Formation/background of Layman Hospital System

1. Running head: PART 2 WEEK (4): BACKGROUND 1
Part 2 Week (4): Background to Team Project Service line
Group 3
University of Maryland University College
HCAD 670 9041
February 25, 2018

2. PART 2 WEEK (4): BACKGROUND 2
Part 2 Week (4): Background to Team Project Service Line
Topic: Adding a Mohs Surgery Practice to Layman Hospital Systems
Design: Mohs Surgery Service Line
Purpose of Mohs Surgery Service: Mohs surgery would bring in greater income and provide
better outcomes for skin cancer patients.
Mohs Surgery Service Line Background
Implementing a Mohs Surgery service into Layman Hospital Systems (LHS) will result in
better patient outcomes and system revenues. Skin cancers may be removed through surgical
excision or by Mohs surgery. Mohs surgery creates less scarring than surgical excision, making
it the preferred approach for most patients, particularly for facial skin cancers. Currently, the
lack of a Mohs surgeon requires patient referrals outside of the LHS system for the service,
causing discontinuities in care and lost revenue.
Mohs surgery is considered the most effective technique for treating many basal cell
carcinomas (BCCs) and squamous cell carcinomas (SCCs). Mohs surgery is named after Dr.
Frederic Mohs, who developed the technique in the 1930s. It began as a technique called
chemosurgery but was not widely known until the 1960s, when Perry Robins became the first
dermatologist to study the technique with Dr. Mohs. He advanced and refined the procedure to
treat common types of skin cancer with better cosmetic results than traditional surgical excision
techniques. Mohs surgery may include skin grafts to improve the cosmetic outcome.
Implementing a Mohs surgery line of service requires hiring a Mohs surgeon, providing
logistical support for a dermatology office (including immediately available laboratory services),
billing, and marketing. The Mohs surgery team consists of the Mohs surgeons, dermatology
physicians, histopathology technicians, and nurses. According to the American College of Mohs

3. PART 2 WEEK (4): BACKGROUND 3
Surgery, “the surgery fellowship training programs must pass a rigorous application and review
process before being allowed to train a fellow. Once the training program is approved, it must
continue to adhere to the standards set by the Mohs Surgery and periodically re-evaluated on a 1
to 5-year basis to ensure that their academic and clinical requirements are being followed and
fulfilled” (American College of Mohs, 2018). Mohs surgeons are among the highest
compensative physicians, commanding an annual salary of approximately $600,000 (Rosenthal,
2014). Mohs surgeons may conduct the procedure in an office setting, provided they have
sufficient nursing and pathology support. Having immediately available pathology services is
necessary to ensure complete removal of the carcinoma.
Given the non-emergent nature of the procedure, a typical arrangement places a Mohs
surgeon in an office with other dermatologists. This provides a steady source of referrals, as well
as pre- and post-operative care. Despite the additional cost in surgeon salary and pathology
services, most insurers cover Mohs surgery with much higher reimbursements than traditional
surgical excision of skin cancers, making the procedure both cosmetically desirable for patients
and lucrative for providers.
Describe the circumstances underlying the project
The Layman Hospital Systems (LHS) is located in South Florida. Florida’s hot climate
attracts many retirees and people who enjoy the outdoors. About 100,000 people in the US
receive a diagnosis of skin cancer annually, making it the most common cancer diagnosis
(Siegel, Miller, & Jemal, 2018). However, with 13,500 deaths annually, it is also one of the most
survivable cancers (Watson, et al, 2016).
Sun exposure represents the most serious preventable risk factor for skin cancer, with
skin cancer rates rising with age and cumulative exposure. This gives Florida the second highest

4. PART 2 WEEK (4): BACKGROUND 4
rate of skin cancer in the US (Florida Society of Dermatology and Dermatologic Surgery, n.d.).
The Layman Hospital System is a community hospital established for the emergency care and
primary care with minor surgical procedures. The majority of Layman Hospital patients are
elderly, veterans, and retired government workers. This population has both a greater need for
the service and a greater ability to pay for it than the US average.
Why is there a need for this product, facility, entity or service?
The skin is the largest organ and the body structure that protect the internal organs and
structures. Skin cancers “are by far the most common malignancy of humans” (D’Orazio et al,
2013). The South Florida population served by LHS is particularly susceptible to skin cancer,
and is expected to grow by one third in the next 30 years (Office of Economic and Demographic
Research, 2016).
The need for the Mohs surgery service line is “the growing incidence of cutaneous
malignancies has heralded the need for multiple treatment options” (D’Orazio et al, 2013).
Offering of the Mohs surgery service will provide more convenient as well provide cosmetically
pleasing results to the patients while bolstering LHS’s financial situation. Currently, LHS
provides surgical excision of skin cancers, but not Mohs surgery, requiring referrals outside of
the LHS system for patients desiring it. This discontinuity of care can result in a Hobson’s
choice of remaining in-network and receiving surgical excision or going out of network and
incurring a greater cost for patients covered by LHS’s contracted insurers. Providing the service
will allow them to access Mohs surgery in the network, while also providing greater revenues to
LHS compared to surgical excision.

