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The growth of teledermatology: Expanding to reach the underserved
Journal Pre-proof The growth of teledermatology: expanding to reach the underserved Nadiya Chuchvara, BA, Rachel Patel, BA, Radhika Srivastava, BA, Catherine Reilly, BS, Babar Rao, MD, FAAD PII:
S0190-9622(19)33147-0
DOI:
https://doi.org/10.1016/j.jaad.2019.11.055
Reference:
YMJD 14038
To appear in:
Journal of the American Academy of Dermatology
Received Date: 3 October 2019 Revised Date:
17 November 2019
Accepted Date: 26 November 2019
Please cite this article as: Chuchvara N, Patel R, Srivastava R, Reilly C, Rao B, The growth of teledermatology: expanding to reach the underserved, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/j.jaad.2019.11.055. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
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Article Type: Health Policy & Practice Title: The growth of teledermatology: expanding to reach the underserved Authors: Nadiya Chuchvara, BA1; Rachel Patel, BA1; Radhika Srivastava, BA1; Catherine Reilly, BS1; Babar Rao, MD, FAAD1,2 1. Center for Dermatology, Rutgers Robert Wood Johnson Medical School at 1 Worlds Fair Drive, Somerset, NJ 08873. 2. Department of Dermatology, Weill Cornell Medical Center at 1305 York Avenue, New York, NY 10021. All correspondence to: Nadiya Chuchvara, BA Center for Dermatology Rutgers Robert Wood Johnson Medical School 1 Worlds Fair Drive Somerset, NJ 08873 Email: [email protected] Capsule Summary Word Count: 46/50 Abstract Word Count: 165/200 Text Word Count (excluding references, figures, and tables): 2491/2500 Table Count: 2 Figure Count: 3 Reference Count: 54 Keywords: dermatology, teledermatology, telemedicine, telehealth, underserved, rural, live video, store-and-forward, reimbursement, private payer, parity, Medicare, Medicaid, cross-state licensing, Interstate Medical Licensure Compact, IMLC Funding sources: None Conflicts of interest: The authors do not have any conflicts of interest to disclose.
1
47 48
Abstract: The regulation of telemedicine in the United States is evolving, with new legislation
49
expanding reimbursement and cross-state licensing capabilities. As telemedicine grows,
50
communities with limited access to traditional dermatologic care may find a solution in
51
teledermatology. A search of the medical literature and online healthcare law resources
52
published within the past decade was performed to assess the current status of telemedicine
53
availability, health record integration and security, reimbursement policy, and licensure
54
requirements in the United States, with a focus on teledermatology. The majority of states have
55
implemented policies requiring private insurance coverage. Medicaid reimburses some form of
56
telemedicine in all states, but restricts which modalities can be used, and by which specialties.
57
Medicare places the heaviest limitations on telemedicine coverage. Twenty-four states and Guam
58
are members of the Interstate Medical Licensure Compact (IMLC), while 27 states offer
59
alternative cross-state practice options. With the advent of publicly and privately funded
60
programs, volunteer efforts, and mobile applications, teledermatology is more readily available
61
to rural and underserved communities.
62 63 64 65 66 67 68 69
2
70 71
Capsule Summary: •
a deficit of dermatologists.
72 73
Teledermatology is a promising method of delivering specialty care to communities with
•
This study describes the current state of teledermatology in the United States as it relates
74
to utilization, accessibility, health record integration, security, as well as state-specific
75
reimbursement and licensing legislation.
