Contribution of health care factors to the burden of skin disease in the United States

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1 FROM THE ACADEMY Contribution of health care factors to the burden of disease in the United States HenryW.Lim,MD, a ScottA.B.Collins,MD, b Jack S. Resneck, Jr, MD, c Jean L. Bolognia, MD, d Julie A. Hodge, MD, MPH, e Thomas A. Rohrer, MD, f MartaJ.VanBeek,MD,MPH, g David J. Margolis, MD, PhD, h Arthur J. Sober, MD, i Martin A. Weinstock, MD, PhD, j David R. Nerenz, PhD, k Wendy Smith Begolka, MBS, l and Jose V. Moyano, PhD l Detroit, Michigan; Tigard, Oregon; San Francisco, California; New Haven, Connecticut; Fullerton, California; Boston, Massachusetts; Iowa City, Iowa; Philadelphia, Pennsylvania; Providence, Rhode Island; and Schaumburg, Illinois The American Academy of Dermatology has developed an up-to-date national Burden of Skin Disease Report on the impact of disease on patients and on the US population. In this second of 3 manuscripts, data are presented on specific health care dimensions that contribute to the overall burden of disease. Through the use of data derived from medical claims in 2013 for 24 disease categories, these results indicate that disease health care is delivered most frequently to the aging US population, who are afflicted with more diseases than other age groups. Furthermore, the overall cost of disease is highest within the commercially insured population, and disease treatment primarily occurs in the outpatient setting. Dermatologists provided approximately 30% of office visit care and performed nearly 50% of cutaneous surgeries. These findings serve as a critical foundation for future discussions on the clinical importance of disease and the value of dermatologic care across the population. ( J Am Acad Dermatol 2017;76: ) Key words: burden of disease; burden of disease report; claims-based prevalence; dermatology; direct cost; economic driver; health care economics; indirect cost; inpatient cost; insurer cost; medical cost; office visit cost; outpatient cost; over-the-counter drug cost; prescription drug cost; health care provider; surgery; workforce. Skin disease affects millions of people worldwide and is a leading cause of global disease burden. 1 The past decade has brought therapeutic innovations to medicine but also many changes to the delivery of health care. 2-4 With finite resources available for research, clinical care, and public health initiatives, it is imperative to accurately quantify the overall burden of disease for the US population. Abbreviations used: AAD: American Academy of Dermatology BSD: burden of disease The last national Burden of Skin Disease (BSD) Report was published over 10 years ago. 5 The American Academy of Dermatology (AAD) has From the Department of Dermatology, Henry Ford Hospital, Detroit, Michigan a ; Dermatology Associates PC, Tigard, Oregon b ; the Department of Dermatology and Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California c ; the Department of Dermatology, Yale School of Medicine, New Haven, Connecticut d ; private practice, Fullerton, California e ; SkinCarePhysicians, Boston, Massachusetts f ; the Department of Dermatology, University of Iowa, Iowa City, Iowa g ; the Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania h ; the Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts i ; the Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island j ; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan k ; and the Department of Science, Quality and Practice, American Academy of Dermatology, Schaumburg, Illinois. l Funding sources: None. Conflict of interest: None declared. Accepted for publication March 13, Reprint requests: Jose V. Moyano, PhD, American Academy of Dermatology, 930 East Woodfield Road, Schaumburg, IL BSD@aad.org. Published online April 18, /$36.00 Ó 2017 by the American Academy of Dermatology, Inc