5. PART 2 WEEK (4): BACKGROUND 5
Who would it serve?
Mohs surgery primarily benefits skin cancer patients. While anyone can develop a skin
cancer, cumulative sun exposure represents the greatest risk, making older people and those who
enjoy outdoor pursuits more susceptible. People with nevi and paler skin also have a greater risk
for skin cancer. Approximately 75% of skin cancers may be susceptible to treatment with Mohs
surgery, making it the predominant procedure for addressing the most common cancer in the
population served by LHS (Kantor, 2017).
LHS’s patient population will substantially expand in the next 30 years. The Florida
Office of Economic and Demographic Research projects that Miami-Dade county’s population
will increase from its current level of approximately 2,700,000 to over 3,600,000 by 2045
(Office of Economic and Demographic Research, 2016). The population over age 60 will more
than double, from approximately 475,000 to 1,053,000 (Office of Economic and Demographic
Research, 2016). In summary, Mohs would serve a large need in a growing population.
How will healthcare or an identified population benefit from the initiative?
Mohs surgery provides better long-term outcomes than surgical excision for many skin
cancers, a significant benefit to the patient population (Van Loo, et al, 2014). For other skin
cancers, the results are at least comparable, with better cosmetic outcomes (Mueller, Dawe,
Moseley, & Fleming, 2009). While Mohs has increased relative to surgical excision most in the
younger population, it has expanded in all demographics, including the Medicare-eligible (Viola
et al, 2012). The positive results, both in efficacy and cosmetic appeal, have led to Mohs surgery
being viewed as the preferred approach by primary care physicians for appropriate skin cancers
(Bene, et al, 2008).

6. PART 2 WEEK (4): BACKGROUND 6
The cost-effectiveness of Mohs surgery compared with surgical excision remains
unproven (Chen, Kempton, & Rao, 2016). However, the costs differences between excision and
Mohs are modest (Sebaratnam, Choy, Lee, Paver, & Peñas, 2016). In sum, skin cancer patients
would benefit from Mohs through equal to more effective care, with a better cosmetic outcome,
at a modest cost.

7. PART 2 WEEK (4): BACKGROUND 7
References
American College of Mohs Surgery. (2018, January 9). “The Mohs College Difference".
Retrieve from https://www.skincancermohssurgery.org/about-the-acms/the-mohs-
college-difference accessed February 21, 2018
Bene N. I., Healy C., Coldiron B. M. (2008, May). Mohs micrographic surgery is accurate 95.1%
of the time for melanoma in situ: a prospective study of 167 cases. Dermatologic
Surgery.34 (5): 660–4. doi:10.1111/j.1524-4725.2007.34124.x. PMID 18261099.
Chen, J. T., Kempton, S. J., & Rao, V. K. (2016). The Economics of Skin Cancer: An Analysis
of Medicare Payment Data. Plastic and Reconstructive Surgery Global Open, 4(9), e868.
http://doi.org/10.1097/GOX.0000000000000826
D'Orazio, J.; Jarrett, S.; Amaro-Ortiz, A.; Scott, T. (2013). UV Radiation and the Skin.
International Journal of Molecular Sciences. Int. J. Mol. Sci. 2013, 14, 12222-12248;
doi:10.3390/ijms140612222. Retrieved from http://www.mdpi.com/1422-
0067/14/6/12222/htm
Florida Society of Dermatology and Dermatologic Surgery. (n.d.). Quick facts about skin
cancer. Retrieved from https://fsdds.org/patients/skin_cancer/
Kantor, J. (2017). Costs and Economics of Skin Cancer Management, Mohs Surgery, and
Surgical Reconstruction. Plastic and Reconstructive Surgery Global Open, 5(6).
Muller, F. M., Dawe, R. S., Moseley, H., & Fleming, C. J. (2009). Randomized Comparison of
Mohs Micrographic Surgery and Surgical Excision for Small Nodular Basal Cell
Carcinoma: Tissue‐ Sparing Outcome. Dermatologic Surgery, 35(9), 1349-1354.

8. PART 2 WEEK (4): BACKGROUND 8
Office of Economic and Demographic Research. (2016). Population and Demographic Data.
Retrieved from http://edr.state.fl.us/Content/population-
demographics/data/MediumProjections_2016.pdf
Rosenthal, E. (2014, Jan 18). Patients’ costs skyrocket; specialists’ incomes soar. New York
Times, A1.
Sebaratnam, D. F., Choy, B., Lee, M., Paver, R., & Peñas, P. F. (2016). Direct cost-analysis of
Mohs micrographic surgery and traditional excision for basal cell carcinoma at initial
margin clearance. Dermatologic Surgery, 42(5), 633-638.
Siegel, R. L., Miller, K. D., & Jemal, A. (2018). Cancer statistics, 2018. CA: a cancer journal for
clinicians, 68(1), 7-30.
Van Loo, E., Mosterd, K., Krekels, G. A., Roozeboom, M. H., Ostertag, J. U., Dirksen, C. D., ...
& Kelleners-Smeets, N. W. (2014). Surgical excision versus Mohs’ micrographic surgery
for basal cell carcinoma of the face: a randomised clinical trial with 10-year follow-
up. European Journal of Cancer, 50(17), 3011-3020.
Viola, K. V., Jhaveri, M. B., Soulos, P. R., Turner, R. B., Tolpinrud, W. L., Doshi, D., & Gross,
C. P. (2012). Mohs micrographic surgery and surgical excision for nonmelanoma skin
cancer treatment in the Medicare population. Archives of dermatology, 148(4), 473-477.
Watson, M., Thomas, C. C., Massetti, G. M., McKenna, S., Gershenwald, J. E., Laird, S., ... &
Lushniak, B. (2016). CDC grand rounds: prevention and control of skin cancer. American
Journal of Transplantation, 16(2), 717-720.