Dermatology Online Journal

Limited availability of psoriasis and phototherapy care: An analysis of advertisements
John G. Hancox, M.D., Rajesh Balkrishnan, Ph.D., Jamila Battle, B.S., Tamara Salam Housman, MD, Alan B. Fleischer, Jr., M.D.; Steven R. Feldman, M.D., Ph.D.
Dermatology Online Journal 11(2): 6

Center for Dermatology Research, Department of Dermatology; Wake Forest University School of Medicine; Winston-Salem, North Carolina. sfeldman@wfubmc.edu

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Abstract

Because the number of dermatologists remains stable, patients with medical dermatologic conditions such as psoriasis may find it increasingly difficult to access dermatological treatment. Measuring the competition in the marketing of dermatologic care may provide insight into the availability of dermatology services. The purpose of this study was to determine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. We performed a quantitative and qualitative assessment of dermatologists' Yellow Pages advertisements in small cities and the ten largest metropolitan regions in the country. Per capita, more advertisements were found in smaller markets than larger markets and a higher percentage was descriptive rather than just a name, address and phone number. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. Cosmetic ads were more prevalent in larger markets. In all regions, psoriasis and psoriasis treatment ads were least common. These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis. Efforts to promote psoriasis care should be encouraged.

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Introduction

Psoriasis is at times a devastating condition. Many patients, particularly those with extensive disease, are dissatisfied with their treatment [1]. The use of phototherapy, one of the effective treatments for extensive psoriasis, progressively decreased in the United States, even before the introduction of new biologic treatments. The cause for the reduction in phototherapy is likely multifactorial. In part it has been perceived as a loss of interest among dermatologists in providing the service, leading to National Psoriasis Foundation efforts to increase phototherapy reimbursement rates. The reduction in phototherapy may also be the result of greater copayments for phototherapy visits.

The decreasing use of phototherapy raises the specter that the incentive structures in the United States healthcare system work against treating psoriasis altogether. This is particularly ironic when new treatments for psoriasis have given dermatologists greater ability to manage patients with the most severe involvement. Concerns about disinterest in psoriasis treatment coincide with the general perception that the practice of dermatology is progressively shifting toward cosmetic conditions. Dermatology is changing rapidly as cosmetic and surgical care become more prevalent [2]. The number of dermatologists has remained rather stable and demand for cosmetic services is increasing [3]. One may predict a decrease in the availability of medical dermatological care as a consequence. While many dermatologists continue to focus on medical dermatology, changing workforce patterns and the increased breadth of surgical and cosmetic services being offered raise the possibility that patients with medical dermatologic conditions will find it increasingly difficult to access dermatological treatment.

In a typical month, approximately 65.7 million adults in the continental U.S. arrange for physicians' services, and 28 percent of those using the Yellow Pages are first time patients who do not have a specific physician in mind when they open the directory [4]. Patients site the ability to identify a physicians' specialty as a major purpose of Yellow pages advertising [5]. Physician's also apparently view this form of advertising as important as evidenced by litigation against directory publishers for incorrect information [5].

Dermatologic care can be viewed as a market, and measuring the competition in this market could provide insight into the availability of dermatology services and the types of services being promoted by dermatologists. The purpose of this study was to determine to what extent dermatologists are advertising to patients with psoriasis. We assessed this by analyzing dermatologists' advertisements. We control for the overall level of advertising, and we compare psoriasis advertising to advertising for cosmetic services. Our approach was a quantitative and qualitative assessment of dermatologists' Yellow Pages advertisements. These data also provide information on geographical variations that have not been well assessed in previous studies.

Methods

From the web site www.therealyellowpageslive.net, we evaluated the electronic pdf versions of The Real Yellow Pages published by BellSouth®. Free access was granted to southeastern cities including Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, and Tennessee. We examined ads under the heading "Physicians & Surgeons-MD-Dermatology (Skin)" and "Physicians & Surgeons-DO-Dermatology (Skin)". We randomly assigned every 9th city/metropolitan area to be examined, and repeated that random assignment to every ninth city to obtain more locations. A total of 41 cities or metropolitan areas were examined (from a possible 315). Although other yellow pages are available, we used one company's listings to limit biases between the different potential yellow page sources.

To assess geographical variation between smaller cities and towns with large metropolitan areas, the printed versions of the regional Yellow Pages were also evaluated from the 10 largest metropolitan areas in the U.S. None of the largest markets were in the Southeastern yellow pages we examined, so there was no overlap in these two populations.

