This month's news from across the specialty

January 1, 2024

In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.  

Payer denials are an ever-increasing problem, leading to an increased burden of administrative tasks, and more and more physicians leaving the workplace due to a decreased sense of empowerment and physician burnout. In August’s Dialogues in Dermatology Practice Management Series: Effective Appeals to Payer Denials, guest speakers Dr. Sandy Johnson (Arkansas) and Dr. Howard Rogers (Connecticut) encourage us to keep up the good fight.

Because appeals are so time consuming for physicians, a common question among dermatologists is: should you appeal every denial? Dr. Johnson says that YES you should definitely appeal all of your denials. The good news is that it is estimated that at least 60% of claims denied are eventually paid upon appeal. Remember that the first round of appeals often gets denied. This is common protocol; try again as your appeal will advance to the next level. Appealing all your denials is not only good for your practice, but good for our specialty. If we do not push back, we will continue to see increased expansion of payer denials.

If you start to see a pattern of payer denials, notify the medical director of the insurance company, and please notify the Academy. In doing this, please consider batching your appeals. You may not get the attention of the medical director for a single denial, but if you have a batch of denials and appeals of the same pattern, or affecting multiple physicians in your office, this is attention-worthy.

Lastly, remember that the Academy has resources for you. Dermatologists can report payer denials to the AADA at privatepayer@aad.org.

The epidemic of mpox peaked in the U.S. in the summer of 2022. According to CDC data, daily cases peaked at 647 on Aug. 1, 2022. Cases have trended downward since, with fewer than 10 cases reported daily since mid-January 2023.

Mpox is down but not out. A recent MMWR report details an mpox outbreak in Chicago from March to June 2023, primarily occurring, notably, among people already vaccinated against mpox. Only one case of mpox was reported in Chicago in the two months prior to April 17, 2023. During the following two months, there were 40, prompting the city and CDC to investigate. (Editor's note: The CDC recently announced the detection of a more infectious strain of mpox, Clade I MPXV, which has not been detected in the U.S., but is spreading in the Democratic Republic of Congo.)

Of the cases, 55% occurred in fully vaccinated people (2 JYNNEOS doses or 1 ACAM2000 dose); 13% occurred in under-vaccinated people (only 1 JYNNEOS dose), and 33% in unvaccinated people. All cases occurred in people assigned male sex at birth, of whom 93% identified as male and 70% as gay. Among people affected, 28% were living with HIV; of those, over 90% were well-controlled. Compared with un- or under-vaccinated patients, vaccinated patients had milder infections, less likely to affect genital or ocular mucosa.

Mpox vaccines are very protective but not perfect. This report underscores the need for dermatologists to remain vigilant for mpox infections, to enable prompt testing and treatment, to inquire about gender(s) of their patients’ sex partners, when appropriate, to better understand risk; and to encourage at-risk patients who have not been fully vaccinated against mpox to do so.

Dermatology residency programs provide a variety of didactic conferences, including lectures, Kodachrome sessions, textbook reviews, grand rounds, and journal clubs. In some of these conferences, a faculty member shows dermatologic images to residents, and a resident is called upon to describe the morphologic features of the case and come up with a differential diagnosis and ultimately the correct diagnosis.

A recent editorial reminds us that these educational sessions should promote a safe learning environment and that faculty members should create a respectful culture that allows residents to feel comfortable sharing their thought processes. “We should celebrate the mastery of clinical reasoning — the approach taken to get to an answer, rather than simply to get the answer right. This is not only crucial for training our future master dermatologists, but most importantly for patients in need of a correct diagnosis” (JAMA Derm. 2022; 158(8): 865-866). I wholeheartedly agree with creating an environment in which trainees feel comfortable expressing their thought processes. However, I think this can be achieved only if faculty members are also open and honest about their own thought processes (i.e., their thought processes BEFORE the histopathologic diagnosis or other results are known). One way to be completely transparent is to show one’s “receipt” — the clinical diagnosis section on the pathology report. Instead of listing the differential diagnosis on a PowerPoint slide that was curated AFTER the histopathologic diagnosis or other results were known, the faculty member should show the clinical differential diagnosis on the histopathology report, which reveals the thinking process at the time of the biopsy. Faculty members should reveal to trainees their own clinical reasoning, rather than simply including the correct diagnosis on the differential diagnosis slide after all the results are known. Only when faculty members are transparent about our own missed diagnoses with honesty and humility can the learning environment feel safer for trainees.

Atypical fibroxanthoma and pleomorphic dermal sarcoma are both poorly differentiated skin tumors. The cell of origin for these tumors is unknown, but it is postulated to be either fibrohistiocytic or a poorly differentiated manifestation of another tumor, such as melanoma, squamous cell carcinoma, leiomyosarcoma, etc. The essential difference between these two tumors is that atypical fibroxanthoma is confined to the dermis and has a relatively good prognosis. Pleomorphic dermal sarcoma extends into the subcutaneous tissue or deep soft tissue with reported metastatic rates as high as 20%. A recent population-based cohort of 1,118 patients utilized the Danish National Registries to study prognosis of these tumors.

The risk for metastatic disease for atypical fibroxanthoma was 0.8%, and 16% for pleomorphic dermal sarcoma. Risk factors for metastasis included invasion beyond the subcutaneous tissue (fascia, bone, muscle, cartilage), and perineural/intravascular infiltration. Most metastatic disease occurred within the first three years of follow up. Based on their cohort, the authors recommended that patients with pleomorphic dermal sarcoma be followed by clinical examination and PET/CT twice a year for the first three years and then annually.

Additional DermWorld Resources