NEWPORT BEACH, CALIF. – As the health care delivery landscape continues to evolve, expect the use of telemedicine to expand in dermatology.
“We have a robust evidence base that this is a valid way to deliver health care that can significantly improve patient access and offer comparable diagnostic and therapeutic outcomes, compared with in-person dermatology,” Ivy A. Lee, MD, said at the annual meeting of the Pacific Dermatologic Association. “This is an efficient way to improve access to our small and mighty workforce.”
Many factors are driving teledermatology’s rise in popularity, including patient access issues. “These are getting more prominent and more prevalent, not only in the uninsured and the underinsured, but also in our insured population,” said Dr. Lee, a Pasadena, Calif.–based dermatologist who also chairs the American Academy of Dermatology’s Telemedicine Task Force. “In my private practice, it’s about a 6- to 8-week wait for a new patient appointment, and this is in an affluent part of Los Angeles.”
Then there’s the increasing expectations of today’s health care consumers, who “want a better medical experience,” she said. “They don’t want to spend all their day in our waiting room, and they want to be able to get in touch with their physicians and not play phone tag with the front office staff. There’s also omnipresent technology. We have devices in our office, in our home, and in our hand – in every aspect of our lives. That’s also affecting our experience and expectations of medicine and health.”
Current forms of telemedicine range from “store and forward” (which refers to the submission of clinical images and history to a remote provider who reviews the material and sends a recommendation at a different time), “live interactive” (which uses synchronous video technology similar to FaceTime or Skype where you’re interacting with the patient or with the patient’s provider at the same time, even though you are separated by space), and “hybrid” (a combination of the two forms).
Dr. Lee said that store and forward currently is the predominant form of teledermatology “because of the convenience and ease of use. We’re a lot more efficient with that modality. We’ve used it predominantly for care delivery in a consultative practice model (provider interacts with another provider for consultation or triage of a patient). But, we also see an increasing interest and practice of direct-to-patient or direct-to-consumer care where providers interact with patients. This trend is predominantly led by telemedicine companies as a response to increasing patient demand for convenience, but also we see this practice model being adopted by larger health care systems and private practices.”
In the past, she continued, most telemedicine technology has consisted of stand-alone software platforms. The new focus is integration, asking software platforms to be more interoperable with EHRs. “Also, some EHRs are offering telemedicine capabilities,” she said. Recent interest in value-based medicine, especially since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also plays a role in the growing adoption of telemedicine. “The focus on value and data collection is increasingly imposed upon us by multiple sources,” Dr. Lee said.
Reimbursement remains a barrier for wide adoption of teledermatology. Current models include volume-based (fee-for-service) and value-based models such as capitation, bundled payments, and pay for performance. Advances in the volume-based realm include increasing adoption of parity laws for private insurers (29 states hold such laws, which call for telemedicine services to be covered to the same extent and in a similar manner as in-person services).
In this era of higher-deductible insurance plans and narrowing networks, patients are also paying for their own care out of pocket or by using flexible savings accounts, to the tune of $30-$200 per teledermatology encounter. “We also have seen some progress with government payers in the fee-for-service models: Medicare, and less so with Medicaid,” she said. Telemedicine payments from Medicare have increased, from about $5 million in 2011 to about $18 million in 2015, but it currently reimburses live video with geographic restrictions and reimburses for store-and-forward technologies only in Alaska and Hawaii.
Medicaid “lags behind other payers,” Dr. Lee said. “Few states reimburse for store and forward, and reimbursement depends on distance requirements, eligible patient populations and health care providers, authorized technologies, and patient consent. Currently, reimbursement varies significantly across the country; it varies by state and, within each state, by payer. With the passage of MACRA, we have to start thinking about how we will practice and measure the value-based care we deliver and whether we as dermatologists will implement an alternative payment model or a merit-based incentive system. There are a lot of legislative changes in terms of getting properly paid for these services.”