Though public health officials are urging medical practices to use virtual patient visits to help slow the spread of the coronavirus, a surprising number of dermatology offices, many of them owned by private equity investment firms, remain open for in-person skin checks and other nonurgent services.
Many dermatologists have closed their offices, instead examining rashes and skin growths via Zoom, FaceTime and photos. But in a study to be published by the Journal of Dermatological Treatment, a group of researchers at the University of Cincinnati called 60 dermatology practices on March 23, when California, Illinois, New Jersey and New York already had stay-at-home restrictions in place, to see if they were open. Of the 55 dermatology practices they reached in six states, 29 said they were open to all patients. Seventeen said they were open only to urgent visits, and nine said they were closed to all patients.
This week, with most of the country under shelter-in-place orders, The New York Times found practices large and small still scheduling in-person visits.
Decisions to keep dermatology offices open for all but the most urgent visits ignore guidelines issued last month by the American Academy of Dermatology, which recommended rescheduling visits for all nonessential medical or surgical visits or, alternatively, offering telemedicine services.
Pinnacle Dermatology, based in Lombard, Ill., with 52 locations in five states, states on its website that it is an “essential business’ and its “offices remain open.”
Chicago Pacific Founders, a private investment firm, holds a substantial stake in Pinnacle, which is offering telemedicine visits and, for in-person appointments, gives patients the option of waiting in their car. The site says that Pinnacle will continue to do full-body skin checks, and to see patients for rashes, eczema and psoriasis.
Pinnacle is also offering senior hours at 15 of its locations, for patients over age 60.
The multibillion-dollar dermatology services market thrives on large volumes of small procedures like skin biopsies, patch tests, freezing of precancerous lesions, excisions and layered “Mohs” surgery to treat skin cancer, many of them performed on Medicare patients.
A Facebook group of dermatologists has been debating the ethics of keeping practices open. One member of the group reported that her older relatives had received an unsolicited text from Pinnacle, alerting them to the senior hours.
“How unethical to try to get patients let alone seniors out of their homes for an appointment at this time,” the dermatologist wrote to the group.
Multiple attempts to reach Pinnacle’s chief executive, Chad A. Eckes, were unsuccessful.
“The Covid crisis is bringing out a real tension between what’s good for practices versus what’s best for our patients, staff and community at large,” said Dr. Justin Ko, chief of medical dermatology at Stanford University.
A spate of private-equity acquisitions of dermatology practices in recent years has prompted concern from within the specialty that many of those practices are under increased pressure to generate revenue.
California Skin Institute, a practice with 44 locations throughout California, is not owned by a private equity firm, but Goldman Sachs has a minority investment in it. The practice says on its website that it “is considered an essential business.” Callers to the practice get a recorded message stating that it “remains open and fully operational, providing a full range of services.”
Dr. Greg S. Morganroth, California Skin Institute’s founder and chief executive officer, did not respond to requests for comment, but Jonathan Lindeke, general counsel for the practice, said the company has stopped all cosmetic dermatology, and has furloughed all its aestheticians, laser nurses and cosmetic consultants.
Mr. Lindeke added that the company’s “overall business is down substantially.” Several office locations have closed, he said, and the majority of offices that remain open are on a reduced schedule.
California Skin Institute is keeping as many offices as possible open, Mr. Lindeke said, for patients who need medical dermatology. This, he said, “keeps the patients out of urgent care centers or the emergency room, reducing the burden on those facilities.”
Dr. Carrie Kovarik, a dermatologist at the University of Pennsylvania who is on the American Academy of Dermatology’s ad hoc task force on Covid-19, said the decision to remain open is up to individual practices. “The best we can do is offer our guidance and advice,” she said.
Dr. Kovarik said her university’s dermatology clinics have closed to all but the most urgent cases and is offering virtual visits. Similarly, Stanford Health Care in Northern California, which set up virtual dermatology appointments in early March for patients at its 13 clinics throughout the San Francisco Bay Area, now conducts 98 percent of its patient visits digitally.
Dr. Ko said the only people seen in person at the Stanford clinics are the most urgent cases, such as patients with a suspected melanoma — the most dangerous form of skin cancer — who need a biopsy.
“Unfortunately, we can’t do a biopsy digitally,” he said.
Adults over 65 are at highest risk of severe illness from the coronavirus. At the same time, most people in need of medical dermatology are older adults.
They are more likely to develop nonurgent, slow-growing basal and squamous cell skin cancers than melanoma. Basal and squamous cell skin cancers, which often develop after years of unprotected skin exposure, are 18 to 20 times more common than melanoma. Such cancers are rarely life-threatening, but accurate diagnosis requires a biopsy.
In a 2017 article, The New York Times found a pattern of unnecessary biopsies and other procedures for older adults among dermatologists in the U.S.
Dr. Ko at Stanford said that office visits for slow-growing cancers and other nonurgent problems can pose a danger not only to older patients, but also to office staff and clinicians.
“They’re stuck in the middle,” he said. “And that’s a really stressful, really difficult place to be.”
