Breaking the mold
COVID-19 has sent waves of change throughout the health care system — how will it reshape patient access to dermatology care?
Feature
By Emily Margosian, Assistant Editor, October 1, 2021
It has been approximately 640 days since the first cluster of COVID-19 cases were reported by the Wuhan Municipal Health Commission in December 2019. In the time since, the spheres of work, education, and daily life have undergone constant metamorphoses, the result of which is still continuing to unfold.
The universality of the virus’s impact has demonstrated the shocking speed at which established systems and institutions are able to implement change when necessary. In health care, COVID-19 has already led to sweeping changes in who can receive care and how they access it. Attempts at social distancing and avoidance of health care settings resulted in a surge of telemedicine utilization. Scope of practice lines were hastily redrawn to contend with the rising tide of coronavirus patients. Insurers have (at least temporarily) waived cost-saving measures and footed the bill for an extraordinary new class of vaccines.
But are these changes here to stay?
This month, DermWorld speaks with physicians and subject matter experts to explore how the pandemic has altered patient access to care — and what the future might hold.
Scope of practice
At the start of the COVID-19 pandemic, scope of practice for non-physicians was expanded to keep up with workforce demands caused by a surge in patients. However, as the recovery timeline continues to fluctuate, questions have arisen among physician groups regarding the long-term implications of these changes.
“This was definitely a tough year with scope of practice. There were several scope bills we were fighting across the country that concerned multiple types of professionals: nurse practitioners, physician assistants, and naturopaths,” said Lisa Albany, JD, AADA director of state policy.
While in many cases, scope of practice expansions due to COVID were intended to be temporary measures, in some states, such changes have been made permanent. “In Massachusetts, there was an executive order last year to expand scope of practice for nurse practitioners, which was then made permanent,” said Albany.
However, despite the challenging post-COVID scope of practice landscape, physicians did see wins in Colorado, Louisiana, South Dakota, and Virginia that resulted in the dismissal or scaling back of attempts to fortify non-physician scope expansions made during the pandemic. According to Albany, the AADA is currently focusing on bills in Pennsylvania and Wisconsin that are seeking independent practice for nurse practitioners. “Those are two states where we are actively engaged in scope fights. I think the fights are just going to get harder because there’s so much momentum with this issue right now.”
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Dermatologists concerned about maintaining appropriate scope of practice legislation regarding dermatologic care should contact legislators, advised Albany. “We need more data on the economic implications, and personal stories from physicians when they speak to legislators. They need to give concrete examples of how this is affecting patients adversely. It would be so helpful if doctors made phone calls to just tell them what they’re seeing in their practice.”
Without direct input from dermatologists, “Legislators will just see this as a turf war,” explained Victoria Pasko, AADA assistant director of state policy. “They don’t like dealing with the anger between the nurses and the physicians. I think it’s hard for legislators to see this as a patient protection issue, which is why we try so hard to show them how patients are going to suffer because of this.”
Telemedicine: What’s new in payment policy and provider perceptions
While less than 10% of dermatologists reported using teledermatology prior to COVID-19 according to the Academy’s Dermatologist Experience Under COVID-19 survey, telehealth emerged as an effective mode of care delivery for some patients and conditions during the peak of the pandemic, causing a shift in physician perceptions of its use.
For example:
70% of dermatologists believe teledermatology will continue after COVID-19
50% of dermatologists intend to continue using teledermatology after COVID-19
Source: doi:10.1001/jamadermatol.2021.0195
During the early days of the pandemic, many health plans overhauled their telehealth coverage and payment policies to encourage providers and patients to use virtual care alternatives to in-person treatment. However, while reimbursement for telehealth services was fast-tracked during COVID-19, post-pandemic payment policy is still taking shape. Currently, 22 states have laws that specifically address telehealth reimbursement — with 14 mandating true payment parity — and 43 states have some requirement for how commercial insurers should cover and pay for telehealth.
In April 2021, the CONNECT for Health Act (S.1512) was reintroduced. The Act, for which the Academy has expressed support, aims to codify the currently expanded access to telehealth services due to COVID-19. In the meantime, some change has been observed in the private and public health care arena regarding telehealth reimbursement.
“We’re starting to see some restrictions of those more liberal policies, but coverage for telehealth is still much more expansive than it was prior to COVID-19,” said Louis Terranova, AADA assistant director of practice advocacy. “I think we’re going to see a transition where payers continue with telehealth, but perhaps not as broadly as during the pandemic. From their perspective, they want to apply telehealth so it enhances access but doesn’t create overutilization.”
Currently, policymakers are considering a variety of proposals to expand some or all of the existing flexibility surrounding telehealth services under Medicare beyond the public health emergency. Under Medicare’s existing telehealth benefit, a telehealth visit must be conducted with two-way audio/video technology. In July 2021, CMS proposed limiting payment for audio-only telehealth visits at the end of the public health emergency for all services other than mental health care, although this change is unlikely to have a significant impact on dermatology care.
