Testimony in support of direct access
by Dr. Brodell

COST EFFECTIVENESS & DIRECT ACCESS
BY ROBERT T. BRODELL, M.D.

Testimony May 23, 1995 before the Ohio State Senate 
Financial Institutions, Insurance, and Commerce 
Committee was designed to deal with many of the issues 
raised by our opponents.

It is a great pleasure for me to testify on behalf of 
dermatologists in the State of Ohio and my patients in 
support of Senate Bill 153.  I am motivated by what I 
know is best for my patients.

In my testimony today I would like to outline why 
dermtology is at special risk in the setting of 
"managed care" and detail the data which supports the 
cost effectiveness of dermatology as a direct access 
specialty.  I will also review why many of my primary 
care colleagues support our effort, and finally review 
some of the arguments made by the managed care 
organizations which oppose this bill.

Dermatology Patients Are At Special Risk in the Setting 
of Managed Care
Patients with non-life threatening dermatology problems 
are often viewed as having insignificant diseases when 
compared to patients with internal organ system 
problems. The primary care physician who is being paid 
a bonus for not making referrals to specialists often 
feels quite comfortable managing a skin problem even if 
he does not understand its complexity.  Other 
physicians under threat of "deselection" if they 
order too many tests or make too many referrals feel 
compelled to be an insurance company advocate rather 
than a patient advocate.  Topical medications can be 
used that are safer than many internal medicines, but 
if not chosen wisely, may do little good.  Of course, 
patients can always visit the dermatologist outside the 
managed care plan and pay for these services 
themselves, but they often do not have the knowledge of 
diagnoses and alternative therapists to take this step 
when advised against it by their primary care 
physician.

Dermatologist Provide Patients with High Quality Cost-
Effective Skin Care
1. Common sense would suggest that a physician with a 
minimum of three years extra training in Dermatology 
would have a broader knowledge base when compared to 
the primary care physician



2. Numerous peer reviewed scientific studies show that 
dermatologists score far higher on a variety of 
tests concerning diagnostic and treatment skills, 
even when considering only the mpost common skin 
diseases.
3. Dermatologists can treat skin disease most cost 
effectively. (See Appendix 2)
4. Because skin disease is visible on the outside of 
the body, patients know when they have a skin 
problem. Neither a nurse gatekeeper, nor a physician 
gatekeeper is required in the setting of the vast 
majority of skin problems.

Direct Access to Dermatology Can Make the Primary Care 
Physician More Effective
1. Dermatologists with direct access to patients can 
help take the pressure off a system of health care 
where more and more patients are being required to 
see far too few primary care physicians. Many busy 
primary care doctors are glad to have more time to 
spend with patients with other problems that require 
a generalists skill in diagnosis, treatment, and 
triage.
2. Many primary care physicians support the concept of 
patient choice as it relates to choice among primary 
care physicians and other physician services. It is 
frustrating for the generalists to deal with a 
patient who has been forced to come to his clinic 
for a skin problem when the demand for a referral to 
the dermatologist is the basis for the visit.

