choosing a syringe, amount of silicone coating allows for smooth injection.  Syringes with a lure lock allow for greater variety in needle selection.  Dr. Winkle shared that new syringes will be available soon in the United States.

Next Dr. Winkle explained how neuromodulator can be combined with filler for optimal results.  Newer resorbable sutures made of PLGA and PLLA can be useful to re-drape the face in the appropriate patient, and that a HA filler could be used in combination to reduce fine lines after the sutures are placed.  Next Dr. Weinkle explained that neck rejuvenation may be accomplished using neuromodulator, deoxycholic acid, and HA filler.  She did caution the audience against over treating the platysmal bands with neurotoxin.

Dr. Weinkle concluded the discussion on combination treatments by sharing before and after photographs of patient treated with PLLA (Sculptra) and neuromodulator.  She explained that this combination is a good choice for some patients due to a natural look.

Aesthetic Anatomy
Stephen H. Mandy, MD

Dr. Mandy began the review of aesthetic anatomy by explaining the use of Phi calipers, which allows an injector to measure patients in the 1:1.618 ratio, and that this tool may be helpful in educating patients about goals during cosmetic treatments. He also explained proportions of the male and female face, and that skeletal re-absorption plays a vital role in the aging face. Next, Dr. Mandy shared new research that demonstrates arteries in the face are not always where you think they will be, such as the four major variations in the angular artery. He encouraged the audience to keep facial anatomy in mind while injecting. Blindness has been reported in the plastic surgery journals due to facial injections for volume replacement, but the majority of these were fat injection with larger bore needles. Dr. Mandy advises that all injectors keep Vitrase in the office because it is more effective in the same volume than other hyaluronidases. Also, he shared that newer crosslinked HA fillers may more difficult to reverse with hyaluronidase.

Dr. Mandy reviewed the anatomy for temple injections at the center of the temporal fossa, which is above the zygoma and below the temporal fusion line.  Also Dr. Mandy shared that facial retaining ligaments anchor the skin, and that the placement of these ligaments is where patients will show facial grooves with aging.  He reminded the audience that even with volume correction, these ligaments may hinder the ability to reshape the face.

What Men Want in Corrective Aesthetics
Doris J. Day, MD

Dr. Doris Day reminded the audience that male patients are a small percentage of the aesthetic market, making up only 6% of neuromodulator use, and 4% of all filler procedures. The male aesthetic face differs from that of females in that the peak of brow is more lateral and the chin is more squared off. According to Dr. Day, the features of the aging face include deterioration, deflation, descent, disproportion, and dynamic discord. She encouraged the audience to save treatment of the nasolabial fold for last.

For most men, the goal of aesthetic treatments differs from the goals of the female patient.  While women aim for beauty for themselves or for other women, many men seek cosmetic treatments to stay relevant in the workplace.

Dr. Day shared that when treating the male aesthetic patient, it is important to volumize the cheek and midface first, and that PLLA (Sculptra) is a great product choice for men.

For jowling Dr. Day recommends redraping the face with resporbable sutures such as Instalift.  Dr. Day explained that brow peaking is an aesthetic concern for men, and that this can be addressed with neuromodulator.

What’s New in Clinical Dermatology
Theodore Rosen, MD

Dr. Rosen succinctly presented a current literature review.

