Well, that’s not exactly what he said. And I’m not even sure he’s a dermatologist, though it sure sounds like it.
For newcomers, this is the latest in a four month saga, including these posts:
- Time to practice what I preach: I have skin cancer again. (Feb 9)
- I’ve started an RFP for my skin cancer (Feb 11)
- Decision: Just scrape it off (ED&C) (May10)
- Raw numbers for treating my basal cell carcinoma at three hospitals (May 21)
Today (Saturday 6/16) on the “decision” post, commenter “Joe” (apparently a dermatologist) said the most interesting, thought-provoking stuff I’ve ever seen anywhere about basal cell carcinoma treatment options:
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Been a while since I checked in here.
Would love to know who is charging $3000 for Mohs first stage. We get paid about $700 for the first stage which is the price we do it at.
Well that’s interesting to read; news to me, after all that research.
It probably would be more like $3000 if you had it done in a hospital. (which is where health care is going at huge expense and worse service – guess who wrote the health care bill – big hospitals or a friendly small doctor office down the road)
Then:
There is always much more to recurrence rates than just the published figures.
In general we never ED & C on the face, not least of all because, if done right, the scar will be nasty.
I was aware of that, and decised: with this particular teen-acne-ravaged cheek, I was okay with that, especially on the side under the ear.
Then this delicious thought-provoker:
But also ED & C is much less effective in hair bearing areas – e.g. scalp and beard area. Why? Because the tumor can go down hair follicles, trying to scrape it out is like trying to shovel snow in thick grass, the follicles get in the way and the tumor has a passage to go deeper into the skin.
First, I love that visual metaphor (shoveling snow in thick grass); and nobody had ever mentioned this idea. Thoughts, anyone out there? Especially other knowledgeable clinicians or patients?
With a tumor that size in that location the standard of care is Mohs surgery.
Understood.
It’s fine if one does substandard treatments, we often do especially when cost is involved.
Yep: c’est moi. :-)
The key is follow up to monitor for recurrence.
Yep, as noted in earlier posts. But then this fascinating addition:
The difficulty with ED & C is that the recurrence can be under the scar, so you have to wait for it to grow up and around the edge of the old scar to see it, i.e. the tumor has to get pretty big.
Now that’s interesting. Thoughts, anyone?
Still it can work and hopefully it did, just make sure you continue to get a skin exam every year.
Yep.
The cost of a one stage Mohs and linear repair in my hands is about $1100. You can never guarantee ‘no scar’ even with Mohs, everyone heals differently.
As I look at the photos again blown up it looks pretty small, you will probably be fine, again just keep monitoring it.
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First, Dr. Joe, thanks so much for your contributions. I’m honored and I hope this process continues to help people.
Now, folks, here’s a question that goes to the heart of healthcare social media:
Is there any website anywhere,
government-approved or not,
that says all this?
Again, I emphasize that I don’t know if Joe is who he says he is, and I have no way of verifying what he said above. This is, after all, the internet, and all we know is that somebody said this stuff.
That’s exactly why I asked, twice, what other readers think. When in doubt, verify – then be careful about the verifiers, too.
BUT, if my back-end sleuthing has correctly identified this dermatologist, his local HealthGrades rating is a perfect 5 stars in every category except wait time, where it’s a mere 4.4 stars (usually, not always, within 10 minutes of scheduled time).
THOUGHTS, anyone?
Thanks for publishing your saga. Most patients lack the time or resources to investigate so thoroughly. You have been presented with quite a price spread — $700, $1100, $3000 — with caveats.
Usually, electrolysis kills hair follicles within a few treatments. Can the cancerous area be thus treated safely prior to MOHs (or post-op) to prevent ‘shoveling snow in the grass’ and minimize chance of recurrence?
There is a lot of stuff we know in Medicine but is not in the books…same as in A few Good Men…you know where the latrines are even if it is not written in a book.
That is me Dave, I am fortunate to get good feedback and we strive to treat people the way we would like to be treated.
When it comes to cost we are not deliberately being cagy, as Dave pointed out often we don’t know. All we know is we have to charge more than the insurance companies pay us. If we charge less (unlikely) then they would pay us less. Doctors bills mean nothing – I can bill $100,000 for a Mohs layer, I will only get paid what the insurance company has determined they will pay me.
As a ‘small practice’ – lots of derms seeing lots of patients but essentially completely off the radar of the insurance companies compared with a major health system – we have ZERO negotiating power with companies. I mean ZERO. We just finished meeting with them asking for a 5% increase in reimbursement, they said we are getting the standard 2% – and yes the ‘patients’ health insurance premiums also went up by 2% – oh, wait, sorry 20%, if we don’t like it we can stop seeing their patients. End of Story.
When you get seen in a hospital – those guys have negotiating power – an Insurance company is providing a service – they need doctors to see their patients. If some of the major players in whatever town you are stop seeing their patients then the Insurance company has a product that can’t offer any services – i.e. no good.
So a visit that I get paid $75 for , a big hospital will get paid $150 for from the insurance company. We have a contract with the insurance company which means we accept what we get paid – i.e. we don’t go asking the patient for an extra $75.
So all the talk of better care by closing down the independent practices and transitioning you to a hospital is going to cost you a fortune.
What you pay all goes by codes – there is a diagnosis code – in Daves cases 173.31 (BCC on the face) then there is what we do to it (CPT code) – First stage of Mohs 17311 – then if needed subsequent stages 17312 x how ever many stages are needed. Then Repair of the defect 13132 linear repair or a skin flap 14040. If it is done in a hospital or a surgery center then there are additional charges for that (thousands), no so if done in a regular clinic.
