Only 33% of Visits for Skin Disease in the US in 1995 Were to Dermatologists:
Is Decreasing the Number of Dermatologists the Appropriate Response?
The National Ambulatory Medical Care Survey conducted in 1995 provides an assessment of ambulatory medical practice including diagnoses, physician specialties, and insurance information. The National Center for Health Statistics collected data from non-federally employed physicians of all specialties using their standardized sampling technique. The database was reviewed for aspects of visits for skin diseases for all patients. The total number of visits for dermatologic disease in 1995 was estimated to be 22.0 million. 21.7% of these were first time visits and 24.3% were referrals. The leading dermatologic diagnoses in 1995 in order of frequency were acne, contact dermatitis, hypertrophic and atrophic conditions of skin, viral warts, malignant neoplasm of skin, benign neoplasm of skin, psoriasis, cellulitis and abscess, disorders of skin and subcutaneous tissue, and localized superficial swelling/mass/lump. Dermatology led all specialties in providing 32.6% of the dermatologic outpatient care in 1995, followed by general/family medicine (22.7%), internal medicine (12.8%), pediatrics (11.2%), and all other specialties (20.7%). Of the visits to dermatologist in 1995, 3.78% were paid for by Medicaid. This paper presents dermatologic information pertaining to insurance, first time visits, referrals, diagnoses, and physician specialties.
The purpose of this work is to describe delivery of dermatologic care in 1995. The analysis includes insurance information, dermatology first time visits, dermatology referrals, dermatologic diagnoses, and specialties making dermatologic diagnoses. We have previously published on dermatologic care provided by physicians.
The 1995 National Ambulatory Medical Care Survey (NAMCS) was conducted by the National Center for Health Statistics (NCHS) as an ongoing descriptive data collection effort regarding office-based physician practice.  The sampling was limited to physicians principally engaged in patient care activities who were not federally employed. The multistage probability sampling design is stratified by primary sampling unit (county, or contiguous counties, or a standard metropolitan statistical area), then by physician practices within the sampling unit, and finally, by patient visit within 52 (weekly) randomized periods of 1995. Within small practices, a 100% sample of one week's visits was possible. For very large practices, a systemic random sample from among all visits for a selected week achieved a 20% sampling rate. The resulting national estimates describe the utilization of ambulatory services in the US.
All estimates are subject to sampling error. The relative standard error for each estimate in this study is based upon the number of patient visits. Examples of the relative standard error for estimates in this study are as follows: 8.4% for estimates of 10,000,000 visits, 22.5% for estimates of 1,000,000 visits, 31.4% for estimates of 500,000 visits, and 69.7% for estimates of 100,000 visits.
Insurance Information: The data provided by the NAMCS estimates a total of 22.0 million visits to dermatologists for all conditions in 1995. Excluding other and unknown insurers, there were a total of 18.3 million visits to dermatologists funded by some form of insurance. 3.78% of these visits were paid for by Medicaid. 96.2% were paid for by some other insurer Blue cross/Blue shield, other private insurance, Medicare, Worker's compensation.
Dermatology First Time Visits: Of the 22.0 million visits to dermatologists in 1995, 21.7% were first time visits.
Dermatology Referrals: Of the 22.0 million dermatology visits in 1995, 24.3% were referrals.
Dermatologic Diagnoses: The ten most common dermatologic diagnoses in 1995 are listed in Table 1.
Specialties Making Dermatologic Diagnoses. The physician specialties that made the majority of the dermatologic diagnoses in 1995 are demonstrated in Figure 1. Dermatologists made 32.6% of the dermatologic diagnoses. This is a decline from 37.9% in 1992 reported by Feldman. 
The proportion of patients with skin disease seen by dermatologists has decreased from 37.9% as reported by Feldman et al in 1992 to 32.6% in 1995.3 This could represent an effect of managed care. It could also suggest a need to decrease the number of dermatologists.
Another possibility that must be considered is that there are too few dermatologists and that patients visit primary care doctors because dermatologists are unavailable or the wait is too long to see busy dermatologists. The decreased number of visits per dermatologist favors the former explanation. However, it is also possible that the decreased number of visits to dermatologists reflects growing emphasis on cosmetic and procedural care brought on by lower reimbursement for evaluation and management services which make dermatologists less available to treat patients with traditional dermatologic problems.
But with an irregular distribution of dermatologists, both phenomena could be occurring. In specialty-rich urban areas, a decreased percentage of visits to dermatologists may be due to more aggressive efforts of managed care. In rural or dermatology-neglected areas the unavailability may account for reduced utilization. 
Consideration of the different possibilities is important when planning for future manpower needs. The decreased proportional utilization of dermatologists may suggest a need to train fewer dermatologists, but too few dermatologists may also cause a decreased percentage of utilization of dermatologists. The distribution of dermatologic workforce requirements as well as utilization of dermatology services needs to be addressed.
The findings of decreased utilization of dermatologists also raises the question of who "should" see patients with skin disease. Dermatologists are more accurate at diagnosing skin disease. [4-7] But at present there are only limited data showing more cost-effective outcomes with dermatologists, and the importance of even this has been questioned.
For the past twenty years most skin disease visits have been to non-dermatologists and it appears that, for whatever reason, most skin care will be delivered by non-dermatologists for the foreseeable future. Important ethical issues need to be addressed with regard to training non-dermatologists in the treatment of skin disease. At first thought, it would appear to be in the best interest of patients for dermatologists to train non-dermatologists in skin disease.
While there may be valid concerns regarding the future of the dermatology specialty, it has not been shown that increasing education of non-dermatologists reduces visits to dermatologists. In fact, there are reasons to believe otherwise. Education of non-dermatologists may help them realize the complexity of dermatologic disease, its implications on quality of life, its treatment, and potential adverse outcomes.
References1. Feldman SR, Fleischer AB Jr, Williford PM, White R, Byington R. Increasing Utilization of Dermatologists by Managed Care: An Analysis of the National Ambulatory Medical Care Survey, 1990„1994. J Am Acad Dermatol 1997;37:784-788.
2. National Center for Health Statistics, Public use data tape documentation. 1995 National Ambulatory Medical Survey. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, 1995.
3. Feldman SR, Williford PM, Fleischer AB. Lower utilization of dermatologists in managed care: despite growth in managed care, visits to dermatologists did not decrease: an analysis of National Ambulatory Medical Care Survey data, 1990-1992. Journal of Investigative Dermatology. 1996; 860-864.
4. Federman D, Hogan D, Taylor JR, Caralis P, Kirsner RS. A comparison of diagnosis, evaluation, and treatment of patients with dermatologic disorders. Journal of the American Academy of Dermatology. 1995; 726-729.
5. Basarab T, Munn SE, Jones RR: Diagnostic accuracy an appropriateness of general practitioner referrals to a dermatology out-patient clinic. Br J Dermatol 1996;135;70-3.
6. 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;265:74-7.
7. Brodkin RH. Rickert R. Machler BC. The dermatologist and managed care. Cutis 1996;58(5):352.
© 1998 Dermatology Online Journal