76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 3
94 95
Introduction: Telemedicine is defined as, “the remote diagnosis and treatment of patients by means of
96
telecommunications technology.”1 The concept originated as early as the 1940s, when radiology
97
images were first sent 24 miles over a telephone line for remote evaluation.2 In subsequent
98
decades, multiple US government-funded initiatives provided telemedicine services to special
99
populations, such as astronauts and residents of isolated reservations.2 The rise of the Internet—
100
along with improving communication speeds, information storage, and encryption—has since
101
paved the way for further expansion. Today, physicians from various specialties have adopted
102
telemedicine into their practice, and dermatologists are no exception.3
103
The term “teledermatology” was coined by two dermatologists, Perednia and Brown, in
104
1995.4 Upon observing the shortage of dermatologists in rural Oregon, they investigated
105
teledermatology as an alternative to traditional care.4 The distribution of dermatologists
106
continues to disproportionately favor urban areas in the US. Between 1995 and 2013, the number
107
of dermatologists per 100,000 residents increased from 3.41 to 4.03 in metropolitan areas and
108
from 2.63 to 3.06 in rural areas.5 Patients from rural communities traveled an average of 2.4
109
miles farther to see a dermatologist than patients from metropolitan areas, with some venturing
110
over 200 miles.6 Additionally, patients from rural areas were more likely to be older and
111
impoverished, further compounding the disparity in access.6 Teledermatology provides a time-
112
effective, cost-conscious solution for patients who would otherwise undertake laborious travel to
113
visit a dermatologist.
114
The benefits of teledermatology implementation are supported by the literature. By
115
practicing tele-triage, which prioritizes in-person clinic visits for patients with conditions
116
associated with greater morbidity or mortality—while using telemedicine for the rest—,
4
117
providers can better manage the delivery of specialty dermatologic care to resource-limited
118
settings.7,8 Pilot studies demonstrated a decrease in time-to-consultation for patients—from
119
months/weeks to days/hours—, expediting treatment as a result.9-15 Some studies showed
120
applicability to pediatric populations, as well.16,17
121
The Center for Connected Health Policy (CCHP) classifies telemedicine into three types:
122
live video, store-and-forward, and remote patient monitoring. Live video telemedicine is
123
synchronous, consisting of a real-time interaction between the healthcare provider and the patient
124
using video-conferencing software.18 The remaining two forms of telemedicine, store-and-
125
forward and remote patient monitoring, do not occur in real-time and are therefore asynchronous.
126
Store-and-forward involves the acquisition and storage of clinical information, which is then
127
forwarded for evaluation.18 Remote patient monitoring allows providers to track patient health
128
data over time for those with chronic diseases.18 Due to its heavy reliance on visual data,
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teledermatology most often utilizes the store-and-forward modality, particularly with clinical and
130
dermoscopic images.19,20 Second to store-and-forward are live video interactions, and third is a
131
hybrid of the two modalities.20 The location of the patient where the telecommunication is
132
initiated is termed the “originating site”, while the dermatologist is at the “distant site”.
133 134 135
Methods: A review of the medical literature was conducted, using the keywords, “telemedicine,”
136
“telehealth,” and “teledermatology” in PubMed, EMBASE, Cochrane Library, and JAAD
137
databases. Additionally, online healthcare news databases, such as mHealthIntelligence and
138
Health Care Law Today, were searched using the same keywords. Articles were chosen based on
139
relevance to the topic of teledermatology and date published (between 2009 and 2019). We
5
140
searched the references of articles for primary sources and additional publications that did not
141
populate in our initial search. For individual state legislation on Medicaid and private payer
142
reimbursement, information was collected from the CCHP Fall 2019 State Telehealth Laws and
143
Reimbursement Policies report and cross-checked with the eVisit and VisuWell state-by-state
144
telemedicine policy resources. Information on Medicare legislation was collected from the
145
Medicare Learning Network Telehealth Services report. Cross-state licensing legislation was
146
determined by the IMLC, CCHP, eVisit websites.