The population of each area was obtained from U.S Census Bureau data (www.census.gov) using http://www.cityrating.com and rounded to the nearest thousand. For each city, the total number of dermatology advertisements was recorded (Tables 1 and 2). Descriptive advertisements, defined as those that gave any detail pertaining to the type of practice (more than just a name, address and phone number) were then counted. Mention of "skin cancer", "skin cancer treatment", "surgery", or "Mohs micrographic surgery" was recorded in the surgical category. In the cosmetic category, subsets for the following were recorded: (1) any mention of "cosmetic" procedures, (2) botulinum toxin or filler substances for wrinkles or enhancement, and (3) laser therapy. Mention of the words (or a combination thereof) "skin rashes" or "skin diseases" were recorded. Finally, "psoriasis" was a category and "phototherapy" or a synonym or any mention of types of phototherapy (PUVA, UVB, UVA, narrow-band UV) was another group. Each physician or physician group was counted only once even if listed more than once (i.e., if they had a name, address, phone number in addition to a descriptive ad).

We descriptively examined differences in types of dermatology advertisements within geographical areas using means. Next, we examined statistical significance of differences in various types of dermatology-related advertisements between smaller and larger areas using t-tests of unequal variance. We also examined factors predicting the number of dermatology-related advertisements in a given geographical area using Spearman rank order correlation analysis.

Results

In smaller markets, in order of decreasing frequency, ads discussed the following: skin cancer/surgery > skin diseases/rashes > all cosmetic ads > lasers > botulinum toxin/fillers > psoriasis > phototherapy (Table 1). Cosmetic ads were more prevalent than psoriasis ads (an average of 3.4 ads per city versus 0.6 ads). Laser treatment related advertisements were more common than phototherapy (an average of 1.8 ads per city versus 0.4 ads).

In the largest markets, in order of decreasing frequency, ads discussed the following: skin cancer/surgery and all cosmetic ads > lasers > skin diseases/rashes > botulinum toxin/ fillers > psoriasis > phototherapy (Table 2). Unlike the the ads found in small markets, cosmetic ads were more common than skin diseases/rashes in large cities (average number of ads 10.8 versus 3.4 in smaller cities (p < 0.01). Cosmetic ads were more prevalent than psoriasis ads (average of 10.8 ads per city versus 1.9 ads). Laser treatment was more common than phototherapy (average of 8.8 ads per city versus 1 ad).

There was a higher rate of dermatology-related advertisements in smaller cities compared with large ones. There were 380 ads for an estimated 13,020,400 people in the Southeast or 1 ad for 34,260 people. In large metropolitan areas, 772 ads were present for 88,734,000 people or 1 ad for every 114,940 persons. A higher proportion of descriptive ads were found in the smaller cities (average of 67 % of all dermatology-related advertisements in smaller cities versus 21 % of all dermatology-related advertisements in larger cities, p < 0.01). From the Southeastern U.S. cities, 380 ads were evaluated and 254 (62 %) were descriptive. This equates to one descriptive ad per 51,261 people. In the largest markets, 166 of the 772 total ads (22 %) were descriptive, or one descriptive ad per 534,542 people. Descriptive ads were also more common in larger cities compared to smaller cities (average of 16.6 versus 6.0, p < 0.001).

Some types of dermatology-related advertisements were also more prevalent in large cities compared to smaller cities respectively: (phototherapy [1 versus 0.4, p < 0.05]; psoriasis [1.9 versus 0.6, p < 0.05]; laser therapy [8.8 versus 1.8, p < 0.001]; botulinum toxin/wrinkle treatments [5.7 versus 1.6, p < 0.05]; skin cancer/surgery [10.6 versus 5.1, p < 0.05]; skin disease/rashes [7.2 versus 4.6, p < 0.05]).

In Spearman rank order correlation analysis, both increased population of the area (ρ = 0.85, p < 0.001) as well as metropolitan status (ρ = 0.68, p < 0.001) were significantly positively correlated to the number of dermatology-related advertisements, with a slightly greater effect observed of the population of the city over the metropolitan area status.

Discussion

Assessing the adequacy of the dermatologic workforce is a complex undertaking that must balance both supply and demand [6]. Direct measurements of the supply of dermatologic health care is quite complex, requiring an accounting of the number of hours worked, the efficiency of the practice, the increasing role of physician extenders, and the breadth of services being offered. Demand is probably an even more amorphous quantity to assess. Indirect approaches to assess workforce can be used in place of such direct measures. The absolute number of advertisements should reflect in part the overall availability of medical dermatology care while the specific character of these advertisements provides information about the trends in dermatologic practices.

The advertisement methodology permits assessments of geographical variation in practice patterns. Geographic maldistribution of dermatologists—high levels in large metropolitan areas and low levels in more rural settings—has been thought to be a major component of a perceived shortage of dermatologists [6]. The greater density of dermatologists in large metropolitan areas is thought to be due to the large metropolitan areas being inherently more attractive for cultural and quality of life reasons. Given that, we expected less competition and fewer advertisements in smaller towns than in large metropolitan areas. Unexpectedly, we found more advertising in the smaller markets both in terms of total numbers of ads and percentage of descriptive ads. Less competition in the larger markets may explain why large metropolitan areas continue to strongly draw in new dermatologists. While we do not know why there is lower advertising competition in the large markets, we suspect it may be due to higher levels of per capita demand there.

