Summary by Website Contributor Hadley Johnson


Pay for performance (P4P) is a relatively new initiative within the field of dermatology. Those who advocate for the use of this model believe that it will improve the quality, value, and outcome of dermatologic care. However, in order for it to be a viable payment model in the field, adequate measures of performance and outcome must be established.

There have already been several early attempts at creating instruments aimed at measuring quality of care in dermatology. Examples include the Skin Cancer Index, the Dermatology Life Quality Index, and the Dermatology QOL Scales (491, 492).

To be successful, new measures that are developed should be relevant, accurate, and representative of the field as a whole (486, 487). However, this has proven difficult, especially in the dermatologic subspecialties (486, 489, 490). For example, few valid measures existed in dermatologic surgery until there was a push to create new ones by those close to the field (489).

In addition, despite this push towards a more value-based payment model, there are other models relevant to the field of dermatology. This includes fee-for service, flat rate, fixed, bundled, and time-driven activity-based costing (488). Therefore, in order for P4P to find success amidst these various models, proponents are calling for the field’s active engagement in the process of measure development. Otherwise, dermatologists may also choose to participate in the process of creating other alternative payment models specific to the field (493).

Dermatology Literature

(486) Wilson RL, Feldman SR. Physician performance measures in dermatology. J Am Acad Dermatol. 2010;63(2):e29-e35. doi:10.1016/j.jaad.2010.04.018

PMID: 20633778


  • Quality performance measures have been difficult to develop in dermatology
  • Reviews examples of quality performance measures applicable to dermatology subspecialties (medical, surgical, cosmetic, dermatopathology)
  • Quality performance measure characteristics (relevance, impact, etc.) should be considered before they can be adequately implemented
  • Reviews concerns surrounding P4P and use of performance measures

Significance to Literature:

  • In 2010, P4P had little traction in dermatology but there was a will to actively engage in the process of developing subspecialty-specific measures.



(487) Freedman JD, Gottlieb AB, Lizzul PF. Physician performance measurement: tiered networks and dermatology (an opportunity and a challenge). J Am Acad Dermatol. 2011;64(6):1164-1169. doi:10.1016/j.jaad.2010.07.004

PMID: 21571173


  • Although dermatology has traditionally been excluded from tiered plans, tiered networks are expected to become more prevalent
  • There are few validated dermatology measures, and the established measures are limited
  • To be successful, tiered networks must address issues pertaining to:
    • Accurate comparisons based on scope of practice and patient population
    • Validity, accuracy, and precision of performance measures
    • Weight given to quality over cost

Significance to Literature:

  • Classic description of concerns over tiered performance measurement as applied to dermatology.



(488) Ogbechie-Godec OA, Mostaghimi A, Nambudiri VE. Skin in the game: Existing and upcoming physician payment models in dermatology. J Am Acad Dermatol. 2018;79(1):175-177. doi:10.1016/j.jaad.2018.01.032

PMID: 29409917


  • There is a push to change physician reimbursement in dermatology towards value-based reimbursement
  • Authors describe the pros and cons of 7 different payment models used in dermatology including: fee-for-service, flat rate, fixed (salary and capitated), Merit-based Incentives Payment System (MIPS), bundled, and time-driven activity-based costing (TDABC)

Significance to the Literature:

  • Reviews different payment models in dermatology and calls for the specialty’s engagement in tailoring them to the field.



(489) Chow C, Yuan JT, Ruiz ES, Soon SL, Makhzoumi Z, Arron ST. Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions. Dermatol Surg. 2019;45(6):836-843. doi:10.1097/DSS.0000000000001938

PMID: 31021903


  • The American Academy of Dermatology has instituted the DataDerm registry, which includes 35 performance measures relevant to dermatology. However, few are specific to dermatologic surgery
  • Using data from other surgical specialties, from discussion within the American College of Mohs Surgery (ACMS), and from survey data from 51 Mohs surgeons in an ACMS study, the authors summarize potential performance measures that could be used in dermatologic surgery
  • Examples include:
    • Mohs micrographic surgery: histopathology laboratory certification
    • Average number of stages needed for tumor clearance in Mohs surgery
    • Wrong-site surgery event
    • 5-year recurrence rate
    • Aesthetic outcome measures

Significance to the Literature:

  • Proposal of several dermatologic surgery specific performance measures.



