Analysis of national skin cancer expenditures in the United States Medicare population, 2013

Abstract

s of this work were previously presented at Maui Derm for Dermatologists in Maui, Hawaii, January 28-February 1, 2018, and the 42nd Hawaii Dermatology Seminar in Kauai, Hawaii, February 4-9, 2018. Reprints not available from the authors. Correspondence to: Eric J. Yang, BS, University of California San Francisco Psoriasis and Skin Treatment Center, 515 Spruce St, San Francisco, CA, 94118 E-mail: [email protected] REFERENCES 1. Lim HW, Collins SAB, Resneck JS Jr, et al. The burden of skin disease in the United States. J Am Acad Dermatol. 2017;76:958-972.e2. 2. Schumock GT, Li EC, Wiest MD, et al. National trends in prescription drug expenditures and projections for 2017. Am J Health Syst Pharm. 2017;74:1158-1173. 3. Keehan SP, Poisal JA, Cuckler GA, et al. National health expenditure projections, 2015-25: economy, prices, and aging expected to shape spending and enrollment. Health Aff (Millwood). 2016;35:1522-1531. 4. 2016 Drug Trend Report: Express Scripts. https://doi.org/10.1016/j.jaad.2018.04.019 Analysis of national skin cancer expenditures in the United States Medicare population, 2013 To the Editor: Approximately 3 million adults in the United States are treated annually for skin cancer, costing nearly $8.1 billion per year. Nonmelanoma skin cancer and malignant melanoma (MM) are the fifth and ninth most costly dermatologic conditions, respectively. The few studies that have evaluated allocation of resources on skin cancer have underestimated total cost, as they included only payments to dermatologists. The goal of this study was to analyze 2013 Medicare skin cancer spending by diagnosis and procedure. The 2013 Medicare Limited Data Set Standard Analytic File 5% Sample Physician Supplier was queried for all claims filed for International Classification of Diseases, Ninth Revision, Clinical Modification codes for MM, squamous cell carcinoma (SCC), basal cell carcinoma (BCC), other malignant neoplasms of the skin, carcinoma in situ of the skin (CIS), actinic keratosis (AK), and neoplasm of uncertain behavior of the skin. All payments Fig 1. Stacked bar chart illustrating the cost of each treatment category by diagnosis and showing the amount spent on each treatment modality for each diagnosis. AK, Actinic keratosis; BCC, basal cell carcinoma; CIS, carcinoma in situ; E&M, evaluation and management; MM, malignant melanoma; NUB, neoplasm uncertain behavior; OMN, other malignant neoplasm; SCC, squamous cell carcinoma. J AM ACAD DERMATOL JANUARY 2019 276 Research Letters associated with more than 1570 Current Procedural Terminology codes were classified into 9 treatment categories (evaluation and management, biopsy, surgical procedures, destruction, laboratory and pathology, radiology and other imaging procedures, systemic therapy, radiation, and other) and 22 subcategories by diagnosis. Spending on each subcategory was summed to calculate total and mean spending per person per diagnosis. All analyses were performed with SAS software (version 9.4, SAS Institute Inc, Cary, NC). The Partners Human Research Committee exempted this study. A total of $2.5 billion was spent on skin cancererelated diagnoses in Medicare patients in 2013. Half (49%) of this spending was on BCC ($715 million) and SCC ($525 million), which are highly prevalent cancers. Total spending on AK ($554 million) narrowly exceeded that on SCC, with 76% of AK resources allocated to destruction (Fig 1). MM was the costliest diagnosis per person per year ($1241), followed by BCC ($689) and SCC ($649). The percentages of total spending on skin cancer per diagnosis were as follows BCC, 29%; AK, 22%; SCC, 21%; neoplasm of uncertain behavior of the skin, 15%; MM, 7%; CIS, 3.5%; and other, 3.5%. Mohs micrographic surgical excision accounted for 17.5% of spending ($438 million). Approximately half of spending on MM (48%) was for systemic therapy. Forty percent of spending on MM ($74 million) was allocated to ipilimumab for 920 patients (0.6% of patients with melanoma) at a cost of $80 thousand per patient treated (Table I). In conclusion, of the $2.5 billion spent on skin cancererelated diagnoses, the majority (72%) was divided approximately equally between treatment of BCC, SCC, and AK. Because the costs of topical prescription drugs such as 5-fluorouracil were not included in this analysis, the costs of treatment of AKs, CIS, and superficial BCCs are underestimated. The largest fraction (40%) of money spent on MM is Table I. Detailed spending analysis by diagnosis Indicator MM SCC BCC OMN CIS AK NUB Total cost* (%) Annualized cost per patient Total cost* (%) Annualized cost per patient Total cost* (%) Annualized cost per patient Total cost* (%) Annualized cost per patient Total cost* (%) Annualized cost per patient Total cost* (%) Annualized cost per patient