2 1152 Lim et al JUNE 2017 developed an up-to-date BSD Report to provide a comprehensive assessment of the prevalence and economic burden of 24 disease categories through the use of 2013 medical claims data tabulation. 6 This report estimates that 85 million Americans were seen by a physician for at least 1 disease in This led to an associated direct health care cost of nearly $75 billion and resulted in $11 billion in lost productivity. 7 In this second of 3 manuscripts, these data have been further analyzed relatedtopatientage, disease, insurance status, and other health care factors. These data yield further insights to inform discussions on dermatologic health care access, treatment selection, care coordination, and policy decisions. CAPSULE SUMMARY METHODS In 2014, the AAD appointed a BSD Work Group* to develop a current BSD report. Milliman (New York, NY) was selected to work with the BSD Work Group. Detailed methodology can be found in the AAD BSD Report. 6 US population data and prevalence measurement methodology, identification and categorization of diseases, and definitions of health care cost categories have been described in detail in the first manuscript of this series. 7 They are briefly summarized below. Skin disease category classification Twenty-four disease categories were identified for inclusion in this report and were assigned corresponding -related 2013 International Classification of Disease, Ninth Edition, diagnosis codes. The identification and assignment of conditions and International Classification of Disease, Ninth Edition, codes followed a set of key principles. *Chair: Henry W. Lim, MD; Members: Jean Bolognia, MD, Scott A. B. Collins, MD, Julie A. Hodge, MD, David J. Margolis, MD, PhD, Jack S. Resneck, MD, Thomas A. Rohrer, MD, Arthur J. Sober, MD, Marta J. Van Beek, MD, MPH, and Martin A. Weinstock, MD, PhD; Consultant: David R. Nerenz, PhD; Staff: Wendy Smith Begolka, MBS, and Jose V. Moyano, PhD d d d The prevalence of most diseases increases with age; prevalence is highest among Medicare patients, nearly half of whom have disease. The direct and per-person costs for the 24 disease categories studied here vary by disease and by insurer and are often higher for those with commercial insurance. Dermatologists provide the majority of care for serious and chronic diseases, including cancer, psoriasis, acne, rosacea, and vitiligo. US population by age and insurance status Medical Expenditure Panel Survey data were used to estimate the US 2013 population by age and insurance status. Specifically, the participants primary payer as of July 1, 2013, was used, resulting in assignment to 1 of 4 insurance statuses: commercial, Medicare, Medicaid, and uninsured. The following databases were used for the development of 2013 prevalence and cost estimates: commercial (Truven Health Analytics MarketScan Commercial Database [Market- Scan]), Medicare (Medicare 5% sample and Milliman Medicare Part D Claims Database [Milliman PDCD]), Medicaid (Kaiser Family Foundation report), and uninsured (Kaiser Family Foundation report). 8,9 As described in the first manuscript, a set of data selection rules for each data source was established to ensure representative and quality data. 7 Prevalence measurement methodology Prevalence in this report refers to the portion of the population having at least 1 of the 24 disease categories recorded on a health insurance claim during A disease diagnosis during 2013 may reflect both newly diagnosed disease and chronic disease requiring ongoing treatment. Prevalence, therefore, excludes people with a disease who did not file insurance claims in 2013, regardless of reason. To estimate the number of individuals diagnosed with disease in 2013, the specific prevalence for each disease category was converted to the number of individuals on the basis of the total population for each insured status. The prevalence for a specific disease category was compared on the basis of age groups by averaging the relative prevalence ratio between successive age groups. Medical cost tabulation and dimensions Medical costs associated with disease were determined through the use of diagnosis codes, procedure codes, national drug codes, and physician specialty codes to identify diseaseeassociated claims. When a claim had diagnoses for and non diseases, costs were divided among the conditions such that only the disease portion

