Contribution of health care factors to the burden of skin disease in the United States  Henry W. Lim, MD, Scott A.B. Collins, MD, Jack S. Resneck, MD, Jean L. Bolognia, MD, Julie A. Hodge, MD, MPH, Thomas A. Rohrer, MD, Marta J. Van Beek, MD, MPH, David J. Margolis, MD, PhD, Arthur J. Sober, MD, Martin A. Weinstock, MD, PhD, David R. Nerenz, PhD, Wendy Smith Begolka, MBS, Jose V. Moyano, PhD  Journal of the American Academy of Dermatology  Volume 76, Issue 6, Pages 1151-1160.e21 (June 2017) DOI: 10.1016/j.jaad.2017.03.006 Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 1 US population with skin disease by insurance status. A, The stacked column graph represents the relative percentage of the US population with skin disease (pink), compared to those without skin disease (gray) for each insurance status. The actual number of individuals (in thousands) is indicated inside the bar. B, The table lists the 24 skin disease categories in alphabetical order, and indicates the prevalence of population with a specific skin disease (in percentage) for each insurance status (commercial, Medicare, Medicaid, and uninsured). The colored cells indicate a “heat map” of prevalence, ranging from highest prevalence (dark red) to lowest prevalence (dark blue) for each insurance status. C, The bubble graphs plot the probability of a Medicare-insured individual diagnosed with melanoma, actinic damage, noncancerous skin growths, ulcers, or congenital abnormalities of having another skin disease. The relative probability is indicated by the size of the bubble, with the actual probability percentage in each label. The y axis plots the percentage prevalence of skin disease in the Medicare population and the center of each bubble corresponds to the disease-specific prevalence. Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 2 Prevalence of skin disease across age groups. A, The table ranks the prevalence of the 24 skin diseases across the entire US population by relative change across age group. The ratio in prevalence change across the four age groups was calculated (determined by dividing the prevalence of [18-44y]/[0-17y], [45-64y]/[18-44y] and [65+y]/[45-64y]), and the average was used to define 3 arbitrary categories of change in prevalence by age, namely high increase (>2.32x; red zone of the ‘heat map’), moderate increase (1.28-2.32x; white zone), and null/irregular-to-moderate decrease (<1.28; blue zone). B, The line graphs represent the total percentage prevalence for the top 5 skin diseases with the highest increase in relative prevalence across the four age groups (0-17, 18-44, 45-64, and 65+ years). Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 3 Relative medical costs of skin disease by insurance status. The histogram represents the relative percentage of disease-specific total medical cost by insurance status (commercial [blue], Medicare [orange], Medicaid [green], and uninsured [yellow]), and sorted by decreasing total medical cost. The actual medical costs per insurance status in USD millions is indicated in each bar. Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 4 Direct medical costs and number of diagnosed individuals. The graphs plot the top 10 skin disease categories by direct medical cost (in USD millions; y axis) for commercial (A), Medicare (B), Medicaid (C), and uninsured (D) populations in 2013. The bubble size represents the relative prevalence for each of the indicated diseases. The label includes the skin disease analyzed, its total medical cost, and the actual number of diagnosed individuals. Note that the latter value may indicate more than one diagnosis per individual (overlapping); therefore, the sum of these values will exceed the number of insured individuals in the population. Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 5 2013 cost of skin disease per diagnosed person. The range bar graph represents the cost range across insurers per diagnosed person with skin disease in 2013 for the top 10 most costly skin diseases and ranked by their weighted average cost in USD (indicated by a white line). Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 6 Estimated insured impatient/outpatient cost per diagnosed person. The stacked column graphs represent the total percentage of cost per diagnosed (affected) person by outpatient (gray bars) and inpatient (black bars) services for commercial (upper panel), Medicare (middle panel), and Medicaid (lower panel) populations. The top 10 skin diseases ranked by total inpatient cost are shown. The actual cost in USD per diagnosed person for each type of service is indicated inside (outpatient) or right adjacent to (inpatient) the corresponding bars. Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 7 2013 cost of prescription drugs per insured person. A, The stacked columns (upper panel) represent total cost of skin disease prescription drugs in USD millions segregated by nonspecialty (black) and specialty (gray) drugs for commercial, Medicare, and Medicaid populations. The stacked columns (lower panel) represent the actual cost in USD per person (regardless of having skin disease) by type of prescription drugs (vaccines, specialty and nonspecialty) and by insurance status. The total cost per person by insurer is indicated at the top of each column. B, Relative cost in percentage for the top 10 skin disease drugs (pie charts, red slice) for commercial (top panel), Medicare (middle panel), and Medicaid (lower panel), and a table with the list of skin drugs sorted by descending cost per person. The asterisk indicates a specialty drug. Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions

Fig 8 Portion of office visits for skin disease delivered by dermatologists. A, The stacked column graphs show the percentage of office visits with a dermatologist (green) compared to other health care providers (gray) for commercial, Medicare, and Medicaid populations. The actual percentages for each category are shown inside the columns. B, The stacked column graphs show the percentage of surgeries performed by a dermatologist (green) compared to other health care providers (gray) for commercial, Medicare, and Medicaid populations. The actual percentages for each category are shown inside the columns. C, These bar graphs represent the top 10 skin disease categories by percentage of office visits to dermatologists in 2013 for commercial (upper panel), Medicare (middle panel) and Medicaid (lower panel). The actual count of office visits performed by all providers for each category is plotted in a logarithmic scale and indicated within each column, while the percentage of these visits to dermatologists is indicated at the top of each column. Journal of the American Academy of Dermatology 2017 76, 1151-1160.e21DOI: (10.1016/j.jaad.2017.03.006) Copyright © 2017 American Academy of Dermatology, Inc. Terms and Conditions