Total cost* (%) Annualized cost per patient Total $183,613 (7) $1241 $525,826 (21) $649 $715,427 (29) $689 $88,595 (3.5) $356 $87,256 (3.5) $242 $554,152 (22) $139 $366,882 (15) $152 E/M $16,324 (9) $177 $16,196 (3) $73 $22,713 (3) $68 $7290 (8) $79 $3007 (3) $58 $66,012 (12) $61 $41,368 (11) $58 Biopsy $691 (0.7) $69 $6019 (1) $76 $9206 (1) $74 $1514 (2) $81 $1963 (2) $72 $8908 (1) $87 $203,486 (55) $105 Surgical procedures Excision $14,743 (8) $272 $44,308 (8) $188 $46,205 (6) $180 $8641 (10) $199 $6856 (8) $170 $3545 (1) $134 $5,646 (7) $111 Mohs micrographic surgery $1301 (5) $556 $156,422 (30) $770 $249,072 (35) $804 $16,311 (18) $842 $14,689 (17) $723 $88 (0) $487 $357 (0.1) $458 Primary repairs $9734 (6) $260 $68,469 (13) $261 $80,338 (11) $249 $6959 (8) $237 $9125 (10) $249 $692 (0.1) $177 $16,083 (4) $251 Flaps and grafts $11,615 (6) $771 $79,489 (15) $836 $137,663 (19) $817 $15,396 (17) $761 $6960 (8) $786 $883 (0.2) $649 $5811 (2) $761 LN procedure $3303 (2.2) $273 $348 (0.1) $129 $7 (0) $177 $144 (0.2) $241 $12 (0) $195 — — $24 (0) $200 Other $672 (0.4) $517 $1529 (0.3) $622 $4569 (1) $567 $1830 (2) $520 $214 (0.3) $357 $157 (0) $157 $6607 (2) $171 Destruction $286 (0.2) $114 $37,514 (7) $166 $41,643 (6) $155 $4221 (5) $164 $15,491 (18) $153 $422,363 (76) $115 $5785 (2) $83 PDT — — $37 (0) $122 $28 (0) $140 $3 (0) $135 $18 (0.2) $150 $16,412 (3) $211 $16 (0) $112 Laboratory and pathology $15,520 (8) $174 $53,187 (7) $100 $75,497 (11) $98 $10,339 (11) $117 $27,205 (31) $96 $34,001 (6) $81 $58,991 (16) $88 Radiology and imaging procedures $23,357 (13) $565 $35,334 (7) $1959 $25,304 (4) $1685 $11,033 (12) $945 $1205 (1) $941 $25 (0) $61 $539 (0.2) $69 Systemic therapy Ipilimumab $73,781 (40) $80,196 — — — — $697 (1) $34,861 — — — — — — Interferon $1271 (1) $9077 — — $5 (0) $236 — — — — — — — — Chemotherapy $2994 (2) $1610 $226 (0) $195 $51 (0.1) $213 $111 (0.1) $463 — — — — $28 (0) $172 Monoclonal Ab $1518 (1) $15,178 — — $267 (0.4) $6687 — — — — — — $571 (0.2) $14,272 Immunotherapy $372 (0.2) $18,575 — — — — — — — — — — — — EGFR $148 (0.1) $7417 $1630 $9056 — — $362 (0.4) $6039 — — — — — — Other $688 (0.4) $383 $141 (0) $76 $36 (0) $17 $131 (0.1) $122 $6 (0) $50 $28 (0) $10 $60 (0) $12 Radiation $34 (0.2) $840 $20,926 (4) $19,023 $17,687 (2) $14,264 $558 (1) $13,949 $1205 (1) $941 — — — — Other $5206 (3) $118 $4001 (1) $143 $4981 (1) $138 $3048 (4) $131 $317 (0.4) $151 $1038 (0.1) $126 $1091 (0.3) $45 Ab, Antibody; AK, actinic keratosis; BCC, basal cell carcinoma; CIS, carcinoma in situ; EGFR, epidermal growth factor receptor; E/M, evaluation and management; ICD, International Classification of Disease; LN, lymph node; MM, malignant melanoma; NUB, neoplasm uncertain behavior; OMN, other malignant neoplasm; PDT, photodynamic therapy; SCC, squamous cell carcinoma. *Total costs reported in thousands of dollars. J A M A C A D D E R M A T O L V O LU M E 8 0 ,N U M B E R 1 R esea ch Ltters 2 7 7 J AM ACAD DERMATOL JANUARY 2019 278 Research Letters spent on a small number of patients (\\1%) who require expensive systemic therapy. A limitation of this study is that claims data rely on the accuracy of coding by physicians. Medicare data include information only on individuals age 65 year and older; therefore, additional studies that include patients of all ages are needed to generate a comprehensive analysis of skin cancer spending. Emily Stamell Ruiz, MD, MPH, Frederick C. Morgan, BSPH, Corwin M. Zigler, PhD, Robert J. Besaw, MPH, and Chrysalyne D. Schmults, MD, MSCE From the Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts Funding sources: Dr Ruiz was supported by a Dermatology Foundation Career Development Award. Conflicts of interest: None disclosed. Reprints not available from the authors. Correspondence to: Chrysalyne D. Schmults, MD, MSCE, Department of Dermatology, Brigham and Women’s Hospital, 1153 Centre St, Suite 4J, Boston, MA 02130 E-mail: [email protected] REFERENCES 1. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the US population, 2012. JAMA Dermatol. 2015;151: 1081-1086. 2. Guy GP Jr, Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011. Am J Prev Med. 2015;48:183-187. 3. Lim HW, Collins SAB, Resneck JS Jr, et al. The burden of skin disease in the United States. J Am Acad Dermatol. 2017;76: 958-972.e2. https://doi.org/10.1016/j.jaad.2018.04.035 Survey analysis on the management of moderately dysplastic nevi among academic dermatologists across the United States To the Editor: Currently there are no clinical guidelines for the management of moderately dysplastic nevi (DN), and the decision to observe, rebiopsy, or excise remains up to the discretion of the dermatologist. Many dermatopathologists do not embrace the grading system of mild, moderate, or severe dysplasia but simply comment on the presence of architectural or cytologic atypia. In the literature to date, there is sign