3 VOLUME 76, NUMBER 6 Lim et al 1153 was included in tabulations. Claims data were tabulated as inpatient, outpatient therapies, outpatient surgeries/procedures, other dermatology procedures, and office visits. The complete list of surgical procedures included in the analysis is provided in Supplemental Table I (available at On the basis of established Current Procedural Terminology categories, phototherapy, photochemotherapy, photodynamic therapy, and targeted phototherapy were not considered surgery and therefore not included in the analysis. Whereas the classification used was appropriate to provide a consistent approach across all diseases, it is not intended to represent a standard with regard to defining codes as surgeries/procedures versus other for payment policy or legislative purposes. For the uninsured population, commercial tabulated costs were used and the uninsured-to-commercial cost ratio by type of service was applied. Services and costs for the 24 disease categories were assigned to the first diagnosis on the claim. To calculate the cost per individual with diagnosed disease, the total cost for each disease was divided by the number of individuals diagnosed with the disease. This calculation was performed for the total population and by insurance status. Note that 1 individual may have more than 1 diagnosed disease. Prescription drug tabulation dimensions Through the use of the claims datasets, prescription drug claims in 1 (or more) of the following categories were identified: d Dermatological drugs (as classified by the Medi- Span Therapeutic Classification System): drugs that are nearly always used for conditions d Skin disease vaccines d The top 100 drugs most frequently prescribed by dermatologists (as defined by the 2013 Medicare Part D Prescriber Public Use Files) Costs were tabulated by means of insurance status, type of drug, and specialty status. RESULTS Impact of age and insurance status on disease diagnosis The demographics of each insured population has been shown previously, 7 with Medicaid predominantly patients age 0 to 17 years and Medicare patients predominantly age $65 years. The prevalence of disease was highest among patients with Medicare (47.8%) compared with those who had commercial insurance (22.5%), were on Medicaid (24.6%), and were uninsured (23.6%) (Fig 1, A). Patients with Medicaid had a higher prevalence of wounds and burns, contact dermatitis, and cutaneous infections relative to all other diseases (Fig 1, B). Several conditions were most prevalent in the Medicare population, including noncancerous growths, y viral/fungal diseases, actinic damage, and cutaneous infections. Furthermore, the Medicare population also had a high probability of a concurrent disease diagnosis (Fig 1, C ). The prevalence of disease generally increased with age. Sixteen of the 24 diseases had a noted increase from age 0 to $65 years; these are grouped in high or moderate increase in Fig 2, A. Eight diseases had prevalence that was relatively constant for all age groups, with a notable and expected exception of acne, which showed a decrease. Nonmelanoma cancer, ulcers, and actinic damage had the highest relative change in prevalence over time, increasing by 4- to [14-fold with age (Fig 2, B). Direct medical cost of disease by insurer The medical cost for the 24 disease categories was nearly $46 billion in The medical cost for each disease varied widely, ranging from more than $8 billion for cutaneous lymphoma to $49 million for vitiligo (Fig 3). Total medical costs for the treatment of ulcers, cutaneous infections, and nonmelanoma cancer were highest in the Medicare population. Overall, the top 10 diseases, on the basis of medical cost, generally correlated with the most prevalent disease categories within each insurance status, with some exceptions (Fig 4). For example, melanoma and connective tissue diseases represent a combined prevalence of 0.48% in the commercial population, yet result in 7.3% ($1.4 billion) of the total medical cost for this group. For each insurance status, the 10 diseases with the highest economic burden accounted for[80% of the total medical cost in each group. Cost per person diagnosed with disease Across the total insured population, the diseases with the highest pereaffected person costs were cutaneous lymphoma ($2403 to $4517), ulcers ($1317 to $1979), melanoma ($991 to $1923), nonmelanoma cancer ($1154 to $1311), and connective tissue diseases ($952 to $1703) (Fig 5). y This disease category is clinically broad in nature. In practice, these growths may be biopsied to rule out cancer or other underlying disease pathology. The final pathology results for some are benign (noncancerous).

4 1154 Lim et al JUNE 2017 Fig 1. US population with disease by insurance status. A, The stacked column graph represents the relative percentage of the US population with disease (pink), compared to those without disease (gray) for each insurance status. The actual number of individuals (in thousands) is indicated inside the bar. B, The table lists the 24 disease categories in alphabetical order, and indicates the prevalence of population with a specific disease (in percentage) for each insurance status (commercial, Medicare, Medicaid, and uninsured). The colored cells indicate a heat map of prevalence, ranging from highest prevalence (dark red)to lowest prevalence (dark blue) for each insurance status. C, The bubble graphs plot the probability of a Medicare-insured individual diagnosed with melanoma, actinic damage, noncancerous growths, ulcers, or congenital abnormalities of having another disease. The relative probability is indicated by the size of the bubble, with the actual probability percentage in each label. The y axis plots the percentage prevalence of disease in the Medicare population and the center of each bubble corresponds to the disease-specific prevalence.