147 148
Results:
149
Utilization and Accessibility
150
According to the US Department of Health and Human Services (HHS), 60% of all US
151
healthcare institutions, and 40% to 50% of hospitals, incorporated some form of telemedicine in
152
their practice in 2016.21 In the American Medical Association’s 2016 Physician Practice
153
Benchmark Survey, it was found that 15.4% of US physicians—and 15% of dermatologists—
154
work in practices that utilize physician-to-patient telemedicine.3 Of the specialist subgroups,
155
dermatologists were in 11th place, well behind the top three users: radiologists (39.5%),
156
psychiatrists (27.8%), and cardiologists (24.1%).3 Still, the number of US teledermatology
157
programs rose from 37 in 2011, to 102 in 2016.20
158
Efforts have been made to expand the use of telemedicine—particularly to benefit the
159
underserved. In 2016, the US Health Resources and Services Administration (HRSA) announced
160
funding for sustainable telehealth programs as part of a multimillion dollar grant package to
161
increase healthcare access in rural and underserved areas.22 Funded by the HHS and HRSA, 12
6
162
regional and 2 national Telehealth Resource Centers provide resources, education, and technical
163
assistance to support these efforts.23
164
Through both public and private funding, teledermatology has paralleled this national
165
movement. The American Academy of Dermatology (AAD) developed AccessDerm as a
166
philanthropic teledermatology platform in 2016, where volunteer dermatologists provide free
167
store-and-forward consultations to patients at Federally Qualified Health Centers in underserved
168
communities.24 In 2016 alone, 62 facilities of the Veterans Health Administration performed
169
101,507 teledermatology consultations.20 The University of Missouri has offered
170
teledermatology services with the Missouri Telehealth Network for over 20 years, expanding
171
care to rural Missourians as one of the longest-running telemedicine programs in the nation.25,26
172
In a younger pilot program, seven Massachusetts community health centers serving low income
173
populations partnered with remote dermatologists for store-and-forward tele-triage.15
174
While most literature describes a “hub-and-spoke” model, where “spokes” of specialist
175
care are initiated from the “hub” of a general practitioner’s office, direct-to-consumer
176
teledermatology is a growing phenomenon. The development of mobile teledermatology
177
applications allows patients to connect with dermatologists more easily than ever, offering a
178
direct-care platform for remote diagnosis and management of skin conditions. These
179
teledermatology consultations are accessible to the uninsured, with fees ranging from $25-60—
180
comparable to a copay.27 As of 2017, there were 106 teledermatology applications available on
181
Apple, Android, and Windows platforms, triple in number since 2014.27
182 183 184
7
185 186
Electronic Health Record Integration and Security Though convenient for the patient, external direct-to-consumer teledermatology
187
platforms can lead to fragmented care, since records of consultations are rarely sent to the
188
patient’s primary care provider.28 Internal teledermatology programs that merge with a patient’s
189
electronic health record (EHR) ensure continuity of care and proper record-keeping.11 Two
190
health systems have published their experiences on teledermatology compatibility with their
191
existing Epic EHR (Systems Corporation, Verona, WI), the most widely used EHR in the US.11
192
Carter et. al. successfully integrated store-and-forward teledermatology with Epic at Parkland
193
Health and Hospital System in Dallas.11 Similarly, dermatologists at Stanford Health Care
194
demonstrated Epic integration with both consultative and patient-initiated teledermatology.10,14
195
The use of mobile applications for teledermatology may pose security risks related to
196
Health Insurance Portability and Accountability Act (HIPAA) compliance. In an analysis of 29
197
direct-to-consumer applications in 2014 by Peart and Kovarik, only 69% were found to be
198
HIPAA compliant.29 If a healthcare provider is a HIPAA-covered entity, it is their responsibility
199
to use a secure platform with data encryption, login controls, and other features listed in the
200
American Telemedicine Association (ATA) Practice Guidelines.30,31 Commonly used
201
applications were evaluated by Armstrong et. al. in 2010 and Ho et. al. in 2013, but there is a
202
need for newer studies to keep up with the rapidly-changing landscape of application
203
development.32,33
204 205 206 207
Reimbursement: Private Payer, Medicaid, and Medicare One point of regulation for telemedicine is reimbursement.34 Since individual states hold autonomy over laws governing private payer and Medicaid coverage, discrepancies are
8
208
prevalent.18 As of October 2019, 36 states and the District of Columbia have passed parity
209
laws.18,35 Coverage parity laws and payment parity laws require private payer insurances to cover
210
and reimburse telemedicine services, respectively, at the same rate as traditional, in-person
211
services (Figure 1).36
212
Medicaid reimbursement plays an important role in telemedicine expansion for
213
underserved patients. All states and the District of Columbia require coverage for live video
214
services, although Massachusetts only reimburses mental/behavioral healthcare delivered in this
215
way (Figure 2).18,35,37 Only 20 states cover store-and-forward teledermatology services (Figure
216
3).18,35,37 While 23 states and the District of Columbia have restrictions on originating and/or
217
distant sites, patients are explicitly allowed to initiate the interaction from home in 19
218
states.18,35,37 Additionally, Medicaid will reimburse a facility fee for eligible originating sites in
219
34 states.18
220
Medicare regulations are by far the most restrictive. The telehealth service must consist
