Skin biopsy and skin cancer treatment use in the Medicare population, 1993 to 2016

J Am Acad Dermatol. 2021 Jan;84(1):53-59. doi: 10.1016/j.jaad.2020.06.030. Epub 2020 Jun 15.

Abstract

Background: Skin biopsies are increasing at a rapid rate, and some may be unnecessary. Although skin cancer incidence is rising, there is varied biopsy accuracy between dermatologists and advanced practice professionals (APPs). A comparison of Current Procedural Terminology code (American Medical Association, Chicago, IL) use for skin biopsy and skin cancer treatment over 18 years and a comparison of provider types is needed. Excess skin biopsies increase health care costs and patient morbidity.

Objective: To examine changes in skin biopsy and skin cancer treatment utilization rates per year in the Medicare fee-for-service (FFS) population and to compare skin biopsy utilization rates between dermatologists and APPs.

Methods: Retrospective cross-sectional study of Medicare FFS paid claims using the Centers for Medicare and Medicaid Services Physician Claims databases. We calculated the number of skin biopsies and skin cancer treatments in the Medicare FFS population from 1993 to 2016, and percentage use by provider type from 2001 to 2016. Our primary outcome measurements were the number of skin biopsies and skin cancer treatments per 1000 Medicare FFS beneficiaries per year and the number of additional skin biopsies per 1000 Medicare FFS beneficiaries per year, or the difference in the number of skin biopsies and number of skin cancer treatments per 1000 Medicare FFS beneficiaries. Our secondary outcome measurements were the skin biopsy-to-skin cancer treatment ratio and the number of procedures per 1000 Medicare FFS beneficiaries per year by provider type.

Results: After adjusting for the number of enrollees in the Medicare FFS population from 1993 to 2016, skin biopsies per 1000 Medicare FFS beneficiaries increased 153% (from 39.31 to 99.33), and skin cancer treatments per 1000 Medicare FFS beneficiaries increased 39% (from 34.67 to 48.26). Between 1993 and 2016, the skin biopsy-to-skin cancer treatment ratio increased 81% (from 1.134 to 2.058), and the number of additional biopsies per 1000 Medicare FFS beneficiaries increased 1001% (from 4.638 to 51.072) between 1993 and 2016. Utilization data by provider type is available from 2001 to 2016. The number of skin biopsies per 1000 Medicare beneficiaries performed by APPs increased from 0.82 to 17.19 or 1996% (nurse practitioners, 2211%; physician assistants, 1916%) and the number of biopsies by dermatologists increased by 41% from 53.98 to 76.17.

Limitations: Medicare claims data do not provide specific information regarding skin biopsy or skin cancer treatment use.

Conclusion: The number of skin biopsies has risen 153% since 1993, while the number of skin cancer treatments has only increased 39%. Our data highlight the rise of biopsy use and the increase in biopsies that do not result in skin cancer diagnosis or treatment. This suggests APPs may be responsible for increasing the cost of skin cancer management by biopsying significantly more benign lesions than dermatologists.

Keywords: Mohs micrographic surgery; destruction; excision; skin biopsy; skin cancer.

MeSH terms

  • Aged
  • Biopsy / statistics & numerical data
  • Biopsy / trends*
  • Cross-Sectional Studies
  • Fee-for-Service Plans / economics*
  • Health Care Costs
  • Humans
  • Medicare / economics*
  • Middle Aged
  • Mohs Surgery
  • Procedures and Techniques Utilization
  • Retrospective Studies
  • Skin Neoplasms / diagnosis*
  • Skin Neoplasms / surgery*
  • United States
  • Unnecessary Procedures