5 VOLUME 76, NUMBER 6 Lim et al 1155 Fig 2. Prevalence of disease across age groups. A, The table ranks the prevalence of the 24 diseases across the entire US population by relative change across age group. The ratio in prevalence change across the four age groups was calculated (determined by dividing the prevalence of [18-44y]/[0-17y], [45-64y]/[18-44y] and [65+y]/[45-64y]), and the average was used to define 3 arbitrary categories of change in prevalence by age, namely high increase ([2.32x; red zone of the heat map ), moderate increase ( x; white zone), and null/irregular-tomoderate decrease (\1.28; blue zone). B, The line graphs represent the total percentage prevalence for the top 5 diseases with the highest increase in relative prevalence across the four age groups (0-17, 18-44, 45-64, and 651 years). Fig 3. Relative medical costs of disease by insurance status. The histogram represents the relative percentage of disease-specific total medical cost by insurance status (commercial [blue], Medicare [orange], Medicaid [green], and uninsured [yellow]), and sorted by decreasing total medical cost. The actual medical costs per insurance status in USD millions is indicated in each bar.

6 1156 Lim et al JUNE 2017 Fig 4. Direct medical costs and number of diagnosed individuals. The graphs plot the top 10 disease categories by direct medical cost (in USD millions; y axis) for commercial (A), Medicare (B), Medicaid (C), and uninsured (D) populations in The bubble size represents the relative prevalence for each of the indicated diseases. The label includes the disease analyzed, its total medical cost, and the actual number of diagnosed individuals. Note that the latter value may indicate more than one diagnosis per individual (overlapping); therefore, the sum of these values will exceed the number of insured individuals in the population. for this group. Across the 24 disease categories, total aggregate medical costs for the commercially insured often exceeded those of the other insurance groups. Fig cost of disease per diagnosed person. The range bar graph represents the cost range across insurers per diagnosed person with disease in 2013 for the top 10 most costly diseases and ranked by their weighted average cost in USD (indicated by a white line). For 21 of the 24 diseases, approximately 75% of the medical costs attributable to disease were for outpatient services, whereas 25% were for inpatient services (data not shown). The top 10 disease categories associated with high inpatient costs for each insurance status are shown in Fig 6. Accurate data for the uninsured population are lacking; therefore, no information can be presented Top prescription drugs for disease by insurer The majority (82.5%) of total prescription drug costs for disease across insurance statuses were for nonspecialty drugs (typically nonbiologic, longestablished drugs), 10 and 17.5% were for specialty drugs (typically biologic and/or injectable drugs) 10 (Fig 7, A). Total prescription drug costs for disease was highest in the commercially insured population (Fig 7, A, upper panel); however, the peremedicare-insured person cost for prescription drugs z was higher than for other insured populations (Fig 7, A, lower panel) because of a higher disease prevalence in this population. Prescriptions for 10 disease drugs accounted for approximately 40% of total prescription drug costs across all insurance statuses (Fig 7, B). These z Skin vaccines may be billed as either a medical or a prescription drug benefit; when the costs for these benefits were added to the total per person cost, the final costs were $53.34 for commercially insured individuals, $79.53 for Medicare enrollees, and $26.15 for Medicaid participants.

