Dermatology Crisis: Doctors aren’t accepting new skin care patients

A recent shakeup in Mercy Springfield Communities dermatology department is shining light on an industrywide crisis amplified across the Ozarks.

In June, Dr. Jenifer Insley left Mercy to join Ozarks Dermatology Specialists LLC. Earlier this month, 20-year Mercy dermatologist Dr. Raffaele Pennella followed suit at the private practice. Compound that with a pair of retirements since October and the Mercy department is down to just one dermatologist on staff, Dr. Dean Mittman.

“Over the last few years, our region has lost about eight dermatologists,” said Linda Earnest, vice president of operations at Mercy. “This is a bigger issue than just at Mercy. There is a nationwide shortage, and the Ozarks has been hit hard.”

The equation is simple: A rise in skin cancer, combined with small dermatologist graduate numbers hampered by government funding and compounded by retirements equals an overburdened system with long patient wait times and little hope for change.

Springfield Business Journal research found 11 dermatologists doing business in the city. Dr. Michael Swann believes the area could easily double in skin care doctors and still have a need.

“In Springfield, when a couple people leave that’s a big percentage,” said, Swann, a dermatologist at Swann Dermatology LLC. “We’ve got three more ready to retire soon.

“Mercy is on volume overload right now. They are doing whatever they can to get by. That’s going to be happening all over.”

Mercy movements
Pennella said hospital constraints were his primary reason for leaving, opting for what he calls more freedom in private practice.

“Basically, the constraints, or the practice style, within the health systems is becoming more dictated,” he said. “Being in the hospital system like that, we can’t just say ‘I want three (registered nurses) so I can see more patients.’ You get two full-time equivalents because that’s what the medical system model dictates.”

Earnest declined to comment directly on the reasons for Pennella and Insley’s departure, saying she believes they felt private practice was in their better interest.

“They are both excellent dermatologists and there are benefits to private practice,” she said. “The good news is they are staying in our community and our [insurance] network.”

A Mercy spokeswoman said staffing levels are determined based on patient volumes.

According to a 2014 study by online medical news website MedScape, one benefit of private practice is increased pay. Physicians working in health care organizations or group practices earned significantly more than their counterparts. Dermatologists in multispecialty group practices earned on average $336,000 annually, while those in outpatient clinical settings earned $211,000.

To fill the void, Mercy is turning to physician assistant Jeff Armstrong and – starting Aug. 24 – telemedicine consultations with the University of Missouri-Columbia.

“Telling a patient it will take four months to see them for a rash won’t cut it,” Earnest said.

Ideally, Earnest would like to see the department back up to at least five full-time dermatologists, but recruitment takes time.

“Our timeline is obviously ASAP,” she said. “We are in talks with a dermatologist in residency right now, which would put us on a timeline of next summer.”

Systemic issue
How did the dermatology sector wind up in crisis? Local officials say it’s a systemic issue dating back to the early 1990s and beyond.

“There are only 115 dermatology residency programs in the country with about 45 new doctors available each year,” said Paula Johnson, CoxHealth’s director of physician recruitment. “Because it’s government funded, it’s underfunded and there isn’t a great chance of increase.”

Residency positions are largely funded through the Medicare program, with most institutions receiving funding from Medicare Part B for associated residency education costs. The number of funded positions was frozen by Congress as Medicare funding growth has slowed. According the Kaiser Family Foundation, in 2015, spending on Medicare accounted for 15 percent of the federal budget – about $540 billion – but the average annual growth in total Medicare spending was 4.4 percent between 2010-15, down from 9 percent in the prior decade.

CoxHealth currently employs five dermatologists, four on staff and one independently contracted – similar to Pennella and Insley for Mercy. However, Pennella said two CoxHealth docs are slated to leave in October to start their own practice. CoxHealth’s Johnson could not be reached for further comment on the departures.

For the city’s second largest employer, recruiting is a tough process.

“When there is such a huge demand nationwide and they can go anywhere they want, it’s hard to get them to consider Springfield,” Johnson said, noting she’d like to have seven signed on.

Swann believes it’s all about lifestyle, and the Queen City doesn’t offer enough diversity and culture.

“Millennials want a way of life,” he said. “On a two-day visit to a city, they will remember the skyline and the food. Springfield is struggling.”

Recruitment aside, Pennella said the problem dates back to 1993 and Hillary Clinton.

“Before Obamacare there was Hillarycare, a managed health care system,” he said of the Clinton administration’s universal health care plan the Health Security Act, in which then first lady Clinton served as taskforce chairwoman. “The plan emphasized more primary care doctors and less specialists.”

In 1994, the plan was declared dead by the U.S. Senate, but Pennella said the specialist residency spots lost to primary care never came back.

“We shot ourselves in the foot,” he said.

Patient effect
On calls to dermatologists offices, potential patients are told they can’t get a timely appointment without having skin cancer.

“That’s not a good thing, but true,” said Swann. “We have to focus on the most serious first. That’s the priority.”

At Swann Dermatology, the wait on a standard skin check is three months to see the physician assistant and six months to see the dermatologist. At Ozarks Dermatology, they aren’t even taking patients with common skin aliments, such as acne and eczema.

Pennella said an existing patient with skin cancer could expect a couple-week wait and a new patient with skin cancer would be seen within a month.

According to the American Academy of Dermatology, dermatologists have been inundated with skin cancer patients – the most common cancer in the United States – with 8,500 diagnosed every day. About 4.9 million adults were treated in recent years, with one in five developing it during their lifetime.

“For other issues, like a rash or acne, patients should see their primary care doctor,” Pennella said, noting some patients are leaving town for treatment.

Dr. Karen Edison, chairwoman of the Mizzou dermatology department, has seen an increase in Columbia, saying Springfield-area patients have a lack of general dermatology care.

“I feel like we are all in it together – whether you are in a system or a practice – trying to best service the community’s needs,” Swann said. “The problem is we can’t work enough to do it. There aren’t enough hours in the week.

“That’s frustrating when you are a patient and you’re worried about something, but right now there isn’t enough manpower in the community to take care of you.”