Telemedicine in the time of COVID-19...and beyond

By Allison Evans, assistant managing editor, July 1, 2021

Since its beginnings in the late 1960s, telemedicine has been relegated to the periphery of the health care system. Rigid rules around patient location and eligible services, interstate licensure challenges, inconsistent reimbursement models, and other aspects of care have created substantial barriers to telehealth utilization. A novel virus, however, changed everything — and decades’ worth of telemedicine policy advocacy was realized in a matter of weeks. 

Shortly after most stay-at-home orders were put into place, CMS — under the 1135 waiver — broadened access to Medicare telemedicine services by removing the geographic and originating site restrictions, eliminating state-specific licensure requirements, and supporting payment parity so that physicians and other providers could be compensated for the care provided to Medicare patients regardless of patient and clinician location. Many states and private insurers followed CMS’ lead. 

“During the public health emergency, telemedicine has been able to bridge the gap and allow access to care to continue without putting patients and physicians at risk, all while saving personal protective equipment for in-person care when needed,” said Jules Lipoff, MD, immediate past chair of the Academy’s Teledermatology Task Force and assistant professor of clinical dermatology at the University of Pennsylvania’s Perelman School of Medicine.

However, while CMS has the authority to loosen telehealth restrictions during a public health emergency (PHE), without congressional action, these changes are not permanent.

Pre-pandemic to public health emergency

“Prior to the pandemic or the public health emergency taking effect, you had to be in a provider’s office in a rural location in order to have reimbursable telehealth through the Medicare program. Therefore, telehealth utilization and reimbursement in Medicare was well below 1%,” said Kyle Zebley, director of public policy at the American Telemedicine Association. 

Throughout the pandemic, telemedicine has made up a substantial number of claims for both Medicare and private payers. In early March 2020, more than 50% of Medicare medical encounters were telemedicine encounters. However, the flexibilities that have allowed providers to practice medicine this past year are temporary; they are tied to the declaration of a PHE, Zebley explained. 

“There is an incredibly diverse and large body of evidence supporting that telemedicine, and teledermatology, specifically, can be quite effective and equivalent to in-person management, in many circumstances. It was frustrating that before the pandemic, we were not able to advance its use more,” said Dr. Lipoff, who has been an advocate of telemedicine for more than a decade. “Given the millions of patients who have tried telehealth and benefited from it during the pandemic, telemedicine’s importance is clear, and I believe Congress must act to extend and expand telehealth support permanently beyond the public health emergency,” he said.

A changing landscape

Currently, 22 states have laws that specifically address telehealth reimbursement, up from 16 states in 2019. A portion of them — 14 states — now mandate true payment parity, up from 10 states two years ago. All but seven states now have some requirement on the books for how commercial insurers should cover and pay for telehealth.

Ultimately, telemedicine needs to be sustainable, said Cory Simpson, MD, PhD, deputy chair of the Academy’s Teledermatology Task Force and clinical instructor of dermatology at the University of Pennsylvania’s Perelman School of Medicine. “We’re expected to provide care for a patient; we’re still liable for it; and we’re dedicating the time and resources to it. There’s just no solid argument for why that shouldn’t be paid for as a normal physician evaluation and management service if we are evaluating and managing a problem regardless of how it is accomplished.”

“The Academy supports fair reimbursement for telemedicine, and we want telemedicine services to go through the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) process, just like with in-person codes,” said Rachna Chaudhari, MPH, the Academy’s director of practice management. “We support patients accessing telehealth services across state lines if it allows access to a board-certified dermatologist who already has an existing relationship with that patient.”

“There is an incredibly diverse and large body of evidence supporting that telemedicine, and teledermatology, specifically, can be quite effective and equivalent to in-person management, in many circumstances.”

One major gap in the PHE telehealth flexibilities, said Dr. Lipoff, is that CMS did not expand payment for store-and-forward telemedicine such as shared digital photograph visits. Since there isn’t payment parity for store-and-forward visits, there isn’t the same incentive to adopt the practice, despite the potentially dramatic gains in efficiency.

Nearly all states have lifted restrictions on patients’ originating site — which would have required patients to be in a specific clinical setting for virtual visits to be covered. These restrictions prohibit accessing virtual care from home, for example, which became commonplace during the pandemic and made telehealth more accessible for patients. Now, Tennessee is the only state with originating site requirements, although lawmakers have loosened the requirements in a bill passed last year.

“One thing is clear: A doctor’s time is a doctor’s time, whether it’s in person or virtual. When it comes to facility costs and brick and mortar costs, we understand telehealth doesn’t have that physical infrastructure by nature,” Zebley said. “We also understand that it takes a strong level of investment to get the technology off the ground and to continue to innovate the technology, so you can’t say that there are no costs involved behind the scenes. But we’re not getting to the reimbursement issues if we don’t first get past this geographic and originating site barrier,” he said.  

Teledermatology in practice

Many policymakers and practitioners assume that dermatology is perfect for telemedicine because it is such a visual specialty, said Joseph Kvedar, MD, professor of dermatology at Harvard Medical School and chair of the board of the American Telemedicine Association. Yet, as many dermatologists adopted the practice of telemedicine for the first time during the pandemic out of necessity, they realized that virtual care can indeed be optimized for effective management of many cutaneous conditions.