7 VOLUME 76, NUMBER 6 Lim et al 1157 lymphoma were predominantly seen by dermatologists for all insurance statuses (Fig 8, C ). Furthermore, for Medicare patients and the commercially insured, actinic damage, acne, and nonmelanoma cancer were also among the top 10 disease categories seen by dermatologists. Fig 6. Estimated insured impatient/outpatient cost per diagnosed person. The stacked column graphs represent the total percentage of cost per diagnosed (affected) person by outpatient (gray bars) and inpatient (black bars) services for commercial (upper panel), Medicare (middle panel), and Medicaid (lower panel) populations. The top 10 diseases ranked by total inpatient cost are shown. The actual cost in USD per diagnosed person for each type of service is indicated inside (outpatient) or right adjacent to (inpatient) the corresponding bars. top 10 prescription drugs varied by insurance status but included drugs used primarily for the treatment of psoriasis, infections, acne, and rosacea. Dermatologist provision of care for disease The percentage of office visits for disease with dermatologists was 35.4% for the commercially insured population, 42.6% for Medicare patients, and 17.4% for Medicaid recipients (Fig 8, A). The percentage of surgical procedures for disease performed by dermatologists was 53.7% for the commercially insured population, 53.0% for those on Medicare, and 31.5% for Medicaid patients (Fig 8, B). Vitiligo, psoriasis, rosacea, and cutaneous DISCUSSION In 2013, nearly 85 million Americans were diagnosed with and treated for disease. 7 The economic burden to the US society is affected by the prevalence of specific diseases, patient age, and insurance status. These results indicate that disease is a lifelong health care concern and affects individuals of all ages. Furthermore, most diseases increase in prevalence over a lifetime, resulting in nearly 50% of the Medicare population having at least 1 disease and often concurrent disease(s). With estimates that by 2030 the $65 years of age US population will grow by 30 million and continue to increase through 2050, 11 the burden of disease is likely to increase substantially. The pereaffected-person per-year medical cost of treating a diagnosed disease showed great variability, ranging from less than $100 (seborrheic dermatitis) to more than $4500 (cutaneous lymphoma), depending on the disease and insurance status. Overall, the aggregate total medical cost of those commercially insured was higher compared with the costs of Medicare and Medicaid populations, although Medicare disease patients tended to have higher inpatient and prescription drug costs. These findings also show that dermatologists were seen by 1 in every 3 people diagnosed with disease in In addition, dermatologists provided approximately 50% of surgical care for the treatment of disease. These results reinforce the role of these specialists in diagnosing and treating a vast array of diseases, many of them of frequent concern to patients, particularly those in the Medicare population Among Medicaid patients, there was a smaller percentage of visits to dermatologists compared with patients from the other 2 insurance statuses. This difference may be a reflection of the younger age of Medicaid patients, supported by the finding that the top 10 medications prescribed to this group are mostly for treatment of infections or dermatitis (Fig 7, B). A possible explanation could be that many were probably cared for by pediatricians for some diseases and only referred to dermatologists for further evaluation and treatment of lesions or other dermatologic conditions.

8 1158 Lim et al JUNE 2017 Fig cost of prescription drugs per insured person. A, The stacked columns (upper panel) represent total cost of disease prescription drugs in USD millions segregated by nonspecialty (black) and specialty (gray) drugs for commercial, Medicare, and Medicaid populations. The stacked columns (lower panel) represent the actual cost in USD per person (regardless of having disease) by type of prescription drugs (vaccines, specialty and nonspecialty) and by insurance status. The total cost per person by insurer is indicated at the top of each column. B, Relative cost in percentage for the top 10 disease drugs (pie charts, red slice) for commercial (top panel), Medicare (middle panel), and Medicaid (lower panel), and a table with the list of drugs sorted by descending cost per person. The asterisk indicates a specialty drug. Within each insured population, the 10 diseases with the highest economic burden generally correlated with the most prevalent disease categories, but this list also included diseases with lower prevalence such as cutaneous lymphoma, melanoma, and nonmelanoma cancer in the commercially insured and Medicaidinsured populations. Collectively, the top 10 most common diseases represented[80% of the total medical cost for each insured population.

9 VOLUME 76, NUMBER 6 Lim et al 1159 Fig 8. Portion of office visits for disease delivered by dermatologists. A, The stacked column graphs show the percentage of office visits with a dermatologist (green) compared to other health care providers (gray) for commercial, Medicare, and Medicaid populations. The actual percentages for each category are shown inside the columns. B, The stacked column graphs show the percentage of surgeries performed by a dermatologist (green) compared to other health care providers (gray) for commercial, Medicare, and Medicaid populations. The actual percentages for each category are shown inside the columns. C, These bar graphs represent the top 10 disease categories by percentage of office visits to dermatologists in 2013 for commercial (upper panel), Medicare (middle panel) and Medicaid (lower panel). The actual count of office visits performed by all providers for each category is plotted in a logarithmic scale and indicated within each column, while the percentage of these visits to dermatologists is indicated at the top of each column.

