Current issues & opinion
A relative value unit–based cost comparison of treatment modalities for nonmelanoma skin cancer: Effect of the loss of the Mohs multiple surgery reduction exemption

https://doi.org/10.1016/j.jaad.2008.07.047Get rights and content

Background

The incidence of skin cancer has increased dramatically, with as many as 2.8 million skin cancers treated in 2005. In an era of decreasing reimbursement, insurer policy changes, and increasing pressure to deliver cost effective care, physicians should understand the total cost of different skin cancer treatment modalities in order to determine which yields the best value for patients.

Objective

To estimate the costs of treating nonmelanoma skin cancers by multiple modalities based on their assigned relative value unit (RVU) values.

Methods

The cost analysis was performed for the treatment of two skin cancer examples, a basal cell carcinoma (BCC) on the central cheek and a squamous cell carcinoma (SCC) on the forearm of varying sizes. The estimated costs of treatment of each of the skin cancers was calculated for treatment with electrodessication and curettage (EDC), imiquimod immunotherapy, Mohs micrographic surgery, traditional surgical excision with permanent section margin evaluation in an office setting (with immediate repair or with repair delayed until clear margins are confirmed), surgical excision with frozen section margin control in both an ambulatory surgery center and hospital-based setting, and radiation therapy. The effect of the loss of exemption from multiple surgery reduction on the cost of Mohs surgery is also examined.

Results

Our estimation of costs for each of the treatment modalities reveals that EDC is the least expensive option, with average costs of $471 (BCC cheek) and $392 (SCC arm). Imiquimod treatment and office-based excision with immediate repair of the surgical defect have similar total average costs of $959 (BCC cheek) and $931 (SCC arm) and $1006 (BCC cheek) and $907 (SCC arm), respectively. If repair of the defect is delayed until negative surgical margins are confirmed by permanent section, the cost of excision increases to $1170 and $1041. The average cost of Mohs micrographic surgery is $1263 (BCC cheek) and $1131 (SCC arm). Mohs surgery's recent loss of multiple surgery reduction exemption has decreased the cost of Mohs surgery by 9% to 25%. Excision with frozen section margin control in an ambulatory surgery center results in costs of $2334 (BCC cheek) and $2200 (SCC arm). However, if the excision is performed in a hospital operating room, the procedure is substantially more expensive, at $3085 and $2680. The cost of radiation therapy treatment is $2591 to $3460 for the BCC of the cheek and $2559 to $3431 for the SCC of the arm, depending on the fractional dose used.

Limitations

These are cost estimates based on literature examples and 2008 RVU values; variations related to individual practices and procedure valuations by private insurers are expected.

Conclusion

Tumor destruction by EDC or imiquimod and office-based procedures, such as traditional surgical excision or Mohs surgery, are the lowest cost options for treatment of nonmelanoma skin cancer.

Section snippets

Methods

In order to estimate and compare the costs to the health care system of treating NMSC, two typical skin cancer cases (a basal cell carcinoma [BCC] of the central cheek and a squamous cell carcinoma [SCC] on the forearm) of varying sizes were selected for evaluation. The tumor sizes selected for analysis are 0.6, 1.1, 2.1, and 3.1 cm. Insurance-based reimbursement of medical procedures is dependent on the relative value units (RVU) values assigned to the individual medical, surgical, and/or

Results

Our cost analysis of NMSC treatments reveals that EDC is the least expensive treatment modality examined (Table I, Table II). The average cost for EDC is $471 (BCC cheek) and $392 (SCC arm). Imiquimod and office-based excision with permanent sections and immediate repair have approximately equal average costs of $959 (BCC cheek) and $931 (SCC arm) versus $1006 (BCC cheek) and $907 (SCC arm), respectively. At smaller lesion sizes, excision is less expensive than imiquimod, with 0.6-cm lesion

Discussion

This study evaluates the cost to treat two skin cancer examples of varied initial clinical size and location with different therapeutic modalities and clinical settings. EDC is the least expensive treatment option at all tumor sizes examined, with costs about 64% lower than Mohs surgery and 55% lower than office-based excision. Imiquimod therapy has average total costs approximately equal to office-based excision but is more expensive than excision at smaller lesion sizes. Mohs surgery is about

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    Funding sources: None.

    Conflicts of interest: None declared.

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