According to Terranova, private payers have largely followed CMS in their expansion of telehealth payments throughout the pandemic. “The whole question right now is whether payment parity for telehealth services will continue. It’s likely we’ll see private payers tier that payment after the public health emergency ends, so it may not be the same as an in-person visit.”
Patients may also expect some tweaks to what will be covered under their benefit plan as far as telehealth services. “Here again, we’re seeing some refinement to carrier coverage,” said Terranova. “For example, currently UnitedHealthcare will cover telehealth for COVID-related services. For non-COVID related services, they will cover telehealth for in-network providers based on its telehealth reimbursement policy, and for out-of-network providers the expansion of telehealth access ended. Out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s standard telehealth reimbursement policy. So, we’re starting to see some distinctions being made there as well.”
Read more about teledermatology in the time of COVID-19 and beyond.
Insurance policy changes
During the spring of 2020, payers took steps to expand access to health services for both COVID-19 and non-COVID health conditions by waiving administrative requirements and reimbursing for telehealth visits. According to Louis Terranova, AADA assistant director of practice advocacy, while not all these changes are likely to be permanent, “It won’t be business as usual. The genie is out of the bottle, especially in regard to telehealth.”
While health plans evaluate whether to allow COVID-era flexibilities to expire or extend beyond the public health emergency, much of their decision-making will be driven by anticipation of pent-up demand for health services. “I think payers are bracing themselves for increased utilization,” said Terranova. “Last year at the height of the pandemic, we saw deferred care through the cancelation of elective procedures and patient hesitancy to go to health care facilities due to social distancing. They’re in a tough spot right now in terms of trying to project what utilization is going to be for 2022. They can’t really use 2020, because it was such an aberration. How this affects the premiums for next year remains to be seen.”
“It won’t be business as usual. The genie is out of the bottle.”
While private and public payers determine new policy in the wake of the pandemic, physicians and their patients will grapple with a rising rate of uninsurance, particularly as many Americans have lost employment-based coverage in the last year. See sidebar for an overview of who was uninsured prior to the pandemic, and what effects the pandemic might have on this growing cohort.
Although many insurers waived prior authorization requirements for aspects of COVID-related care during the pandemic, a key question for payers and policy makers going forward is whether they will extend such flexibility to non-COVID indications. “As we start to come over on the other side of the public health emergency, those waivers are ending. There are so many opportunities there,” said Terranova. “There may be a case to be made by looking at data on how the waiver of prior authorization affected access to care. It could further the advocacy against prior authorizations if the point could be made that when eliminated or waived, it didn’t really result in increased costs. We’re going to see a number of studies during this time on the impact of COVID on health care policy — on the effectiveness of telehealth and waived prior authorization, so we can learn more about how to apply those more effectively.”
Payer advocacy 101
Learn more about the Academy’s private payer advocacy activities and what members can do to get involved.
Other changes to post-COVID insurance coverage on the horizon may have greater implications for dermatologists and their patients. “One thing we’ve started to see are formulary changes, particularly as it relates to psoriasis. This was happening before COVID, but I think it will certainly escalate as payers look to control their costs,” said Terranova. “Some payers have begun to eliminate certain drugs from their formulary in what we call a non-medical switch. This has been problematic for dermatologists and patients with chronic conditions such as psoriasis or atopic dermatitis, because once they’re stable on their medication, if you switch to another drug for non-medical reasons, you lose some of the efficacy and it takes a while to reestablish that stability. We’ve seen a couple of major carriers make those formulary changes mandating a non-medical switch, and we’ve had discussions with them. We’ve sent letters; we’ve advocated against payer-mandated drug substitution. The bottom line is: if a patient is stable on their medication, they should not be forced to switch.”
Dermatologists may also expect to see changes in how widespread adoption of telehealth will be used by payers to adjust for network adequacy. “Another advocacy area for dermatology is to make sure that the plan’s provider network includes dermatologists, and to have a sufficient number of dermatologists within the plan network,” said Terranova. “There is a concern that payers may think that signing up with a telehealth vendor will address their network adequacy. So rather than dealing with local dermatologists, they would use one of the telehealth vendors for their network adequacy. That’s another top-priority issue that needs to be addressed. We’re all about making sure that families have access to dermatologists, and ideally dermatologists within their medical home or local community.”
Who was uninsured before COVID-19?
According to a September 2020 report from the National Health Interview Survey (NHIS), in 2019, 14.5% of adults between the ages of 18-64 were uninsured in the United States.
Within this group, the report identified certain demographic characteristics (age, ethnicity, and gender) and poor health status to be more common among the uninsured. Older adults were more likely to be uninsured due to coverage unaffordability — 67% among those aged 18-29 versus 81% among those aged 50-64. Whereas Hispanic adults (30%) were more likely to be uninsured than non-Hispanic Black (14%) and non-Hispanic white (10%) adults. Data also showed that men (27%) were more likely than women (15%) to indicate they were uninsured because coverage was not needed or wanted, and adults in poor health (18%) were more likely than adults in good health (14%) to be uninsured.