10 1160 Lim et al JUNE 2017 Additionally, the 10 most commonly prescribed drugs that were based on insurance status accounted for 40% of the total health care dollars spent on prescription drugs. These drugs are primarily used to treat psoriasis, acne, and cutaneous infections. Skin disease is a significant and serious health consideration for patients, physicians, and payers. As the US population and health care systems continue to evolve, 15 it is critical to develop strategies that ensure effective access to dermatologic treatment in outpatient and inpatient settings across the insurance coverage spectrum, appropriate care coordination and referral to specialists, and resources to support patient self-care when appropriate. The BSD Work Group and the AAD would like to thank the following people: Milliman staff: Tia Goss Sawhney, DrPH; Bruce Pyenson; Helen Blumen, MD; Rong Yi, PhD; Michele Berrios; Alice Cha, MS; and Monica Son. Clinical advisors (alphabetical): AAD members: Tim Berger, MD; Brian Berman, MD, PhD; Michael Bigby, MD; Joi Carter, MD; Brett Coldiron, MD; Terry Cronin, MD; Ralph Daniel, MD; Karen Edison, MD; Ronda Farah, MD; Ron Feldman, MD; Ilona Frieden, MD; Larry Green, MD; John Harris, MD, PhD; Robert Kirsner, MD, PhD; Barbara Mathes, MD; Amy McMichael, MD; Chris Mowad, MD; So Yeon Paek, MD; Jonathan Silverberg, MD; Sabra Sullivan, MD; Michael Tharp, MD; Diane Thiboutot, MD; Hensin Tsao, MD; Vickie Werth, MD; Jashin Wu, MD; and Gil Yosipovitch, MD. Representatives of other organizations: Natasha Atanaskova (National Alopecia Areata Foundation), Clifford Bassett (Asthma and Allergy Foundation of America), Anna Bruckner (Society for Pediatric Dermatology), Adam Friedman, MD (National Eczema Association), Rob Galiano (Wound Healing Society), Sergei Grando, MD (International Pemphigus and Pemphigoid Foundation), Iltefat Hamzavi, MD (Vitiligo Working Group), Sewong Kang, MD (Acne and Rosacea Society), Ellen Kim, MD (US Cutaneous Lymphoma Consortium), Naomi Lawrence, MD (American Society for Dermatologic Surgery and American Society for Dermatologic Surgery), Mark Lebwohl, MD (National Psoriasis Foundation), Edward Maytin (BCC Nevus Syndrome Life Support Network), Amy McMichael, MD (Skin of Color Society), Susan Nedorost, MD (American Contact Dermatitis Society), Tim Straight, MD (Association of Military Dermatologists), and Martin Zaiac, MD (Council for Nail Disorders). AAD staff: Elaine Weiss, Stephanie Peditto, Melanie Tolley Hall, Barbara Greenan, Suzanne Lothary, Leslie Stein Lloyd, Cindy Kuhn, Diane Simmons, Krista Kauper, Dan Reyes, Detra Davis, Katie Domanowski, Missy Lundberg, Richard Nelson, Andie Pivarunas, and Jennifer Keating. We also thank any others not listed here who contributed to the development and success of this report. REFERENCES 1. Hay RJ, Johns NE, Williams HC, et al. The global burden of disease in 2010: an analysis of the prevalence and impact of conditions. J Invest Dermatol. 2014;134: Obama B. United States health care reform: progress to date and next steps. JAMA. 2016;316: Arrowsmith J. A decade of change. Nat Rev Drug Discov. 2012; 11: Tensen E, van der Heijden JP, Jaspers MWM, Witkamp L. Two decades of teledermatology: current status and integration in national healthcare systems. Curr Dermatol Rep. 2016;5: Bickers DR, Lim HW, Margolis D, et al. The burden of diseases: 2004 a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol. 2006;55: American Academy of Dermatology/Milliman. Burden of Skin Disease. Avaliable from: URL: Accessed August 19, Lim HW, Collins SAB, Resneck JS, et al. The burden of disease in the United States. J Am Acad Dermatol. 2017;76: e2. 8. Young K, Rudowitz R, Rouhani S, Garfield R. Medicaid per enrollee spending: variation across states. Kaiser Family Foundation; Available from: URL: Accessed March 29, Couglin TA, Holahan J, Caswell K, McGrath M. Uncompensated care for the uninsured in 2013: a detailed examination. Kaiser Fam Found; Available from: URL: uncompensated-care-for-the-uninsured-in-2013-a-detailedexamination-the-cost-of-uncompensated-care/. Accessed March 29, Milliman. Health Cost Guidelines. Grouper; Available from: URL: Health-Cost-Guidelines/Health-Cost-Guidelines--Grouper/. Accessed April 23, Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. From the US Census Bureau; Available from: URL: publications/2014/demo/p html. Accessed October 6, Landis ET, Davis SA, Taheri A, Feldman SR. Top dermatologic diagnoses by age. Dermatol Online J. 2014;20: Tellechea O, Cardoso JC, Reis JP, et al. Benign follicular tumors. Anais brasileiros de dermatologia. 2015;90: Adamson AS, Dusetzina SB. Characteristics of Medicare payments to dermatologists in JAMA Dermatol. 2017;153: Kirby JS, BA, Rosamilia L, Miller JJ. Improving Dermatological Care in Primary Care: Consideration of the Collaborative Care Model. Austin J Dermatol. 2016;3:1050.