• He first reviewed the effect music has on anxious patients undergoing a surgical procedure. This has been studied in dermatology, but it was noted music did not help the patient but was beneficial to the surgeon.
• In a study comparing photoprotection using an umbrella vs. sunscreen, erythema was evaluated in fair skinned individuals exposed to 2.5 hours of sun protected by shade vs. the use of SPF 100. Shade alone is not sufficient to provide adequate photoprotection.
• Patients using hydrochlorothiazide (HCTZ) for hypertension therapy are at increased risk of developing non-melanoma skin cancer. Patients who reached a cumulative dose of 200,000 mg of HTCZ (about 10 years of therapy) were found to have almost a 7 times higher risk for developing BCC or SCC.
• Short term field therapy reduces the risk of developing SCC. This benefit was seen in those who used 5-fluorouracil BID for two weeks.
• A new drug, Cemiplimab, which is a PD-1/PD-L1 monoclonal antibody has shown great results in the treatment of unresectable or metastatic cutaneous SCC in phase 1 trials. Phase 2 trials will be initiated soon. This therapy may allow for complete/partial response and disease stability in locally advanced SCC.
• Avelumab is now approved for metastatic Merkel Cell CA. On 12-month follow up, complete response has increased and is a major advancement in therapy. Avelumab can cause severe immunologic side effects but should not deter treatment as patients are having extension of survival.
• Evaluation of patients diagnosed with melanoma who underwent lymph node dissection are not shown to have improvement in survival. We must question why we put patients through this procedure, which can result in significant morbidity.
• In regard to nutrition and acne (high glycemic diet, milk products), there is no way for dermatologists to make appropriate therapeutic recommendations.
• Psoriasis patients and especially those who suffer from psoriatic arthritis, are at increased risk of developing liver disease. Thus, hepatotoxic medications like methotrexate should be used cautiously in psoriasis patients.
• Molluscum lesions can be treated with hyperthermia. In a study, patients heated to 111F for 30 minutes once weekly for 12 weeks were noted to have clearance of nearly half of their molluscum lesions.
• Evaluation of different modalities to treat warts: Pulsed dye laser was found to be superior in comparison to salicylic acid, cryotherapy and CO2 laser therapies. It was also found that smoking prompts the recurrence of warts. In smokers, there is a 5 times greater risk of wart recurrence.
• A new recombinant herpes zoster vaccine, Shingrix, is available (two doses, IM at months 0 & 2-6 months). The antigen in Shingrix is a surface protein of zoster virus. It is found to have a higher overall effective rate in protecting against shingles and post-herpetic neuralgia. It is recommended that patients who received previous zoster vaccine, Zostavax, be re-vaccinated with Shingrix because it is more efficacious.
• Ozenoxacin 1% topical cream has been approved for treating impetigo.
• A study from the New England Journal of Medicine noted that small abscesses fared better with use of antibiotics than incision and drainage.
• Benznidazole is a first-line treatment for Chagas disease despite its major side effect profile.
• Rituximab is a first line therapy following a short-term dose of prednisone for Pemphigus. Complete remission has been achieved in 90% at 24 months.
• By treating hepatitis C virus, PCT goes away.
• Regardless of HIV patients being on antiretroviral treatment, almost 1/3 still have HIV detected in their semen even if asymptomatic.
• A small study in Germany showed patients with mild drug rush can remain on antibiotic if under close observation. This does not apply to severe drug rashes. Hemodialysis can be used to treat drug rash.
• Evidence that patients taking Biotin 10 mg/day for nail disease can have altered lab testing indicating thyroid abnormalities. We do not know how low doses of Biotin affect these results.

What the Dermatologist Needs to Know About Wound Healing
Robert Kirsner, MD

Dr. Kirsner presented information on low risk skin grafting techniques and their effect on wound healing.  New technology allows for scarless donor graft sites. Traditionally, a dermatome was used to cut graft tissue, which was then meshed and applies to a chronic wound. Autografting was also done for venous ulcers. It improves quality of life for patients significantly. However, there are a lot of disadvantages in doing the traditional way as patients may need to be under anesthesia and a second wound is created.

Simpler techniques have been designed including the pinch graft technique in which snips of skin are cut using a dermablade and then placed into wound. The healthy tissue can stimulate the wound to heal by its innate properties, but the donor site can still take time to heal.

In order to minimize scarring of the donor site, the low risk skin grafting procedure can be used. A device is applied to a patient’s thigh and it produces suction and heat to the healthy skin and separates the epidermis at the lamina lucida with virtually no scarring. This epidermal harvesting system takes approximately 30 minutes, does not require anesthesia and the epidermis can be transferred easily as a dressing to the wound. There is also very little bleeding and the donor site heals within 2 days. This graft technique can also be used to transfer pigment as the cells transferred from the donor site continue to grow and can repopulate the area, healing the wound and simultaneously delivers melanin to the depigmented area. It also is a great modality to use for individuals with PG to avoid the pathergy phenomenon. Epidermal harvesting is also successful in the setting of venous insufficiency wounds.