You can get ball park figures of what it might cost – but the whole point of Mohs existence is that you don’t know what is happening under the skin – if you did you would never need Mohs. Something that looks small – might be small – or it could go 4 stages.
Doctors eat, drink, live and breath uncertainty. We are always playing the odds. We don’t always know the odds. We are swayed by one off terrible personal experiences. We are always conscious of getting sued – being dragged through a process for something that may or may not be our fault that could drag on for years.
It is likely that Daves cheek tumor may be small and completely cured by a simple procedure. There is a chance that it was going deeper, the scar will mask any recurrence, it will, in this area, eventually, go into his Parotid Gland and necessitate a surgery under general anesthesia to remove his parotid gland, with the risk of damage to the VII Cranial Nerve leaving him with a facial palsy i.e. he would look like he had a stroke. Lets say he also has to stay two nights in hospital for recovery. Then subsequent surgeries to lift the face up and reduce the drooping along with yearly scans to look for deep tumor recurrence. The tumor may spread to a lymph node – vanishingly rare but I have seen it happen once in 17,000 the cases I have done. That fact it is rare means nothing to the chap it happened to – leading Dave to be put on the new miracle drug for metastatic BCC – at $70,000 a treatment with a cure rate of 20%.
range of cost for Dave: best case scenario : $200 (if ED & C with me) he can tell us what bill he gets from his doc .
To, say, a load of surgeries and hospital stays costing $150,000+ – albeit spread out over time.
People go on about evidence based medicine – you need to realize that the evidence is not there for a huge amount of what we do. Its there for plenty of it, but not everything.
I suspect Dave will be fine.
> you need to realize that the evidence is not there
> for a huge amount of what we do
That’s a vital part of it … not to mention the statistical weakness of many studies, and all the evidence that’s suppressed from publication. (See Ben Goldacre’s TEDMED talk this year, The Missing Data. I don’t know how a doctor can be expected to make good decisions in world of such shaky pudding!)
Plus, there’s the whole issue of the illusion of certainty in what is inherently a chaotic environment – the living body, when we don’t know (today to at least) exactly what’s wrong in most cases. That subject is just too deep for most people (including many docs) to grasp, especially if they’ve all been raised in the delusion that physicians are all-knowing gods.
A more abstract version of this came up the other day in the members’ email list at the Society for Participatory Medicine – he called it “epistemic certainty.” (Google that if you haven’t had enough philosophy today.)
So here’s to the people who do get things done, and fight to do the right thing!
Again, Joe, how do patients find people like you – or, more broadly, how do buyers of medical services (patient or self-insured employer) find out the full range of options?
In the three months of my blogging about this cost hunt not a soul showed up to mention this idea… otoh, on the CT scan thread I did mention what the HealthCareBlueBook guy said… I wonder why it never occurred to ME to look for a dermatologist outside a hospital.
What the heck is wrong with us (collectively) that we don’t know this??
“What the heck is wrong with us (collectively) that we don’t know this??
I’m not in the US, I’m in the province of Quebec, in Canada. As you know, we have a public health system. Is that perfect? Not by a long shot, but it does save us (patients) some of the horrendous costs I keep hearing about from patients in the US.
However, that ‘What the heck…’ question is just as relevant here as it is in the States. Since it is cancer we are talking about, I would say it comes from a basic assumption: the best care and the best doctors are found in hospitals. The doctor working in a hospital will have a bigger volume of cases, more hands-on expertise. In marketing, there’s a saying that ‘perception is reality’. Well, that seems to hold true in the medical field as well.
Why is it so expensive, you’re supposed to be paying not exceeding $2000 plus you shouldn’t worry about it if you have a healthcare. Are you looking for laser hair removal?
I’ve recently deleted numerous spammy comments like this. I’m leaving this one in, just to make it clear that yeah there’s random crap on the internet, and yeah you hear from heaven-only-knows-who, and nobody with a brain responds to spam comments on the internet as if they were credible.
“Shouldn’t worry about it if you have a healthcare,” eh, Thomas? Good luck with that –
Common sense tip: avoid any provider (in ANY industry, especially healthcare) whose marketing consists of googling related keywords and paying semi-literate people to leave comments with links to their website!
e-P Dave,
Now I’m totally confused. I’m pretty sure I have a couple BCCs and maybe a few SCCs. I was searching all over the web for a ball park figure for the MOHS procedure. I did come across that site that competes with WebMD and it said between $1000-$3000. I live in Houston and own my own business (no insurance), but I’ve got the cash. Did you ask about cash discounts? It’s obvious the Docs and insurance companies are really going at it. Like someone told me once. Insurance companies have two objectives (1) Selling Policies and (2) Rejecting claims. But after reading the research you did and all the different options. They have creams for small BCCs early stage and squamous now too. As you can see I’m all over the map. As I was reading that string of comments that got me here. It helped me a great deal to get all that info (or opinions) all in one place.
Thank you so much for your information. I have basil cell cancer and atypical mole on back, both Moh’s procedure on front and excision on back supposedly at the most 2000.00 as stated by receptionist. Unfortunately, I have gone through other insurance hell where I’ve been told one thing in office and bill is completely different. We should not accept this. We should demand claity and transparency at all levels of health care. Keep up the good work.