Lauren A. V. Orenstein, MD | She/her/hers  Assistant Professor of Dermatology

Dermatology: Financial Reimbursements Better for White Males, Primarily Due to Treatment of Premalignant Lesions and Biopsies Interview with:

Lauren A. V. Orenstein, MD | She/her/hers  Assistant Professor of Dermatology

Dr. Orenstein

Lauren A. V. Orenstein, MD | She/her/hers
Assistant Professor of Dermatology

Robert A. Swerlick, MD Professor and Alicia Leizman Stonecipher Chair of Dermatology Emory University School of Medicine

Dr. Swerlick

Robert A. Swerlick, MD
Professor and Alicia Leizman Stonecipher Chair of Dermatology
Emory University School of Medicine
Atlanta, GA 30322 What is the background for this study?

Response: Financial incentives have the potential to drive provider behavior, even unintentionally. The aim of this study was to evaluate differences in clinic “productivity” measures that occur in outpatient dermatology encounters. Specifically, we used data from 2016-2020 at one academic dermatology practice to evaluate differences in work relative value units (wRVUs, a measure of clinical productivity) and financial reimbursement by patient race, sex, and age. 66,463 encounters were included in this study, among which 70.1% of encounters were for white patients, 59.6% were for females, and the mean age was 55.9 years old. What are the main findings?

Response: This study found that outpatient dermatology encounters for patients who were female and/or persons of color generated significantly less clinical “productivity” as measured by fewer wRVUs and financial collections than encounters for white male patients. Further, the majority of these differences could be explained by destruction of premalignant lesions and skin biopsies. When adjusting for age, sex, and insurance type, visits for Black patients generated 18% fewer wRVUs; visits for Asian patients generated 15% fewer wRVUs, and visits for individuals with other racial backgrounds generated 13% fewer wRVUs. Being female was associated with 7% fewer wRVUs. What should readers take away from your report?

Response: Outpatient dermatology encounters for patients of color and females led to lower clinical productivity metrics and reimbursement. In systems where providers receive RVU- or collections-based compensation, these differences result in financial incentives to see non-skin of color populations and have the potential to exacerbate disparities in access to dermatologic care. What recommendations do you have for future research as a result of this work?

Response: This study was performed at a single institution and should be re-evaluated using nationally representative datasets. It also remains unknown how the 2021 E/M coding guidelines may influence measures of clinical “productivity” and collections by patient race and sex. Is there anything else you would like to add?

Response: This study was not designed to study the direct influence of financial incentives on provider behavior. Although this study demonstrated lower wRVUs and compensation in outpatient dermatology encounters for female patients and persons of color, it was unable to evaluate provider time spent on encounters by patient demographics. Although we do not expect this to be the case, if encounters for premalignant destruction and biopsies were more time consuming than dermatology encounters for women and persons of color, then perhaps the relative differences in encounter values could be justified.


Orenstein LAV, Nelson MM, Wolner Z, et al. Differences in Outpatient Dermatology Encounter Work Relative Value Units and Net Payments by Patient Race, Sex, and Age. JAMA Dermatol. Published online February 17, 2021. doi:10.1001/jamadermatol.2020.5823 



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Last Updated on February 18, 2021 by Marie Benz MD FAAD