According to survey respondents, top reasons for being uninsured included:
73.7% — Not affordable
25.3% — Not eligible
21.3% — Do not need or want
18.4% — Signing up was too difficult or confusing
18% — Cannot find a plan that meets needs
8.5% — Applied, but has not started
Source: www.cdc.gov/nchs/data/databriefs/db382-tables-508.pdf#2
According to the United States Census Bureau, 2019 marked the third straight year of gradual increases in the number of uninsured Americans, rising from a historic low in 2016. While factors vary, the rising uninsured rate may be attributed to limited funding for health programs and other policy changes, including a provision of the Tax Cuts and Jobs Act that repealed the individual mandate, causing some individuals to forgo coverage without a penalty for not having health insurance.
While the impact of the COVID-19 pandemic on the uninsured rate is still being calculated, in 2019, employment-based plans accounted for more than half of the population with insurance (67.4%). According to a June 2021 Congressional Research Service report, in April 2020 the unemployment rate in the United States reached 14.8% — the highest rate observed since data collection began in 1948. Although definitive data on the effects of COVID-19 on the uninsurance rate are not yet available, recent surveys and media reports suggest a deepening affordability crisis as millions have been laid off from work or lost income, likely exacerbating the downward trend in coverage observed over the last few years.
Staffing shortages
COVID-19 has exacerbated the ongoing shortage of health care workers, leaving many hospitals and private practices short-staffed. Like many other specialties, dermatology practices have not been shielded from the impact of a shrinking health care workforce. “In the first two to three months of trying to reopen, we lost probably a third of our practice workforce,” said Sarah Jackson, MD, FAAD, a New Orleans dermatologist in private practice. “Some unfortunately lost family members to COVID or needed to stay home due to lack of childcare, while others just became very frightened of the virus and did not want to return to in-person work at all.”
While burnout and a sense of fatigue regarding the virus’s pendulum-like surges have driven many out of medicine, in some instances, private practices have been able to recruit staff looking to leave the hospital setting behind. “Usually, because we’re a private practice, we are MA- and LPN-heavy and hired very few RNs because we couldn’t compete with competitive hospital salaries,” said Dr. Jackson. “Interestingly, over the last six months we’ve had an influx of RNs who are looking to leave the hospital and get into private practice. It’s just been a hard time. There’s a lot of trauma and anxiety among health care workers who have had to watch so many people die. We have more RNs now in our employment than we ever have in the history of our practice.”
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Finding qualified front desk staff has also been an ongoing challenge for many dermatology practices throughout the pandemic. “We would receive 20 applications, and maybe one would actually show up to the interview. It felt like no one actually wanted the job,” said Dr. Jackson. “Ultimately, most of our new employees in the last six months have been word-of-mouth hires who had a connection with someone currently employed at our practice.”
The ongoing national vaccination effort has also put practice owners in a difficult situation when trying to recruit in vaccine-hesitant areas. “I’m in Louisiana and we’re currently the second leading state in COVID cases. My biggest challenge with employees right now is going to be vaccination and whether to make it mandatory. I, unfortunately, have some employees who are not vaccinated, so I’m in a very difficult situation,” said Dr. Jackson.
However, not all dermatology practices have experienced staffing shortages during COVID-19. Craig Burkhart, MD, MPH, MSBS, FAAD, opened his private practice in Cary, North Carolina, in March 2020, roughly two weeks before the first shutdowns occurred. “At the time, we had three employees: myself, an office manager, and a licensed practical nurse. Since then, we’ve just been steadily growing,” he said.
“It’s just been a hard time. There’s a lot of trauma and anxiety among health care workers who have had to watch so many people die.”
Dr. Burkhart’s practice has picked up five additional staff members since the start of the pandemic and has not lost any due to reasons related to COVID. “We all stayed full time, and definitely lost money the first few months, but we didn’t furlough anybody and didn’t go part time,” he recalled.
Like Dr. Jackson, Dr. Burkhart has found word-of-mouth to be the most effective way of recruiting new staff. “That’s the main method that has worked. We went around asking general pediatric practices if they had people who might be interested in joining us. All our good recruits have come that way, except for our office manager who was recruited by using an online service.”
Dr. Burkhart attributes his practice’s successful staff retention to the implementation of several key core values. “Our practice mission is to be pediatric-focused, celebrate diversity, and be community-based,” he said. “We also try to have a very flat management structure — what we call adaptive leadership. For example, I share desks with the nursing and admin staff. So, in terms of space, everyone has a sense of equality. If anyone’s going to have the worst desk, it’s going to be me. I also try to instill a sense of joy in our clinic. That means having treats and snacks, celebrating people’s birthdays, and making sure that special events are recognized. I think that all those things have helped with retention and recruitment.”
Practicing with a purpose
DermWorld talks to Vinh Chung, MD, FAAD, about the value of promoting meaning and purpose at work. Read more.
