A months-long stalemate in talks over a new deal between Wayne State University's physician group for dermatologist coverage at Detroit Medical Center hospitals led to a shortfall in the specialists to check out patients' unusual and sometimes life-threatening skin conditions, according to multiple sources.
A tentative deal was struck last week, and DMC says patients were never in danger and dermatologists were available. But two Wayne State dermatologists, a private dermatologist and a chief resident at DMC said consultations were often sought and not available for many months.
Lack of dermatology consultations — as is true for many other such specialties as neurology, psychiatry and nephrology and is especially acute for Medicaid and uninsured patients — can lead to life-threatening conditions or result in emergency hospitalizations that unnecessarily increase health care costs.
Last Nov. 15, two top DMC medical executives sent out a letter to private dermatologists in metro Detroit asking for dermatological coverage at DMC's Harper University Hospital and Detroit Receiving Hospital's level-one trauma center.
Dermatology sources told Crain's that DMC has been suffering from a lack of dermatology consultations directly related to expiration nearly two years ago of a contract with the seven-physician dermatology department at Wayne State University Physician Group, the medical school's 500-physician academic medical group, and the ending of a dermatology residency position sponsored by Wayne State.
"We are currently in need of attending dermatology physicians to respond to inpatient consultations," Monique Butler, M.D., Receiving's chief medical officer, and William Berk, M.D., Receiving's chief of staff, said in the letter obtained by Crain's.
For more than six weeks, DMC officials declined to comment on the letter and why it was sent but issued a statement in early December to Crain's about dermatology coverage.
"Inpatient dermatology consults are covered by DMC's 28 staff dermatologists," said DMC spokesman Melanie Moss. "These dermatology specialists, as well as our team of highly trained emergency, surgical and internal medicine providers respond to requests for consults at all of our DMC locations. In the case of a potentially life-threatening disease, rash or medication allergy, a patient would be admitted and cared for by this team."
But in a joint statement e-mailed to Crain's Wednesday morning, Jan. 11, one minute before an interview began with DMC officials, DMC and Wayne State said they had reached preliminary agreement on a contract.
"(We) are pleased to announce a new program agreement in which the DMC will host Wayne State University dermatology residents at DMC's various inpatient and outpatient sites. This opportunity will further the education of future medical specialists who will help serve the dermatologic needs of our community. Once finalized, this agreement will be mutually beneficial to both parties," said the statement.
Wayne State officials declined further comment, but confirmed that the outline of a new contract was unexpectedly reached.
In the interview with Crain's, Reginald Eadie, M.D., DMC's regional COO, said DMC CEO Joe Mullany on Monday night spoke with Jack Sobel, M.D., Wayne State medical school dean, about resolving the issue to return the dermatology resident and UPG coverage, among other topics. Tuesday night, Sobel talked with Suzanne White, M.D., DMC's chief medical officer, to further discuss the tentative deal.
Eadie also confirmed that DMC had a previous agreement with WSUPG for dermatology coverage. He said he wasn't privy to why the older contract ended.
"They (Wayne State) decided not to provide coverage, so we needed to shift to non-UPG doctors," said Eadie, who previously was CEO of Receiving, Harper and Hutzel Women's Hospital.
In response to the Nov. 15 letter, Butler said several private dermatologists have agreed to accept inpatient consultations at DMC's downtown hospitals.
"We play a role in recruitment," Butler said. "We had changes that occurred with coverage, but there has never been a situation where we did not have coverage. We have a group of dermatologists who provide coverage."
But sources told Crain's that the need for inpatient dermatology consultations on difficult to diagnose skin cases has been a long-term problem that began when former CEO Mike Duggan, who is now Detroit's mayor, eliminated funding for the Wayne State University School of Medicine's dermatology department in a cost-cutting move in 2006.
Duggan also terminated funding for Wayne State's departments in family medicine, urology, orthopedics, and ear, nose and throat as DMC was teetering near bankruptcy. Four of the five departments shifted clinical services and residency programs from DMC to former Oakwood Healthcare hospitals. Family medicine residency went to Crittenton Hospital.
For several years, WSUPG dermatology had a small contract for a dermatology resident with Receiving to cover inpatient consultations, but that ended Jan. 1, 2015, when DMC cut funding, sources said. From that time until July 2016, WSU dermatologists provided consults without funding as a community service, sources told Crain's.
"We continued to try to negotiate during that time," said a Wayne State dermatologist, who asked to remain anonymous. "Budget cuts at other hospitals reduced our funding and caused us to be unable to provide DMC consults. Since July, we have been trying to negotiate, but the DMC has given us no response."
On Jan. 10, Wayne State issued the following statement to Crain's: "The Wayne State University School of Medicine currently does not have a dermatology contract, but would consider any proposal for those services. Despite any contention to the contrary, we are interested in providing our high-quality dermatology services to Tenet Healthcare Inc.'s Detroit Medical Center."
Last September, Wayne State medical school and DMC agreed to an 18-month clinical services and administrative contract. But the contract did not cover dermatology services, which sources said was disappointing to the UPG dermatology department.
Eadie declined to comment on why dermatology was not included as a provision in the contract. Wayne State sources told Crain's that DMC did not propose an agreement for dermatology to accept or reject in the contract talks last year.
Over the last few months, however, Eadie said several doctors and dermatologists have asked DMC to reinstate the subsidy for the residency position and attending coverage.
"I gathered the facts and I now have a plan to reinstate the subsidy," said Eadie, referring to the joint statement and proposed deal with Wayne State. He declined to detail the terms of the agreement. Sources said the agreement could range from a single year to multiple years and could include several dermatology residents.
Despite DMC's denials, Crain's sources confirmed the lack of dermatology consultation affected Receiving, Harper, Hutzel and the Rehabilitation Institute of Michigan. WSUPG dermatology has separate agreements with DMC Children's Hospital of Michigan and Karmanos Cancer Institute. Sources also said DMC's other hospitals, including Sinai Grace and Huron Valley-Sinai, have sufficient dermatology consultations and were not affected.
"Dermatology inpatient services may not seem very important, and many patients in the hospital don't require them," said the Wayne State dermatologist, who estimated three to four dermatology consultations are needed each week at Receiving and Harper, but that some weeks consultation requests can be as high as 10.
"But there are some very serious skin disorders that can be life-threatening. One of those diseases is called Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. It is a skin problem in which a medication causes all the patient's skin to start to blister and fall off. The mortality rate can be as high as 35 percent."
The Wayne State dermatologist said these Stevens-Johnson skin patients can require intense care at Detroit Receiving's burn unit. It takes a specialist to identify the Stevens-Johnson infections because it can mimic other less-severe conditions that require only antibiotics, the source said.
A senior internal medicine resident at DMC also circulated an email last fall among Wayne State dermatologists and DMC officials that indicated problems residents had last year with dermatology consultations. The resident said the topic of dermatology consultations became an issue because they were often needed, but unavailable for patients.
"Our fear is that a patient will develop a complication ... and we will not have dermatology to help," the senior resident said. "We did try to circumvent this by consulting surgery for a patient who required a biopsy; however, surgery is not trained for punch biopsies, and therefore there are issues with the preparation and handling of the sample."