Dr. Arash Mostaghimi discusses the need for deliberate decision making and cost consideration when managing dermatology patients.
Arash Mostaghimi, MD, MPH, is Assistant Professor of Dermatology, Brigham & Women’s Hospital, Newton Centre, Massachusetts
“Value is a simple equation. It is basically what you get divided by how much it cost. So when we have some new, really expensive medications in dermatology—I think about our new treatments for atopic dermatitis or new treatments, for instance, for alopecia areata coming out—they’re expensive, but they allow us to treat patients in ways that we never were able to before,” said Arash Mostaghimi, MD, MPH, who presented “Cost Effectiveness in Dermatology” at the Annual Meeting of the Pacific Dermatologic Association 2022.
“So the idea is not to not use those medications. We want to use them. We want to make people better.”
However, it’s important to be thoughtful and make deliberate choices without running on autopilot with labs, medications, and more, said Dr. Mostaghimi.
“When we examine our practices, we find treatment choices where the cost-benefit ratio is off, and the value that we provide to our patients may not be what we think it is.”
Cost has become a widespread issue in patient care, said Dr. Mostaghimi.
“That’s a big shift from when I was in medical school. We were explicitly taught to be completely agnostic to cost when making treatment choices.”
However, costs then weren’t what they are today, said Dr. Mostaghimi.
“While we have many new medications and better options for patients, they all have an associated price tag.”
Deliberate Decision Making
There are many drivers of costs in medicine that physicians do not have control of, including macro issues like administrative overhead, pharmaceutical prices, and so on, said Dr. Mostaghimi.
“…the main theme of this talk was to go through what we do have control over and that’s the idea of being deliberate in our decision making and considering costs when managing patients.”
“Again, we’re not just talking about how expensive things are. We’re talking about value, which is what you get for your money.”
You can think about this in a couple of different ways, said Dr. Mostaghimi.
The first is, “…if something is harmful, then there’s no cost at which it makes sense to do it.”
In dermatology, one example would be checking the potassium levels of young, healthy women on Spironolactone for acne, he said. Not only is it unnecessary, but it’s also “harmful” to cost effectiveness.
“Time and time [again], the studies have shown across large databases that this is an unnecessary practice. That research has been translated into societal guidelines, so dermatologists should be comfortable knowing that this practice is now standard of care.”
The second is a grayer area because of selective value, said Dr. Mostaghimi.
“What do we do if something is expensive, but shows some benefit? How much should we pay for that?”
In non-medical situations, people can self-select what price they’re willing to pay for additional benefits, whether it’s an upgraded car rental or a first-class flight, for example, said Dr. Mostaghimi
“These are decisions that we leave to individuals, who pick based on their values.”
More difficult is making these choices in medicine, for example, checking liver enzymes for patients with onychomycosis taking terbinafine.
“We did an evaluation of this several years ago that shows that the costs associated with the amount of testing you need to identify one case of …clinically meaningful hepatic injury caused by terbinafine is 10s of millions of dollars.”
The question becomes, is spending that much money on testing worth it to find that single patient?
“I think most of us would probably say intuitively, no, that’s not worth it. That’s not where we want to allocate our resources. But it’s not without benefit.”
According to Dr. Mostaghimi, dermatologists engage in this kind of decision making when biopsying a pigmented mole, for example.
“We don’t biopsy every mole on every person. We have an inner sense of some threshold of abnormality in that mole where we decide it’s worth the money, it’s worth the scars, it’s worth the discomfort to the patient to completely assess that nevus and move on.”
Improving Value
Improving value overall means doing the research and working with the American Academy of Dermatology and patient advocacy organizations not only to create new standards and guidelines for all dermatologists, but also to protect physicians within the profession, said Dr. Mostaghimi.
“As testing standards change, the decision to change can be supported by formalization and dissemination of new standards of care.”
At the same time, good doctoring is finding a balance between treating patients at a population vs individual level, said Dr. Mostaghimi.
“Physicians are not meant to mindlessly apply algorithms to every patient. While we should have a sense of treatment pathways, what we get paid for, what real doctoring is, is the ability to identify when and where that patient fits into that algorithm.”
The issue of reducing lab monitoring is a case in point, he said.
“A one size fits all approach doesn’t make sense. While we may aim for a reduction in lab testing overall, for some patients, it is a necessity.”
For example, you may need to monitor more closely an obese patient on methotrexate who has a history of liver involvement on other medications, said Dr. Mostaghimi.
“You want to make sure you take a complete history, and if risk factors exist, evaluate the patient more closely while they’re on the medication. But you won’t want to apply that same reasoning to a completely healthy 22-year-old who had no past medical history and no other risk factors.”
According to Dr. Mostaghimi, this is an empowering message for physicians who largely find themselves with less time for patients but still face high levels of required patient documentation and consequences of negotiating with insurance, and more.
“I feel that in many ways it will allow us to reduce burnout, to respect the clinical reasoning and decision making that we spent so many years of training to hone, and to feel empowered in our choices. As doctors, we’re able to connect with our patients, assess them, and then apply guidelines in a thoughtful, personalized manner.”
