Value of Dermatology Nights at a student-run free clinic

Abstract

The Free Clinic at Lubbock Impact is a student-run free clinic affiliated with the Texas Tech University Health Sciences Center in Lubbock, Texas. Every Wednesday, the clinic provides free health services to the uninsured patient population of Lubbock and the surrounding West Texas regions. In addition to the weekly essential primary care services, “Dermatology Night” is held once a month for patients in need of dermatologic care. The study presents a cost analysis of the dermatologic procedures performed at The Free Clinic Dermatology Nights over a 2-year period from February 2018 through January 2020 using current procedural terminology codes and Medicare reimbursement rates. The dermatologic procedures performed in this time were valued at $8412.37. The study emphasizes the value of Dermatology Nights at a free clinic and reflects the dermatologic-specific needs of the uninsured Lubbock and West Texas patient population.

The Free Clinic at Lubbock Impact, a student-run free clinic affiliated with the Texas Tech University Health Sciences Center in Lubbock, Texas, has provided free health services to uninsured patients 19 to 64 years old in Lubbock and the surrounding West Texas regions for the past 11 years. In 2018, 16.1% of 19- to 64-year-olds in Lubbock County were uninsured,¹ indicating the need for affordable and accessible primary care and specialty services for this population. Once a month, patients receive comprehensive dermatologic care by volunteer dermatologists on “Dermatology Night.” Various procedures such as shave biopsies, electrodessication and curettage (ED&C), and skin excisions may be performed. These procedures are imperative in assessing and treating nonmelanoma skin cancers (NMSCs) in uninsured patients because they may be at higher risk of skin cancer due to lack of access to medical services and increased sun exposure from insecure housing.² Though studies have been published regarding the operating costs of certain specialty services at free clinics, no studies exist regarding the value of dermatologic procedures performed at a free clinic.

METHODS

We conducted a retrospective chart review on uninsured patients aged 19 to 64 years old who were seen on Dermatology Nights at The Free Clinic from February 2018 through January 2020. Dermatologic procedures from patient encounters were recorded. A cost analysis was performed by matching procedures with Medicare reimbursement rates using current procedural terminology codes.

RESULTS

From February 2018 through January 2020, 136 patient encounters were documented over 24 Dermatology Nights at The Free Clinic, averaging 5 to 6 patient encounters per specialty night. Dermatologic procedures were largely performed for actinic keratoses (premalignant lesions) or NMSCs. Notably, a total of 30 shave biopsies, 4 excisions for NMSCs, and 13 ED&Cs for NMSCs were performed in the 2-year period. On average, dermatologic procedures were valued at $61.86 per patient encounter, not including the value of an office visit for other diagnoses. Table 1 details the estimated value per dermatologic procedure performed in each year and in the 2-year period.

Table 1.

Estimated value of dermatologic procedures at The Free Clinic, February 2018 through January 2020

Procedures	Value ($)
	Year 1a	Year 2b	Total
Shave biopsy	1143.73	1235.15	2378.88
Punch biopsy	122.76	368.28	491.04
Shave removal	151.31	432.90	584.21
Excision of benign lesions	0	175.72	175.72
Excision of malignant lesions	1245.77	0	1245.77
Destruction of benign lesions other than skin tags or vascular (includes ED&C, TCA)	0	435.76	435.76
Destruction of premalignant lesions/actinic keratoses (includes cryotherapy, ED&C, TCA)	383.99	448.70	832.69
Destruction of malignant lesions (includes ED&C)	1019.44	1141.16	2160.60
Intralesional Kenalog	53.85	3.85	107.70
Total	4120.85	4291.52	8412.37

^aYear 1 refers to the time period February 2018 through January 2019.

^bYear 2 refers to the time period February 2019 through January 2020.

ED&C indicates electrodessication and curettage; TCA, trichloroacetic acid

DISCUSSION

Barriers to specialty care exist for patients referred from community health clinics/centers. Patient-related barriers include socioeconomic factors, insurance status, language, access to transportation, and clinic-to-clinic communication gaps.³ In dermatology, this is reflected by significant differences in access to outpatient dermatologic care for patients of minority background, lower education status, lower income, and uninsured status.⁴ These differences may be attributed to barriers in socioeconomic access to care, lack of awareness of skin health, and lack of awareness of the roles of dermatologists in the management of skin disease among minority populations.⁴

As of June 2019, The Free Clinic has served over 5300 unique patients, a portion of whom utilize dermatologic services during Dermatology Nights. There is a need for accessible dermatologic care in the Lubbock community given that NMSC and melanoma morbidity and mortality outcomes are worse in ethnic minorities, people of low socioeconomic status, and the uninsured.⁵ These nights have been necessary for the on-site detection and management of actinic keratoses, NMSCs, and melanomas in an at-risk population, without the need for referrals to another outpatient dermatology clinic, thereby possibly minimizing provider communication gaps and patient barriers such as transportation. The study highlights the value of dermatologic procedures during Dermatology Nights at a free clinic and may provide future guidance in the allocation of supplies and resources.

Limitations of this study include the manual documentation used to record the number of patients and to complete patient charts (including diagnoses, procedures, and management); this method may not have accounted for all of the patients seen and procedures performed during Dermatology Nights. The cost analysis does not account for other aspects of operating costs such as the value of an office visit, volunteer time, medication cost, utility cost, and equipment cost that would provide a more comprehensive representation of the value of Dermatology Nights.

In conclusion, dermatologic care is imperative for vulnerable populations at higher risk of developing NMSCs. Through Dermatology Nights, The Free Clinic provides comprehensive on-site dermatologic care for its patients. This study emphasizes the value of supporting Dermatology Nights, which bridge the gap to accessing dermatologic care for the uninsured patient population of Lubbock and surrounding West Texas regions.