(490) Lee EH. Patient expectations and performance measures in dermatologic surgery. Clin Dermatol. 2016;34(1):111-113. doi:10.1016/j.clindermatol.2015.07.002

PMID: 26773631


  • Primary care physicians acknowledge that dermatologic surgeons are often the most qualified to perform skin cancer and aesthetic procedures. However, the public does not always share this viewpoint
  • This discordance may exist due to a difference between patient and physician expectations.
  • Using patient-reported outcome measures or other physician performance measures could be a way to resolve this discordance.
  • However, few of these measures exist in dermatologic surgery, and the ones that exist may not be valid

Significance to the Literature:

  • There is a need for more validated patient-reported outcome measures and other physician performance measures specific to dermatologic surgery. 



(491) Rhee JS, Matthews BA, Neuburg M, Logan BR, Burzynski M, Nattinger AB. The skin cancer index: clinical responsiveness and predictors of quality of life. Laryngoscope. 2007;117(3):399-405. doi:10.1097/MLG.0b013e31802e2d88

PMID: 17334300


  • The Skin Cancer Index (SCI) was created to evaluate the quality of life of patients with nonmelanoma skin cancer (NMSC)
  • The authors sought to evaluate the clinical responsiveness of the SCI and to establish factors that impacted quality of life in the NMSC population
  • The results of the study revealed that the mean SCI score and each subscale score (emotional, social, appearance) improved post-surgery, demonstrating that the SCI was a clinically responsive instrument for measuring quality of life in NMSC patients
  • The study also discovered factors that could impact quality of life in NMSC patients, including female sex, younger age, and location of the NMSC

Significance to the Literature:

  • The SCI was an early attempt at creating a valid disease-specific outcome measure in the field of dermatology.



(492) Lee EH, Klassen AF, Nehal KS, Cano SJ, Waters J, Pusic AL. A systematic review of patient-reported outcome instruments of nonmelanoma skin cancer in the dermatologic population. J Am Acad Dermatol. 2013;69(2):e59-e67. doi:10.1016/j.jaad.2012.09.017

PMID: 23102770


  • The authors conducted a systematic review of the literature to identify patient-reported outcome (PRO) instruments that evaluated quality of life or patient satisfaction of patients with nonmelanoma skin cancer (NMSC)
  • The search identified 6 PRO instruments that met inclusion criteria, including: Skindex, Dermatology Life Quality Index, Dermatology QOL Scales, Patient Outcomes of Surgery – Head/Neck, Skin Cancer Index, and the Disease-Specific Questionnaire
  • Of these 6 instruments, the authors reported that the Skin Cancer Index was the most useful for the NMSC population. However, they mentioned that which instrument is used is dependent on the objectives of a specific study

Significance to the Literature:

  • By 2013, several PRO instruments existed that measured quality of life and/or patient satisfaction in dermatologic patients.



(493) Barbieri JS, Miller JJ, Nguyen HP, et al. Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children’s Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System. J Am Acad Dermatol. 2017;76(6):1206-1212. doi:10.1016/j.jaad.2017.01.032

PMID: 28365038


  • Under the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), dermatologists have to choose to participate in either the Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs)
  • Although most dermatologists are expected to choose MIPS, some may hope to participate in the APM pathway
  • However, the only option currently available to dermatologists is to join a qualifying Accountable Care Organization. Consequently, fewer than 2% of dermatologists are expected to qualify for the advanced APM pathway in 2017
  • Therefore, more dermatology-specific APMs need to be developed so that interested dermatologists have an alternative to participation in MIPS
  • Disease-specific bundled payment models hold promise as a potential APM for dermatologists

Significance to the Literature:

Explores the APM pathway as it pertains to dermatology and calls for the specialty’s ongoing participation in developing new APMs