Teledermatology’s Staying Power After the Pandemic Requires Sweeping Legislative Changes

While telemedicine has grown exponentially during the COVID-19 pandemic, there are concerns about a coming telehealth cliff as many policies that expanded use of telemedicine during the pandemic are temporary, said speakers during a session at the American Academy of Dermatology (AAD) Virtual Meeting Experience 2021.

When the pandemic hit, dermatologists knew treating patients would be difficult without exposing them to the virus, while ensuring they continue to receive care they need, said Jules Lipoff, MD, FAAD, assistant professor, Department of Dermatology, University of Pennsylvania, and outgoing chair of the AAD Teledermatology Task Force.

Previous research had shown that teledermatology was an acceptable equivalent for diagnosis and management, “yet despite all of this research and information, teledermatology was not widely used because of several barriers,” Lipoff said.

Those barriers included:

• Lack of reimbursement, either not being paid enough or not being covered at all
• Concerns about liability
• Restrictions imposed by state medical licensing

During the pandemic, government policies created parity for video visits, established a waiver for the Health Insurance Portability and Accountability Act (HIPAA) so any platform could be used, and made state licensing reciprocal for many states, Lipoff explained.

“But what will the long-term policy changes be?” he asked. “We have yet to see.”

The AAD Teledermatology Task Force sent a survey to AAD members to better understand what dermatologists were seeing with teledermatology, what they had learned, and what barriers they still saw. The survey went out to 5000 participants, 591 of whom completed the surveys for a 13.5% response rate.¹

The survey allowed the task force to quantify the increased use in teledermatology since the start of the pandemic. Prior to the pandemic, only 14.1% of dermatologists had used it, but that number skyrocketed to 96.9% after.

“There’s been a lot of resistance to using telemedicine in the past,” Lipoff said. “Now that everyone has basically had some experience, this will allow us to really parse out what works and what doesn’t from real experience not just impressions of how it could be.”

The biggest barriers dermatologists identified during their use of telemedicine were low reimbursement (69.8%), technology and connectivity issues (39.1%), concerns about malpractice and liability (27.0%), and government regulations (23.2%). In addition, while 69.8% of respondents believe teledermatology will continue after the pandemic, only 57.9% said they personally planned to continue using it.

“We interpret this as saying, ‘yes, we all know this is important, but there still are concerns,’” Lipoff explained.

A second presentation from Elizabeth Jones, MD, FAAD, dermatologist at Thomas Jefferson University Hospital, delved into the policy behind reimbursement, how it was impacted by the pandemic, and what to expect moving forward.

With the mixed insurance landscape in the United States, there has been a variety of policies on covering teledermatology, which has made the space more confusing for dermatologists in the past, she explained.

For instance, Medicare has a limited definition of telehealth. These services must include audio and video allowing for live 2-way interaction. Reimbursement for telehealth was also limited to specific services, specific site/facility locations, geographic areas, and the modality used to deliver the service.

“So, what this created was layers of obstacles for providers to try and sift through when determining which payers were going to reimburse for telehealth services, which services were going to be covered, which patients they could offer these services to,” Jones said. “So, it created a lot of confusion, which was a barrier for providers for adopting this in their practice.”

During the pandemic a lot of these barriers were broken down as the government allowed expansion of covered services, lifted geographic restrictions and site limitations, stopped enforcing HIPAA, and relaxed state licensures. These changes are not permanent, though, and while CMS can make changes to the physician fee schedule and broaden definitions, real change will require legislative action, according to Jones.

“The real true sweeping changes that can make an impact require statutory change and require us to collaborate with our lawmakers,” she said.

In addition, with private insurance being the primary source of coverage in the United States, the picture is not the same across the country and depends on states. There are 12 states that have both service parity (the service is reimbursed at all) and payment parity (the service is reimbursed at the same rate as in-person care). Twenty-four states, plus Washington, DC, have service but not payment parity, and 14 states have neither.

Nearly all payers had expanded telehealth during the pandemic, “but many are preparing for a reversal of these expansions” once the public health emergency is over. As a result, many physicians and policy experts are concerned about a “telehealth cliff” unless these changes are made permanent or policy changes are enacted.

“We need to start gearing for telereadiness for the future,” Jones said.

There will be another pandemic, and with climate change there will be more weather emergencies, both of which require the health care system to be adaptable to provide care for patients when they can’t come into the office, she said. In addition, there is a need to adapt to the younger generations, which are demanding technology and ease of use.

As policy changes lag behind the growing demand for this service, patients are relying on direct-to-consumer and self-pay models. These models are growing rapidly, but can provide fragmented care and documentation, and a lack of follow-up care. In addition, there is a lack of regulation around these models, Jones said.

“As a field we really need to start advocating and start coming up with guidelines for best use for teledermatology for our long future ahead of using this as a main way of serving our patients,” she concluded.

Reference

1. Kennedy J, Arey S, Hopkins Z, et al. Dermatologist perceptions of teledermatology implementation and future use after COVID-19: demographics, barriers, and insights. JAMA Dermatol. Published online March 31, 2021. doi:10.1001/jamadermatol.2021.0195