Can Telemedicine Survive Beyond COVID-19?

While telemedicine will continue as an important tool for dermatologists after the impact of COVID-19 abates, said an expert, future use will depend on how barriers including connectivity, regulations, and payment inequity are addressed.

Experts who studied and advocated for telemedicine are not surprised it provides incredible potential to expand access to care, said Jules Lipoff, MD, assistant professor of dermatology at the University of Pennsylvania Perelman School of Medicine in Philadelphia, Pennsylvania. “But we didn’t really think about how medicine would be different in the case of a theoretical pandemic.”

Jules Lipoff, MD

The bigger surprise, Lipoff said, is that although past research primarily supported the efficiency of store-and-forward systems in improving access to dermatologists,^1,2 policy changes in the wake of COVID-19 have promoted video visits more exclusively.³ When the pandemic hit the United States, he explains, the US Centers for Medicare and Medicaid Services (CMS) quickly made policy changes that put video visits on par with in-person visits medically, legally, and financially. 

“The store-and-forward method, with digital photographs, is still paying $15 to $20 a visit from insurance at most,” he added.

In a recent survey published by the American Academy of Dermatology (AAD) Teledermatology Task Force, 85.2% of respondents said the level of reimbursement for store-and-forward teledermatology is too low.⁴ The task force, which surveyed 5000 randomly selected members, asked dermatologists how they were implementing the new digital appointments and asked for their thoughts about telemedicine. While physicians had theoretical concerns before implementing telemedicine, he said, the 591 dermatologists who replied to the survey based their answers on their personal experience. 

Since the pandemic started, the proportion of dermatologists providing telemedicine grew from 14.1% to 96.9%. “Also, we’re seeing a diverse coalition of people—mainstream users, not just the tech-savvy, innovative ones—try this,” Lipoff said. “We can learn from any problems they have to make it work for everyone.”

Outside reimbursement issues, the survey identified barriers including technology/connectivity during visits (39.1% of respondents), malpractice and liability (27%), and government regulations (23.2%). In the area of regulation, Lipoff said, many state licensing restrictions that were loosened to boost access in 2020 are again tightening.

Although 70% of dermatologists surveyed believe teledermatology will remain an option postpandemic, only 58% said they intended to continue using it. “I think this reflects how dermatologists realize how important and innovative teledermatology is,” he said. “But some of these issues—reimbursement, regulation, and technology—are holding some people back from fully wanting to dive in.”

Policy makers may have overlooked the fact that video visits are not necessarily more efficient than face-to-face visits, Lipoff added. “You still have to set appointments—the actual visit with a doctor—which is not necessarily shorter.”

Eliminating the need for patients to travel clearly helps, he said. “But as far as doctors are concerned, it’s not necessarily that much more efficient. Most doctors anecdotally tell me that they can’t see as many patients remotely as they can in person.”

Lipoff said he is unsure why that is the case. His impression is that the online environment does not facilitate the typical dermatologist’s pattern of quickly visiting a succession of exam rooms throughout the day. 

“There’s something about a physical space and the division of labor in preparing patients for visits that works more efficiently in person,” he said.

Also, if a telemedicine patient needs a procedure such as a biopsy, Lipoff added, they will need a subsequent in-office appointment. For in-person visits, dermatologists typically perform biopsies at that initial visit.

On the upside, Lipoff said telemedicine probably eliminates many elective procedures, such as removal of benign seborrheic keratoses, that could clog an in-person calendar and prevent patients with more urgent conditions from getting seen. 

Likewise, Lipoff said, store-and-forward teledermatology essentially eliminates small talk. For a simple encounter such as refilling an acne medication, physicians need not speak directly with patients. With a digital photo and message from the patient, doctors can reply at their convenience and see more patients in less time—if that were adequately paid for.

Another factor that physicians and policy makers must address is the digital divide.⁵ “We would intuitively assume if you have more ways to get care, it should only improve access,” Lipoff said. In reality, video visits require greater bandwidth. “And many poor people and marginalized people may only have smartphone internet access, which may not be strong enough for video visits.”

Some patients lack technical savvy, he added, or have trouble navigating systems in English. “There is evidence that the most vulnerable people are getting seen less when it comes to telemedicine,”⁶ Lipoff said. “Maybe because the wealthier patients are using it more, they’re crowding out the poor and less resource-connected patients.”

Telemedicine may carry unintended consequences, he said. “We need to make sure that we’re still holding high quality and high access for everyone as priorities.”

Disclosure:

Lipoff is a consultant for Havas Life Medicom (honoraria) and an adviser for Elbe Pharma (Acneaway: no compensation received). He is also outgoing chair of the AAD Teledermatology Task Force and a member of the AAD Ad Hoc Task Force on COVID-19.

References:

1. Jariwala NN, Snider CK, Mehta SJ, et al. Prospective implementation of a consultative store-and-forward teledermatology model at a single urban academic health system with real cost data subanalysis. Telemed J E Health. Published online November 4, 2020. doi:10.1089/tmj.2020.0248

2. Nelson CA, Takeshita J, Wanat KA, et al. Impact of store-and-forward (SAF) teledermatology on outpatient dermatologic care: a prospective study in an underserved urban primary care setting. J Am Acad Dermatol. 2016;74(3):484-90.e1. doi:10.1016/j.jaad.2015.09.058

3. Lipoff J. Lessons on telemedicine from COVID-19 and planning the future. Presented at: American Academy of Dermatology VMX 2021; April 23-25, 2021; virtual.

4. 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. March 31, 2021. doi:10.1001/jamadermatol.2021.0195

5. Bakhtiar M, Elbuluk N, Lipoff JB. The digital divide: how COVID-19’s telemedicine expansion could exacerbate disparities. J Am Acad Dermatol. 2020;83(5):e345-e346. doi:10.1016/j.jaad.2020.07.043 

6. Eberly LA, Khatana SAM, Nathan AS, et al. Telemedicine outpatient cardiovascular care during the COVID-19 pandemic: bridging or opening the digital divide? Circulation. 2020;142(5):510-512. doi:10.1161/CIRCULATIONAHA.120.048185