221
of real-time audiovisual communication, barring coverage for asynchronous telemedicine, except
222
for a store-and-forward demonstration program in Alaska and Hawaii.38,39 The originating site
223
must be in a qualifying health center within a rural Health Professional Shortage Area or a
224
county outside a Metropolitan Statistical Area.39 This excludes a patient’s home as a permissible
225
originating site in all cases save for substance use disorder treatment.39 The HRSA provides an
226
online Medicare Telehealth Payment Eligibility Analyzer tool to determine whether a location
227
qualifies.40
228
In order for a telemedicine service to be reimbursed through Medicare, The Current
229
Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) code
230
must be on the list of covered Medicare telemedicine services (Table I).38 Additionally, the
9
231
originating site can bill a facility fee for the telemedicine visit using the code Q3014.39
232
Regardless of insurance type, a provider must bill with the proper modifiers: GT for live video,
233
and GQ for store-and-forward.18,37
234
When insurance coverage persists as a barrier to telemedicine utilization, an up-front fee
235
can be charged directly to the patient—generally ranging from $30-75—, with the caveat that the
236
patient must sign a waiver not to use insurance for their telemedicine visit if the provider is in-
237
network.41 There is evidence to support that patients are willing to pay median values of $25-
238
48.84 out-of-pocket for teledermatology services, especially for the benefit of shorter wait time
239
to consultation.42-44
240 241 242
Licensure In most cases, physicians are legally allowed to practice telemedicine only in the state in
243
which they are licensed, posing a barrier to cross-state telemedicine. The Interstate Medical
244
Licensure Compact (IMLC) offers a solution by expediting the process of licensure for qualified
245
physicians who wish to practice in multiple states.45 According to the IMLC, all physicians who
246
possess a full and unrestricted medical license are eligible to apply for expedited licensure in
247
participating states. Currently, 24 states and Guam are members of the IMLC agreement and 5
248
states and the District of Columbia are in the process of joining.45 As of 2019, IMLC legislation
249
has been introduced in New Jersey and South Carolina.45 Beyond the IMLC, some states have
250
special provisions which allow out-of-state physicians to practice telemedicine without acquiring
251
an additional full medical license (Table II).18,35,45
252 253
10
254 255
Discussion: As with most technologies involving remote interaction, there are some drawbacks to
256
teledermatology. Essential elements of the physical examination, including palpation of the skin
257
and lymph nodes, cannot be performed. Lack of in-person interaction can potentially erode the
258
patient-provider relationship, leading to incomplete histories or imprecise communication. Poor
259
quality videos and images can compromise a diagnosis. A combination of these factors might
260
explain why—despite multiple studies demonstrating adequate diagnostic and management
261
concordance in teledermatology—, one weak point is skin cancer.46,47 Diagnostic accuracy of
262
cutaneous malignancies may improve by incorporating teledermoscopy, in which the referring
263
provider sends dermoscopy images for interpretation.31,48 For high-risk patients who require
264
serial lesion surveillance and prefer the direct-to-consumer model, smartphone-attachment
265
dermatoscopes like the DermLite HÜD (3Gen Inc., San Juan Capistrano, CA) and
266
Molescope/Molescope II (Metaoptima Technology Inc., Vancouver, BC, Canada) can be
267
purchased for $79.95-299.49-51
268
Ultimately, the responsibility and potential liability falls on the teledermatology provider
269
in a direct-care interaction and is shared with the referring provider in a teleconsultation.52 It is
270
prudent for providers to determine coverage of telemedicine under their medical liability
271
insurance policy, including cross-state telemedicine, prior to initiating these services.52 The ATA
272
and AAD provide expert guidelines that facilitate the creation of quality teledermatology
273
programs, both in technical caliber and clinical excellence.31,52
274
Despite expansion of telemedicine and teledermatology, most physicians and
275
dermatologists do not see patients via telehealth. Without a standardized definition of
276
telemedicine, variations can lead to vague interpretations of the law, and consequent legislative
11
277
barriers to wider implementation. In states like Colorado, Michigan, and Minnesota, the private
278
insurer decides what qualifies as telemedicine.18 While the 12 states have mandated payment
279
parity by private insurances—making telemedicine a financially practical alternative for
280
providers—, more states have implemented coverage parity instead, which alone does not
281
guarantee equal reimbursement. Despite the fact that store-and-forward is the most-studied and
282
most-practiced modality of teledermatology—used independently in 72% of programs and in
283
combination with live video in another 35%—, it is met with the steepest reimbursement
284
challenges.20 Medicaid in the majority of states, and Medicare as a whole, strictly define
285
telemedicine as a two-way, real-time interaction between patient and provider, preventing
286
coverage for store-and-forward. Still, many states have progressed their legislation to expand
287
Medicaid reimbursement for telemedicine, and Medicare recently approved new CPT codes for
288
prolonged telehealth interactions. Unfortunately, the restrictive nature of Medicare coverage to
289
specific originating sites and geographical locations overlooks the potential benefits of telehealth
290
to all elderly beneficiaries, who often experience challenges with transportation.