The different types of advertisements are a marker of the direction of our specialty. The trend toward greater cosmetic advertising is clear. However, the greater efforts to attract cosmetic service patients may not be due to financial incentives alone. Dermatologists may be motivated by the improved quality of life cosmetic patients experience in contrast to the often frustrating results for medical conditions. The willingness of patients to pay more out of pocket for cosmetic services than for medical services (more than what the physician is paid by the insurer plus the patient copayment for the medical service) may suggest that to the patient the cosmetic service is providing greater benefit.

More than a third of ads in smaller Southeastern markets mentioned cosmetic care compared to only 6 percent mentioning psoriasis. One fifth of the ads offered botulinum toxin or fillers compared to 4 percent offering phototherapy. In fact, 32 of 41 Southeast cities had no dermatologist advertising phototherapy in the yellow pages. In large markets, there was less advertising overall, but the relative lack of psoriasis or phototherapy advertisements were similar. Cosmetic advertisements compared to psoriasis advertisements were 14 percent versus 2 percent, and 11 percent offered lasers while only 1 percent mentioned phototherapy. Four of the 10 large metropolitan areas had no mention of phototherapy. Like other studies of this type, our findings offer no insight into the workforce levels of towns that have no dermatologists; such places are the least well served from a dermatological workforce standpoint and are also the most poorly studied.

Are the yellow pages an appropriate measure of competition? Studies have indicated that yellow page advertising over-represents advertising for optional and occasional services, and does the reverse for long term relationships (health care providers, attorneys, etc.) [7]. It has been suggested the yellow pages play an important role when the consumer has little information about the service needed, and a wide range of options. Some may argue that patients are often referred by physicians for medical conditions like psoriasis, but that patients often shop themselves for cosmetic care. Therefore, the higher level of advertising for cosmetic services indicates that dermatologists are advertising in a similar fashion than many other professions in the yellow pages (for short term or optional services). An analogy would be the heavy advertising for emergency services by plumbers versus a lower lever of advertising for remodeling or new construction services which comprising a larger part of there industry.

Another important limitation of this study to consider is that there are 2 other yellow pages in addition to BellSouth (offered by Southern Yellow Pages and White Publishing) available in the medium and large southern U.S. markets. Without this data from medium and large southern markets, we may have underrepresented the data in these areas. This may have contributed to our finding of a higher level of advertising in smaller communities versus large ones in southern states.

Finally, we acknowledge that directly surveying dermatologists to ask about their advertising practices, psoriasis care and lack or lack of phototherapy would perhaps be more meaningful. However, we feel that our approach still captures (at least in part) what advertising dermatologists seek to portray to the community who reads the Yellow Pages.

These findings raise the concern that incentive structures in the U.S. healthcare system do not adequately support delivery of dermatologic care for psoriasis. Psoriasis patients have a complex immune condition requiring complicated, and often risky, treatment regimens. Reimbursement for the visit may not cover the cost of this care. Moreover, poor reimbursement and high copayments may further limit both the demand for and supply of psoriasis services. The findings have direct implications for the development of algorithms and health plan policies for the treatment of patients with moderate-to-severe psoriasis. Phototherapy appears to be largely inaccessible in many areas. Until policies are in place that effectively promote the use of phototherapy, coverage policies should not require this treatment as a precursor to coverage of other treatments. Efforts to promote psoriasis care are warranted. Although Medicare reimbursement rates for phototherapy doubled in 2002 [8], other large insurers may not have followed Medicare's lead and Medicare has already cut these increases back. Because the burden of disease will continue to remain high for psoriasis patients, efforts to promote excellent treatments such as phototherapy need to be increased.

References

1. Krueger G, Koo J, Lebwohl M, Menter A, Stern RS, Rolstad T. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol. 2001;137:280-4.

2. Kimball AB. Dermatology: A unique case of specialty workforce economics. J Am Acad Dermatol 2003;48:265-70.

3. Kimball AB, Lorenzo CL, Krueger H, Loevy S, Lowery B. Employment opportunities experienced by recent dermatology training program graduates. J. Invest Dermatol 2002;119:246.

4. Cobb-Walgren CJ, Dabholkar PA. The value of physician advertising in the yellow pages: Does the doctor know best? Journal of Health Care Marketing 1992;12:55-64.

5. Reade JM, Ratzan RM. Yellow professionalism: Advertising by physicians in the yellow pages. N Engl J Med 1987;316:1315-9.

6. Resneck J. Too few or too many dermatologists? Arch Dermatol 2001;137:1295-1301.

7. http://www.yppa.org/pdf/research/2003_media_impact_study.pdf, 2003.

8. NPF helps gain increase in phototherapy reimbursements for physicians. http://www.psoriasis.org/news/news/2001/20011109_phototherapy.php, Nov 9, 2001.

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