Another modality being used is the fractional full thickness skin grafting in which a device can pluck out micro tissue skin columns (MTCs) which are full thickness grafts and functionally alive. The device has microneedles that harvests > 300 columns of skin within 20 seconds and then sprays the MTCs into the wound, simultaneously depositing and harvesting it with full thickness skin. The MTCs stimulates fast healing of chronic wounds while preventing wound contraction. It is virtually a painless procedure. New data is being generated but evidence thus far has demonstrated faster healing in wounds treated with fractional full thickness skin grafting vs. untreated wounds. This technology has also been used anecdotally in acute wounds post-Mohs and achieves a pretty good cosmetic result that may be better than secondary intention healing. Comparative studies need to be performed.

Dr. Kirsner concluded that low risk skin grafting techniques certainly have many applications in dermatology.

Infectious Disease Update
Kenneth Tomecki, MD

Dr. Tomecki provided an infectious disease update applicable to dermatology:

He began by noting measles should be considered on the differential diagnosis if child or adult presents with fever, diarrhea and a rash. An astute clinician should examine for Koplik spots present for 1-2 days during the prodrome, which are pathognomonic for measles. Measles is the leading cause of death in children <5 years old and it is preventable by vaccine. Most infected people are not vaccinated, and the goal is to have a 90% vaccination rate.

Gianotti Crosti Syndrome is a well-known viral syndrome among pediatricians. It presents as papulovesicules on acral sites/extremities. It is due to infection with EBV.

The total number of AIDS patients in the world is about 80 million with about 1.2 million reported in the United States (with approximately half of patients living in Southeast United States). There are approximately 2 million new HIV cases/year as well as 2 million deaths/year due to AIDS. The prevalence of AIDS is highest in Southern African, with 1/6 of individuals living in Republican South Africa. It is primarily seen in young bisexual men. There are many cutaneous presentations of AIDS. Patients should be started on anti-retroviral therapy (4-5 medications) as soon as being detected serologically positive. Unfortunately, less than 50% of affected individuals receive treatment and this number is even lower in children. PrEP/Truvada is now available to prevent in high risk individuals or treat HIV. Studies show it can decrease the risk of contracting HIV by 90%.

Syphilis cases have been increasing, particularly in men who have sex with men (60%) and congenital cases. Disease is stable in women. There are 12 million cases around world, with prevalence in Southeast Asia and Africa. It is also on the rise in Latin America and Caribbean. Within the United States, the highest area of prevalence is California, followed by Louisiana. Oral sex is a risk factor for syphilis, unlike HIV. It was noted that 30% of women with syphilis did not receive prenatal care leading to transplacental infection. It attributed to 5% of deaths in children. The development of Penicillin has helped to decrease syphilis.

Leptospirosis is a worldwide disease due to infection with the spirochete Leptospira. Cases are prevalent in Texas and Florida as well as Southeast Asia as areas that are subjected to heavy rainfall or urban dense are at risk. The reservoir for Leptospira are wild/domestic animals (rat, dogs). Urine from these animals containing Leptospira are washed into the water. The incubation period is 7-12 days. It is most prevalent in older men. Infected individuals can present with a febrile illness, aches and a vasculitic/purpuric-like rash. Treatment is with Doxycycline for mild disease and Penicillin for severe disease.

There is shortage of Penicillin G Benzathine and it should be reserved for pregnant women. Avoid Ketoconazole.

Key Indicators of Practice Health
David Wagener, MBA, CPA

Mr. Wagener encourages practitioners to learn about the following indicators, choose those that are pertinent and accessible to you and monitor trends. First, growth rate – “If you are not growing your revenue, your bottom line is most certainly going backwards.” Next, calculate the daily revenue average (DRA) by dividing the last 3 months of revenue by the number of days in the period. It’s a simple metric, but if you calculate it on a rolling basis, you get an idea of your accounts receivable performance. Accounts receivable aging tells you how quickly you are being paid. For instance, Medicare turns around fast, typically in 14-17 days. If you see mostly Medicare patients, you should be receiving your highest percentages within 30 days. If you still have high percentages after 60, 90, or over 120 days, your staff may not be fully resolving accounts receivable and action must be taken (send to collections, etc). Finally, for the days revenue in AR and aging analysis, the more self-pay or cosmetic you do as a percentage of total revenue, the lower your days in AR should be.

Next Mr. Wagener talked about patient refunds. He says that if you are not doing a good number of refunds, you are either perfect or, more likely, doing something very wrong. Charges are only estimates, and it is normal for patients to receive refunds for over-collection at POS or duplicate payments. Evaluate your “bad debts” with the net collections on net charges.