291
Regarding cross-state licensing, the IMLC increases the pool of physicians available to
292
patients in rural communities, which is particularly important for delivery of specialty care. In
293
states like Kansas, the number of dermatology providers ranges from 0-1 to 3-4 per 100,000
294
people in the majority of 3-digit ZIP code regions, limiting the extent to which teledermatology
295
can be delivered from within the state.53 Contrast this to states like Florida and Hawaii, where
296
most regions have from 3-4 to 10-plus dermatology providers per 100,000 people.53 Through
297
cross-state licensing, Kansas residents would gain access to out-of-state dermatologists.
298
However, neither Florida nor Hawaii are currently members of the IMLC.45 To optimize this
299
system, more states with a high proportion of dermatologists must join the compact.
12
300
As new legislation expands reimbursement and eases cross-state practice,
301
teledermatology will become more appealing to the provider. More than ever, teledermatology
302
has shown potential as a beneficial and accessible method of delivering care. The growth of
303
mobile applications makes participation easier than ever. Volunteer efforts and pilot programs
304
have demonstrated that telemedicine services can address the barrier between underserved
305
populations and specialty dermatologic care. Government agencies are subsidizing telemedicine
306
as they did many decades ago, allowing for the development of new programs—from schools, to
307
community hospitals, to academic centers.54 Teledermatology stands as a viable option to
308
provide dermatologic care for individuals who would otherwise go without.
309 310 311
Conclusion: Teledermatology is expanding, as evidenced by increased accessibility and functionality,
312
legislative support of insurance coverage, and expedited cross-state licensing. Private payer
313
reimbursement is growing secondary to parity laws. Medicaid reimburses live video
314
teledermatology in nearly all states, and store-and-forward services in nearly half. Medicare
315
reimbursement is the most restrictive. Dermatologists may practice telemedicine across state
316
lines using special licenses and the IMLC in participating states. With growing availability,
317
teledermatology expands access to specialty dermatologic care.
318 319
Acknowledgements:
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We would like to thank Trilokraj Tejavsi, MD, Chair of the ATA Teledermatology Special
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Interest Group, for his insight on teledermatology in the US.
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Flaten HK, St Claire C, Schlager E, Dunnick CA, Dellavalle RP. Growth of mobile
402
applications in dermatology - 2017 update. Dermatol Online J. 2018;24(2).
403
doi:13030/qt3hs7n9z6.
404
28.
Resneck JS, Jr., Abrouk M, Steuer M, et al. Choice, transparency, coordination, and
405
quality among direct-to-consumer telemedicine websites and apps treating skin disease.
406
JAMA Dermatol. 2016;152(7):768-775. doi:10.1001/jamadermatol.2016.1774.
407
29.
2015;72(5):907-909. doi:10.1016/j.jaad.2015.01.019.
408 409
Peart JM, Kovarik C. Direct-to-patient teledermatology practices. J Am Acad Dermatol.
30.
Luxton DD, Kayl RA, Mishkind MC. mHealth data security: the need for HIPAA-
410
compliant standardization. Telemed J E Health. 2012;18(4):284-288.
