After a steep rise in the beginning of the COVID-19 pandemic and a slow decline that started in the summer, telehealth consults in dermatology remain far elevated over those provided prior to the COVID-19 pandemic. But it is not clear whether the current rate will fall further, be sustained, or even climb again, according to data presented and opinions expressed in a forum on this topic at the American Academy of Dermatology Virtual Meeting Experience.
There are many unknowns, not least of which is future reimbursement from the Centers for Medicare & Medicaid Services and other third-party payers, according to several participants in a scientific session devoted to this topic. The CARES Act, which was passed in the early stages of the pandemic, provided only a temporary increase in reimbursement for telehealth. Postpandemic payments for telehealth services are yet undetermined.
Many of the assembled experts are convinced that teledermatology will continue to be offered at far higher rates than prior to the pandemic, but many issues, including physician acceptance of this approach remain unresolved. This was reflected in an AAD survey of members conducted in June 2020.
“Seventy percent of dermatologists responded that teledermatology will continue, but only 58% reported that they intend to offer it,” after the pandemic, reported Jules Lipoff, MD, assistant professor of dermatology at the University of Pennsylvania, Philadelphia, who is one of the authors of the paper that reported the results.
The low relative proportion of dermatologists planning to participate in teledermatology might at least in part reflect uncertainty about reimbursement, according to Lipoff, who is the outgoing chair of the AAD teledermatology task force
Many dermatologists might find it difficult to opt out of telehealth. In some types of care, such as follow-up visits, a combination of patient demand and institutional policy, particularly if reimbursement is adequate, might compel or at least strongly incentivize teledermatology services.
“Now that telemedicine has gotten out there, we will never go back to what once was normal practice,” Lipoff predicted. According to Lipoff, there was a great deal of data even prior to the pandemic to conclude that mobile dermatology is “an acceptable equivalent” for delivering many types of dermatologic care.
The rapid evolution in telemedicine is remarkable. According to the results of the AAD survey, 14.1% of dermatologists had experience with teledermatology prior to the COVID-19 pandemic, which increased to 96.9% by June, 2020, when the survey was conducted. Nearly 600 dermatologists completed the survey, for a 13.6% response rate.
At the beginning of the pandemic, the CARES act, along with other pandemic legislation and policy changes, changed the landscape of telemedicine by providing reimbursement commensurate with in-office visits, modifying HIPAA regulations, and permitting reciprocal licensing to allow physicians to provide care to patients who had moved out of the state. While these were among the factors that facilitated the phenomenal growth in telemedicine, nearly all of these changes were temporary or are subject to revision.
“Reimbursement [for telehealth] was very low prior to the pandemic,” noted Elizabeth K. Jones, MD, assistant professor of dermatology, Thomas Jefferson University, Philadelphia. While many physicians and policy makers were convinced that reimbursement levels had to be increased temporarily to provide medical care when in-office visits were unsafe, Jones said it is unlikely that pandemic reimbursement rates will be preserved. But recent statements from the CMS foreshadow lower rates for most video and telephone consults, she added.
Reimbursement is not the only consideration. George Han, MD, PhD, chief of teledermatology at the Icahn School of Medicine at Mount Sinai, New York, spoke about the frustration of using imperfect tools. He, like many dermatologists, have become familiar with the difficulty of making a definitive diagnosis from transmitted images of skin lesions.
As long as patients communicate with personal computers and phones under variable lighting conditions, this problem might never go away, but suboptimal quality images do not necessarily preclude other types of consults, particularly follow-up visits, according to Han, who is also system medical director for dermatology at Mount Sinai Health System.
“Now that patients know about teledermatology, they are for it,” he said. He suggested that increased efficiency of follow-up using telemedicine for both patients and physicians might increase the frequency with which these types of visits are scheduled. Citing evidence that follow-up visits increase patient retention rates, Han sees these visits among the routine uses of telemedicine when the pandemic is over.
At the height of the pandemic, teledermatology was employed broadly, but after the pandemic, Han and others predict a narrower focus. Some consults, such as those for acne or other conditions reasonably treated on the basis of patient history, appear to lend themselves to telemedicine. Others, such as a skin check for malignancy, might not.
As the role of telemedicine is sorted out and finds its equilibrium in a postpandemic world, Lipoff pointed out the need to consider populations without good-quality internet access. Without specific strategies to ensure these patients are not forgotten, he warned of “wealthier patients consuming more than their fair share” of health care resources, further widening an existing disparity.
“Is telemedicine here to stay? It is clear that, yes, it is in some way,” said Lipoff, who sees no reason for dermatology to be an exception.
Lipoff reported a financial relationship with AcneAway. The other investigators reported no potential conflicts of interest related to telemedicine.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.