When it comes to patient care, evaluate service mix. What do you want your breakdown to be between medical, surgical, cosmetic, pharmaceutical dispensing, and clinical research? Next, payer mix – who pays you? Options include traditional commercial insurers, PPO, HMO, OWA, Medicare, Medicaid, self-pay, and employers. The service mix and payer mix will determine who you are trying to attract to your practice and thus how you will reach them via marketing, advertising, and social media. Finally, maintain and monitor your mix of new vs. established patients. You want your practice to be accessible to both new and established patients – you don’t want patients waiting months for an appointment, it is bad for your practice. Grow your practice with demand.

Mr. Wagener closed by reminding us of the importance of being aware of the regulatory environment you live in (MACRA) and issues of compliance.  Evaluating any of the above indicators can help practitioners determine the health of their practice and where improvements need to be made.

Living with MACRA: Pearls for the Dermatologist
Mark Kaufmann, MD

Dr. Kaufmann began by reminding the audience that with MACRA, there was a mandatory increase of 0.5% in the PFS every year from 2016-2019. This was the first time legislation afforded us this increase in fee schedule. MACRA also prevented CMS from pulling the global periods from our codes. For now, our 10- and 90-day global periods for freezing AKs, destruction of benign lesions, malignant destructions, excisions – benign/malignant, intermediate/complex repairs will remain. Essentially, we get paid for a follow-up visit, regardless of whether we actually see a patient for follow-up in the global period. Dr. Kaufmann states that if you do see a patient within that global period (whether it is for the same reason or a new complaint), you should use the 99024 code, which is how CMS is tracking visits occurring in the global period. This is a non-payable code, but as of July 2017, 9 states require the 99024 code (FL, KE, LA, NV, NJ, ND, OH, OR, RI). If you don’t submit 99024, you will be penalized, up to 10% of your Medicare income. Time will tell what the results of CMS data collection on the 99024 code will be. Elimination of the global periods may become an issue again in a few years.

Almost all dermatologists will be working with MIPS, rather than Advanced APMs (only 140 dermatologists in the country). Remember, there is a 2-year lag period, so 2018 MIPS are for the 2020 fee schedule. There are several ways to be exempt from MIPS. If your annual Medicare income is less than $90,000 or if you have seen fewer than 200 unique Medicare patients, you are exempt from MIPS. This will exclude pediatric dermatologists, part-time derms, and those who opt out of Medicare. You can visit qpp.cms.gov, enter your NPI number, and see your current MIPS status.

Your MIPS score at the end of the year can result in a bonus, penalty, or neutral payment adjustment. CMS predicts that 93% of dermatologists will receive a positive or neutral payment adjustment, while only 7% will be penalized. 91% of clinicians in small practices, defined as 15 or fewer clinicians (MD, DO, NP, PA) will receive a positive or neutral adjustment. The 2018 score is determined by Quality (50%), CPIA (15%), Advancing care information aka meaningful use (25%), and resource use aka cost (10%). This cost aspect of the MIPS score is new in 2018, and will increase to 15% next year. Also new in 2018 is the ability to can report as an individual, group, or virtual group.

In order to avoid the 5% penalty for 2020, you need to earn 15 MIPS points. Small practices with 15 or less clinicians receive a 5 point bonus and only require 10 MIPS points. Dr. Kaufmann suggests the easiest MIPS measures to perform are medication list review (measure 130), influenza vaccination status (110), Pneumovax status (111), and tobacco use +/- counseling (226). If you submit the G codes on those 4 measures for only one patient, you will be exempt from MIPS penalty in 2018. Dr. Kaufmann suggests choosing one clinic day and performing those measures on all the Medicare patients you see that day. Of note, the influenza vaccine measure is only valid to use during flu season (ending 3/31/18 OR from 10/1/18-12/31/18). A final option is logging on to qpp.cms.gov and submit one high-weighted improvement activity. This will exempt you from MIPS penalty. MACRA is here, and it is important to be prepared to avoid penalties and potentially earn bonuses.

Increase Your Practice ROI – Seven Easy Steps
Cheryl Whitman

The world is changing. We have a more diverse population and traditional marketing strategies don’t appeal to millennials the same way as they do to older age groups, especially with the ever-increasing amount of competition. Return on investment (ROI) is measure used to evaluate the efficiency of an investment or to compare the efficiency of a number of different investments. It is calculated by dividing the benefit (or return) of an investment by the cost of the investment. The following steps are easy ways to increased your ROI.