411
doi:10.1089/tmj.2011.0180.
17
412
31.
Telemed J E Health. 2016;22(12):981-990. doi:10.1089/tmj.2016.0137.
413 414
McKoy K, Antoniotti NM, Armstrong A, et al. Practice guidelines for teledermatology.
32.
Armstrong AW, Sanders C, Farbstein AD, et al. Evaluation and comparison of store-and-
415
forward teledermatology applications. Telemed J E Health. 2010;16(4):424-438.
416
doi:10.1089=tmj.2009.0133.
417
33.
Ho B, Lee M, Armstrong AW. Evaluation criteria for mobile teledermatology
418
applications and comparison of major mobile teledermatology applications. Telemed J E
419
Health. 2013;19(9):678-682. doi:10.1089/tmj.2012.0234.
420
34.
Giambrone D, Rao BK, Esfahani A, Rao S. Obstacles hindering the mainstream practice
421
of teledermatopathology. J Am Acad Dermatol. 2014;71(4):772-780.
422
doi:10.1016/j.jaad.2014.04.043.
423
35.
policy/. Published 2019. Accessed November 11, 2019.
424 425
State telemedicine laws, simplified. eVisit Web site. https://evisit.com/state-telemedicine-
36.
Telemedicine private payer issues. eVisit Web site.
426
https://evisit.com/resources/telemedicine-private-payers-issues/. Published 2018.
427
Accessed August 26, 2019.
428
37.
reimbursement/map/. Published 2019. Accessed November 11, 2019.
429 430
Reimbursement by state. VisuWell Web site. https://visuwell.io/telemedicine-
38.
Lacktman NM. Medicare proposes (and rejects) new telehealth services for 2019. Foley
431
Web site. https://www.foley.com/en/insights/publications/2018/08/medicare-proposes-
432
and-rejects-new-telehealth-servi. Published 2018. Accessed August 26, 2019.
433 434
39.
Telehealth Services. Medicare Learning Network / Centers for Medicare and Medicaid Services; 2019.
18
435
40.
Administration; 2019. https://data.hrsa.gov/tools/medicare/telehealth.
436 437
Medicare Telehealth Payment Eligibility Analyzer. Health Resources & Services
41.
Telemedicine reimbursement guide. eVisit Web site.
438
https://evisit.com/resources/telemedicine-reimbursement-guide/. Published 2018.
439
Accessed September 4, 2019.
440
42.
Raghu TS, Yiannias J, Sharma N, Markus AL. Willingness to pay for teledermoscopy
441
services at a university health center. J Patient Exp. 2018;5(3):212-218.
442
doi:10.1177/2374373517748657.
443
43.
Qureshi AA, Brandling-Bennett HA, Wittenberg E, Chen SC, Sober AJ, Kvedar JC.
444
Willingness-to-pay stated preferences for telemedicine versus in-person visits in patients
445
with a history of psoriasis or melanoma. Telemed J E Health. 2006;12(6):639-643.
446
doi:10.1089/tmj.2006.12.639.
447
44.
Mori WS, Houston N, Moreau JF, et al. Personal burden of isotretinoin therapy and
448
willingness to pay for electronic follow-up visits. JAMA Dermatol. 2016;152(3):338-340.
449
doi:10.1001/jamadermatol.2015.4763.
450
45.
August 26, 2019.
451 452
The IMLC. Interstate Medical Licensure Compact Web site. https://imlcc.org/. Accessed
46.
Warshaw EM, Hillman YJ, Greer NL, et al. Teledermatology for diagnosis and
453
management of skin conditions: a systematic review. J Am Acad Dermatol.
454
2011;64(4):759-772. doi:10.1016/j.jaad.2010.08.026.
455
47.
Finnane A, Dallest K, Janda M, Soyer HP. Teledermatology for the diagnosis and
456
management of skin cancer: a systematic review. JAMA Dermatol. 2017;153(3):319-327.
457
doi:10.1001/jamadermatol.2016.4361.
19
458
48.
2018;102:102-105.
459 460
49.
50.
Dermlite HÜD. 3Gen Web site. https://dermlite.com/products/dermlite-hud. Accessed November 14, 2019.