At the height of the pandemic, Dr. Lipoff was seeing about 80-90% of patients by telemedicine. “I think it’s going to settle down to somewhere like 15% moving forward, which is still way higher than we were doing pre-pandemic.”

“If you think about a patient who has a known condition like acne, psoriasis, or atopic dermatitis, who’s stable, but needs to check in and get medicines refilled, most physicians will likely agree that it can be done very efficiently through a telemedicine visit,” Dr. Simpson said. “If a melanoma patient wants to utilize telemedicine, that’s very different. You’d be less willing to take the risk if there’s a high chance that you could be missing something malignant in a virtual encounter.”

“Conditions like acne, psoriasis, eczema, and rashes can be handled reasonably well over the video visits,” said Sara Perkins, MD, assistant professor of dermatology at Yale School of Medicine’s department of dermatology, in the July 2020 issue of DermWorld. “Telemedicine has also been a useful tool to triage patients. At the height of the pandemic, we had to make difficult decisions about which patients to see right away and which to reschedule, particularly those patients with potential skin cancers,” she said. 

Dr. Lipoff and his colleagues published a survey in JAMA Dermatology that affirmed some of the assumptions that had been made about dermatologists’ perceptions of teledermatology. The vast majority of dermatologists did not feel comfortable doing a total body skin exam unless it’s in person, he said. In contrast, almost no dermatologists felt that acne needs to be treated in person (doi:10.1001/jamadermatol.2021.0195). 

Video visits for isotretinoin management have been a huge success, said Elizabeth Jones, MD, assistant professor of dermatology at Thomas Jefferson University. “They have saved valuable time for pediatric and young adult patients and their parents as they balance extracurricular activities and school demands. Also, the current allowance of at-home pregnancy tests makes these visits much more convenient for female patients.”

Before the pandemic, only 14% of dermatologists had practiced teledermatology. A few months in, nearly 97% had used it. “While not shocking, this tells us that for the first time, most dermatologists are getting real experience with teledermatology, which will help us figure out what works and what doesn’t,” Dr. Lipoff explained.

A hybrid model

For the most part, practices have returned to seeing patients in person at near pre-pandemic levels, said Chaudhari. “Now, practices are incorporating telemedicine into the practice workflow so that physicians are seeing a mix of in-person and telemedicine patients during the day. It’s more integrated with the practice.”

An individual practice must consider the population it serves, the planned application of use (i.e., consultative, triage, direct care, or follow up), and reimbursement,” said Dr. Jones. “Creating a sustainable model at the outset is crucial to success.”

For a hybrid approach to be effective, dermatologists must have a plan for what conditions and types of patients they’re willing to see virtually, both for the comfort level of the practicing physician and allowing for efficient triaging by office staff, Dr. Kvedar said.

“Now, practices are incorporating telemedicine into the practice workflow so that physicians are seeing a mix of in-person and telemedicine patients during the day. It’s more integrated with the practice.”

People have noted that there have been issues with both live-interactive and store-and-forward modalities, Dr. Perkins said. “One thing that has been discussed is this hybrid model where you have patients upload photos before their visit, as in the store-and-forward modality, and then you pair it with a live-interactive video.”

Because many teledermatology appointments rely on patient-generated images, it’s important that dermatologists figure out how they are going to accept those images or add them to charts, if not done via an electronic health record system, Dr. Kvedar said. “Our patients submit photos over the patient portal and then we have a nurse check the image quality before the appointment. While this is labor intensive, it actually saves quite a bit of time in the end.”

The JAMA Dermatology survey reported that 72% of respondents felt the hybrid model — that combines video and stored photographs — to be the most effective system, although 85% agreed that reimbursement for store-and-forward was too low, said Dr. Lipoff. “We want to make sure that all teledermatology services are adequately compensated, so that physicians can be empowered and able to use them,” Dr. Lipoff noted.

Will Congress carve a path forward?

“We have bipartisan champions on both sides of the aisle,” said Zebley. The House Committee on Energy and Commerce held a hearing on telehealth in March in which everyone agreed about the usefulness and clinical appropriateness of telemedicine. 

There are a number of bills that would permanently lift the geographic and originating site barriers that are currently embedded in law — notably, the CONNECT for Health Act of 2021, of which the Academy has expressed its support. “The issue is that it’s very difficult for a standalone bill to pass, and Congress tends to act on deadlines. The American Telemedicine Association is optimistic that whether it’s an extension of flexibilities or permanency, it’s hard to imagine that members of Congress, President Biden, and HHS Secretary Xavier Becerra would allow these flexibilities to lapse,” said Zebley.

Looking to the future

“There is this narrative that people are very happy with the convenience and quality of telehealth and so we won’t go back to where we were pre-pandemic when there was little use of telehealth for patient visits. But that’s an emotional case we’re making, not an economic or legal one,” Dr. Kvedar said.

Indeed, according to the JAMA Dermatology survey, 70% of respondents believe teledermatology will continue after the pandemic, but only 58% said they intended to personally continue using it. While telehealth shows real promise in our health care system, there are still many concerns about supportive reimbursement, regulations, and technological innovation, Dr. Lipoff said.

Over the past year and a half, there has been more research published than ever before about telemedicine — and it’s critical that this research continues, noted Dr. Lipoff. “As policymakers consider permanently loosening regulatory restrictions, we should aim to establish a system that amplifies and leverages telemedicine where it can add the most value — by lowering overhead costs and improving access to care.”

Additional DermWorld Resources