Remuneration of specialist doctors is the subject of analysis and debate, not only in terms of salary,1–4 but also with regard to how services are billed. While some studies have analyzed payment models in non-English-speaking Europe (the first of these were performed in the middle of the 20th century5), most studies that deal with payment of doctors per patient or per intervention come from the English-speaking world.6–12 Recently, some authors have criticized regional differences in financial compensation because of the inequality this may generate in the geographic distribution of dermatologists.13

Private health are in Spain is growing.14 Part of this growth is a result of cutbacks in public spending (and the subsequent transformation of the health care system), diversification of supply, and changes in patterns of demand.15 Another factor that explains this growth in our specialty is the growing trend of esthetic procedures.16

After reviewing the literature, we found no scientific publications to date that show the variations in fees per intervention and payment-collection habits among dermatologists providing private care in the different autonomous communities in Spain. Spanish studies examine general aspects of private care14 or pay conditions of doctors in all specialties.1

We consider the description of the characteristics and fees of specialists in medical and surgical dermatology and venereology who provide private care in Spain in 2018 to be important from a scientific, sociological, and historical perspective. This snapshot of the current economic situation in dermatology makes it possible to determine the current state of private care in this specialty, how it is developing, and which areas require criticism or improvement; it is also an historical testament to the social and economic environment.

The primary goal of this study was to describe the characteristics of private dermatology practice and the fees for the most common medical and esthetic procedures. The secondary goal was to analyze these fees by region, age, and sex.

We carried out an online survey (Appendix B; questions are shown in Supplementary Table 1), which was open for responses from 17 May to 5 June, 2018.

Requests for responses were sent through the following professional forums with access controlled by dermatologists: Foroderma 2.0 (Facebook group with 668 members at the date of closure of the survey), Dermachat (chat forum with 340 members on the closure date), and Dermus (dermatologists who attended the 11th Meeting of Private Dermatology and New Technologies [XI Reunión de Dermatología Privada y Nuevas Tecnologías], held in Madrid from May 31 to June 2, 2018). This meant that all respondents were medical specialists in medical and surgical dermatology and venereology. Although these groups consist of mostly Spanish members, the introduction to the survey and the initial questions excluded any specialist not working in Spain. Responses were only accepted from professionals carrying out private practice (ensured by an exclusion question at the start of the survey).

Data were analyzed using the χ2 test, comparing region, sex, and age. Questions regarding fees were asked in terms of categories to make the survey more acceptable. In order to analyze these data, each category was recoded as its mean value (assuming that fees are distributed uniformly in each category) and the mean fees of the extreme categories were estimated (Appendix B, Supplementary Table 2). The fees were compared using analysis of variance (ANOVA) and linear regression after verifying that these techniques were applicable. To evaluate the factors that affect fees by sex, we performed successive linear regression models, including the variables sex, age, autonomous community, type of center, and a variable for interaction between sex and age. The SPSS (version 20.0) and Stata (version 15) statistical software packages were used for the statistical analysis. Results of the tests were assumed to be significant for values of p<.05.

In this study, we describe the characteristics and fees in private care provided by specialists in dermatology working in Spain. Some differences were found based on the sex, age, and geographic location of the dermatologists, notably including greater presence of older dermatologists in private practice, different acceptance rates for credit cards by regional section, and differences in fee changes by age and sex. In terms of fees, differences were observed in the price of first appointments by regional section, and in practically all fee items by sex, where the fees set by female dermatologists were significantly lower than those set by male dermatologists.

We have been unable to identify similar publications in the literature. Unlike the analyses of the consequences of certain types of payment in the English-speaking world,6–12 Spanish studies focus on general aspects of private care14 or pay conditions of doctors in all specialties.1 The survey sample included equal numbers of male and female respondents and was proportional with respect to the number of academic belonging to each regional section of the AEDV. Furthermore, measures were taken to prevent social desirability bias (consisting of giving answers in the survey that are closer to what is socially more acceptable)17; this was achieved essentially by means of anonymous data collection and processing) and to facilitate participation (such as category-based questions). The study may, however, have some limitations, such as the relatively small sample size (although it represents more than 10% of academics and, therefore, of dermatologists in Spain18), its selection, and the restrictions on representativeness that may result from the differences in age, geographic area, and type of private clinic.

The ages shown in the survey correspond to the current demographics of health care professionals.1 It can be stated that the older Spanish dermatologists are, the more frequently they work in private practice. While there are approximately 3000 private medical centers in Spain and the majority of the turnover (€3,96 million in 2015) comes from 9 main actors (large hospital groups and insurers),14 dermatologists usually work in small clinics (their own clinics, with up to 4 doctors on the team). Clinics owned by dermatologists and with more than 4 doctors on the team are the exception and are restricted to a few geographic areas.

At present, teledermatology consultations are rare. Domiciliary visits by dermatologists are rare and, in general, more common among male dermatologists. In terms of payment-collection habits, we can conclude that most dermatologists tend to delegate this responsibility to administrative personnel, payment is rarely collected in advance, and financing of treatments or the provision of vouchers is also rare. Notable discrepancies were observed in terms of acceptance of payment by bank card, with 100% acceptance in the Canary Islands (possibly owing to the tax-deductible nature of medical expenses included in the Canary Islands 2018 budget with effects retroactive to 2017, which requires submission of proof of payment by bank card, transfer or check19) and lower rates of acceptance in other sections (probably linked to tax-related differences between autonomous communities). It is also of note that most dermatologists set their fees in multiples of 10 and do not adjust them in accordance with the consumer price index. The fact that fees are rounded is probably due to convenience when collecting payment in cash and providing change; a similar reason may explain why prices are updated in increments of 10. The fact that older dermatologists usually have a more established system of setting fees may indicate that experience provides them with greater financial education.

With regard to fees, the differences in the price of a first appointment are linked to the presence of extreme values in certain geographic areas. Nevertheless, the values are relatively uniform between regional sections. While no differences were observed in nearly any of the fees by age of the dermatologist, medium-complexity surgery (performed privately by most of the specialists surveyed) show a tendency to be charged at a higher rate by older dermatologists. Highly complex surgery is performed by a smaller proportion of dermatologists and by an even smaller proportion of older dermatologists.

The most surprising finding in our survey is that female dermatologists charge lower fees than male dermatologists. We do not know the reasons for this. These findings are in line with a recent publication that observed mean differences of €12,000 in annual salaries (to the detriment of female doctors) in Spain,1 but in our study, it is noteworthy that the differences are not in overall salary but in fee per medical intervention and probably self-imposed.

We believe that this study may serve as a frame of reference for understanding the habits of Spanish dermatologists providing private care. The fact that the fees of female dermatologists are lower requires more detailed study —probably using qualitative research techniques.

The authors declare that they have no conflicts of interest.