A Review of Misinformation from our Opponents
1. "Dermatologists are more expensive." This is 
untrue. The CPT code book that defines the nature of 
services provided is used by all physicians. 
Dermatologists are paid the same amount for a given 
service as a generalist physician.
2. "If this bill passes, all specialties will demand 
direct access." This is simply not true. The 
cardiovascular surgeon, cardiologist, pulmonologist, 
and many other specialties have no desire to see 
patients without a referral. The vast majority of 
their patients have complicated internal problems 
which are referred by primary doctors after they 
have been evalusted to make optimal use of our 
health care system. The patient with chest pains can 
not know if the problem is related to his stomach, 
heart, lungs, etc. without the aid of his primary 
care doctor. The patient with a rash knows he can 
get the most expert help from his dermatologist. If 
Ophthalmologists, Orthopedists, and others can 
support their cost effectiveness when compared to 
the generalist physician, then direct access might 
be appropriate for these specialties. The entire 
managed care system will not break down if selected 
specialties are given direct access to patients that 
demand their services.
3. "Only the Primary Care Physician can Coordinate 
Care." Not true. For the patient with psoriasis who 
requires the long term care of a dermatologists, the 
dermatologist often will coordinate care with other 
physicians when this is required. We have attended 
medical school and all dermatologists have one or 
more years of generalist training.
4. "The Insurance Company knows better what is in the 
best interest of the patient...not the patient 
himself or his family." None of my patients believe 
this.
5. "This bill changes everything." Wrong. In 1995 
most patients seen in the dermatologists office are 
self referred. Only 10% are referred by primary care 
physicians. If managed care suceeds in controlling 
the entire insurance marketplace in the next five 
years, and if direct access to dermatology is not 
permitted...then everything will change. The current 
system of providing dermatologic care to the 
citizens of Ohio is not broken. It should not be 
"fixed" by a system which will deny access to the 
care my patients are currently demanding as 
demonstrated by their decision to visit my office.
6. "Dermatology care is not "real" medicine and 
anyone can do it." I discover dermatologic clues to 
internal disease on a daily basis. I provide relief 
from illness. I believe in the Hippocratic Oath. My 
training has been rigorous and I am proud of my 
specialty. Because of my interest in education, I 
have spent about 20% of my time teaching primary 
care physicians over the past ten years. The body of 
knowledge dermatologists have mastered is not easily 
taught in a few lectures during residency or in a 
two week elective. I have great respect for my 
generalist colleagues and the difficult job they 
perform. I have earned the same respect for the job 
I perform.
7. "Dermatologists support of this bill is only to 
maintain their income." Wrong. If managed care 
succeeds and capitation of services becomes the 
norm, the path to financial success is to keep 
patients out of your office, not to allow them free 
access. I will sacrifice financial gain in this new 
system to continue providing the best and most up-
to-date services to patients with skin disease who 
wish to visit me.
8. "Dermatologists who are not permitted to see 
dermatology patients can be easily retrained to 
become generalist physicians and help with extreme 
need for primary care physicians." This is 
insulting to the primary care physician! The body of 
knowledge they are required to maintain is just as 
difficult to master as the body of knowledge I have 
mastered.

In summary, SB 153 will allow the patient a choice to 
see either their primary care physician or a 
dermatologist for their skin problems in a managed care 
plan. My patients in the past have always had this 
choice. They wish to maintain that right as managed 
care systems evolve in the State of Ohio.

APPENDIX I

Cassileth BR, Clark WH. Lusk EJ, et al. How well do 
physicians recognize melanoma and other problem 
lesions? J AM Acad Dermatol. 1986:14:555-560.

McCarthy CM, Lamab CC, Russell TJ, et al. Primary care 
based dermatology practice: Internists need more 
training. J Cen Inter Med. 1991;6:52-56.

Pariser DL, Fox AB. The ability of priomary care 
physicains to recognize the common dermatoses. Arch 
Dermatol. 1981;117:620-622.

Stern RS, Boudreaux C, Arndt KA. Diagnostic accuracy 
and appropriateness of care for seborrheic keratoses: A 
pilot study of an approach to quality assurance for 
cutaneous surgery. JAMA. 1991;265:74-77.

Wagner RF, Wagner D, Tomich JM. Residents Corner: 
Diagnosis of skin disease: Dermatologists vs. 
nondermatologists. J Dermatol Surg Oncol. 1985;11:476-
479.

APPENDIX II

Brohm M. Analysis of charges of dermatologists versus 
primary care physicians for the most commonly performed 
dermatologic procedures. Report to the Blue Ribbon 
Committee on Dermatologic Practice and Public Issues of 
the American Academy of Dermatology. May 1984.

Clark RA, Rietschel RL. The cost of initiating 
appropriate therapy for skin disease: A comparison of 
dermatologists and family physicians. J AM Acad 
Dermatol. 1989;9:787-796.

Direct patient access to dermatologists in an HMO 
practice; an update from the Kaiser-Permanente Medical 
Care Program. No author listed. January 15, 1990. 
(Unpublished Report)