11 Supplemental Table I. HCPCS code lists: evaluation and management visits, procedures, and vaccines x Other 0015F Refer to an AMA-licensed code list Nonstandard benefit - temporary codes x Other Refer to an AMA-licensed code list Anesthesia - burn excisions or debridement x Other Refer to an AMA-licensed code list Anesthesia - burn excisions or debridement x Other Refer to an AMA-licensed code list Anesthesia - burn excisions or debridement x Surg Refer to an AMA-licensed code list Surgery - integumentary system - acne - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - pilonidal cyst x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - pilonidal cyst x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - debridement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - debridement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - debridement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - debridement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - paring or curettement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - paring or curettement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - paring or curettement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - biopsy - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - biopsy - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - removal of tags - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - removal of tags - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of scalp, neck, hands, feet VOLUME 76, NUMBER 6 Lim et al 1160.e1

12 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of face etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of face etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of face etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - shaving of of face etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of face, etc 1160.e2 Lim et al JUNE 2017

13 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of sweat glands x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of sweat glands x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of sweat glands x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of sweat glands x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of sweat glands x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of benign lesions - of sweat glands x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of trunk, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of scalp, neck, hands, feet VOLUME 76, NUMBER 6 Lim et al 1160.e3

14 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision of malignant lesions - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - paring or curettement - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - debridement - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - debridement - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - incision and drainage - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - nails x Surg Refer to an AMA-licensed code list surgery - integumentary system - biopsy - nails x Surg Refer to an AMA-licensed code list surgery - integumentary system - repair and/or reconstruction - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair and/or reconstruction - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - nails x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - pilonidal cyst x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - pilonidal cyst x Surg Refer to an AMA-licensed code list Surgery - integumentary system - excision - pilonidal cyst x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction e4 Lim et al JUNE 2017

15 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - epidermal introduction - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of scalp, neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple e x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple e x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - simple e VOLUME 76, NUMBER 6 Lim et al 1160.e5

16 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of scalp, axillae, trunk x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of scalp, axillae, trunk x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of scalp, axillae, trunk x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of scalp, axillae, trunk x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of scalp, axillae, trunk x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of scalp, axillae, trunk x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of neck, hands, feet x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - intermediate - of face, etc 1160.e6 Lim et al JUNE 2017

17 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of scalp, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of scalp, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of scalp, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of forehead, cheeks x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of forehead, cheeks x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of forehead, cheeks x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of eyelids, nose x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of eyelids, nose x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of eyelids, nose x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - of eyelids, nose x Surg Refer to an AMA-licensed code list Surgery - integumentary system - repair/closure of wounds - complex - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of scalp, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of scalp, arms, legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of forehead, cheeks VOLUME 76, NUMBER 6 Lim et al 1160.e7

18 x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of forehead, cheeks x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of eyelids, nose x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of eyelids, nose x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of forehead, cheeks x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - of forehead, cheeks x Surg Refer to an AMA-licensed code list Surgery - integumentary system - tissue rearrangement - x Surg Refer to an AMA-licensed code list Surgery - integumentary system - surgical preparation - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - surgical preparation - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - surgical preparation - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - surgical preparation - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft e x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft e x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of trunk/arms/legs x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of face, etc x Surg Refer to an AMA-licensed code list Surgery - integumentary system - grafts - autograft/tissue cultured autograft - of face, etc 1160.e8 Lim et al JUNE 2017