1. Focus on increasing revenue:
   Increase profits with increased sales. To become a better salesperson, connect with people, help them to understand an idea, negotiate with them, and close the sale. Education of both patients and staff is essential for building relationships that lead to successful sales. Figure out what you are best at and sell yourself. Competitors can’t keep up with you if you come up with unique things.
2. Staff:
   Their happiness affects your bottom line. Staff need to feel loved and there is a major lack of that in this industry. Staff that feel appreciated will form more effective, productive teams who are committed to your practice’s well-being. Staff are your most valuable resource. They should be proficient sales agents, have excellent customer service skills, provide a high-quality patient experience, keep patients engaged, present solutions and provide support.
3. Build your online presence:
   Create a powerful brand that shows who you are, what you do, and why you are unique. Develop a strong website – it is your online brochure. It is important to keep the website constantly updated with new testimonials, new photos, blog posts, etc. Speak language and have sections dedicated to different patient groups – millennials, ethnic groups, men, etc. Utilize videos – interaction and engagement with patients is crucial. Focus on your target audience – you can’t please everyone. Does your website tell a unique, compelling, and intriguing story about your practice? It should. Make a list of key words and phrases to enhance your rank on Google. Search Engine Optimization (SEO) is the practice of increasing the quantity and quality of traffic to your website through organic search engine results. Users are most likely to click on the top 5 results – ensure that you are there.
4. Know your competition:
   What advantages do you have? What are their marketing and promotional strategies? What is their pricing structure? Know what they are doing because there are holes in the market that you can fill (i.e. adding evening or Saturday hours). Have staff meetings to involve everyone to compare your quality, image, name recognition, social media presence, online reputation, patient service, location, convenience, and perceived value. Word-of-mouth is the most important advertising method.
5. Be the expert:
   Provide high-value, free information that establishes you as an expert. You can post educational videos on your website, YouTube, and social media to engage and intrigue patients.
6. Determine your unique selling potential (USP):
   What are you best at? Figure it out and create your brand around that. Make you and your practice recognizable. Use your USP to attract loyal patients and use those loyal patients’ testimonials to attract more patients.
7. Marketing:
   Start internally – it is the least expensive and word-of-mouth marketing makes a major impact, especially on social media. People rely on their family and friends for recommendations.  External marketing is best when you can talk directly to your ideal patient. Use social media platforms like Facebook live.

Reputation Management
Louis R. Frisina MBA

Comments about your practice – from the care of providers and procedures, to your staff and office décor –  is the key link between client search and the practice ultimately selected by client. Patients will only consider offices with 4-5 stars. Having 10+ reviews is a respectable minimum, 40+ reviews are strong practices, and the best practices have over 65 reviews. You should ensure you have current reviews from the last weeks to months and an absence of very bad reviews. Reviews can be found in many locations  – on your website, social media, RealSelf, Google Places, YouTube, and embedded in email blasts. Mr. Frisina recommends first focusing on Google reviews, then RealSelf, then HealthGrades, then Rate MDs. If Yelp is popular in your area, consider getting reviews there, as well.

Videos are watched 10x more on same subject versus the written word – this is especially true amongst millennials. Videos better capture patient feelings and emotion – you can do this while patients are in the office. Other ways to increase your number of reviews are to give patients instructions on how to write and submit a review, send out patient questionnaires, and place follow-up calls post-treatment asking patients to write testimonials. There are so many missed opportunities to ask patients for testimonials: in the exam room, at check-in or check-out, post-op or post-procedure follow-ups, and at practical informational events. Advanced reputation management involves storyboards or journeys, where patients memorialize their patient experience in mini-patient reviews that are archived in a series.

Bad reviews are inevitable. Try to eliminate them from the Internet. Proven “fake reviews” can be taken down. Attempt to reach out to client and “settle.” Legal action is the last resort. Ultimately, you want 10-15 good reviews for every bad review. Target new reviews towards bad review subject areas. Do a press release to reach the public. And lastly, never be reactive, it just makes matters worse. Lastly, Mr. Frisina reminded the audience to always obtain full consent that outlines/lists all channels that the practice is requesting to use testimonial. Allow the patient cross-out undesired channels to not post.