463 464
Chao E, Meenan CK, Ferris LK. Smartphone-based applications for skin monitoring and melanoma detection. Dermatol Clin. 2017;35:551-557. doi:10.1016/j.det.2017.06.014.
461 462
Bleicher B, Levine A, Markowitz O. Going digital with dermoscopy. Cutis.
51.
Molescope. Molescope by MetaOptima Web site. https://www.molescope.com/product/. Accessed November 14, 2019.
465 466
52.
Position Statement on Teledermatology. American Academy of Dermatology;2016.
467
53.
Glazer AM, Rigel DS. Analysis of trends in geographic distribution of US dermatology
468
workforce density. JAMA Dermatol. 2017;153(5):472-473.
469
doi:10.1001/jamadermatol.2016.6032.
470
54.
Case studies of how hospitals and health systems are using telehealth to expand access
471
and improve care in their communities. American Hospital Association Web site.
472
https://www.aha.org/bibliographylink-page/2017-12-11-use-telehealth-hospitals-and-
473
health-systems-members-action. Accessed August 26, 2019.
474 475 476 477 478 479 480
20
481
Figure Legends:
482
Figure 1. Private payer parity laws. Map of the United States colored according to the status of
483
individual state private payer telemedicine parity laws, with a focus on teledermatology.18,35,37
484
_______________________________________
485
Current through October 2019. Created with mapchart.net.
486
* No coverage parity until January 1, 2021, but requirement for telehealth coverage in
487
dermatology and other conditions/settings
488
† Effective January 1, 2021. Does not apply to Medi-Cal Managed Care.
489
‡ Effective January 1, 2020
490
§ Unless the health provider and payer contractually agree to a lower reimbursement rate
491
| Payment must be at least 75% of traditional services
492
¶ Coverage parity for live video, but not store-and-forward
493 494
Figure 2. Medicaid live video coverage. Map of the United States colored according to the
495
status of individual state Medicaid live video coverage, with a focus on teledermatology.18,35,37
496
_______________________________________
497
Current through October 2019. Created with mapchart.net.
498
* Professional relationship must exist between the patient and the distant site provider
499
† If deemed by the commissioner as appropriate, cost effective, and likely to expand access
500
‡ When services are ongoing, the patient should receive a traditional clinical evaluation at least
501
once per year; the distant site provider should coordinate with the primary care physician
502
§ Mental/behavioral health only
503
| Some restrictions apply (beneficiary cannot travel, imminent health risk)
21
504
¶ Must be at an eligible site, in a rural area with a health professional shortage (same as
505
Medicare)
506
** Distant site must be of a sufficient distance from originating site; prior approval required in
507
some cases
508
†† Only for initial and follow-up inpatient telehealth consultation
509
‡‡ Only by TN Managed Care
510 511
Figure 3. Medicaid store-and-forward coverage. Map of the United States colored according
512
to the status of individual state Medicaid store-and-forward coverage, with a focus on
513
teledermatology.18,35,37
514
_______________________________________
515
Current through October 2019. Created with mapchart.net.
516
* Teledentistry only
517
† Only in the case of provider-to-provider communication (electronic consults)
518
‡ Teledermatology only
519
§ Teleradiology only
520
| Effective January 1, 2020
521
¶ Teledermatology, teleophthalmology, and teleradiology only
522
** Patient must be notified of the right to interactive communication with the distant site
523
provider, who must respond within 30 days of the patient’s request
524
†† Not explicitly included, but may be covered under the definition of telemedicine
525
‡‡ Only by TN Managed Care
526
§§ Outpatient teledermatology, teleradiology, and diabetic retinopathy screening only
22
527
Table I. Covered Medicare telemedicine services (and their CPT/HCPCS codes) of relevance to
528
teledermatology39 Service Telehealth consultations, emergency department or initial inpatient Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs Office or other outpatient visits Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service
CPT/HCPCS Code G0425–G0427 G0406–G0408 99201–99215 99354-99355*
99356-99357*
529 530
_______________________________________
531
* New codes for 2019
532 533 534 535 536 537 538 539 540 541 542
23
543
Table II. Summary of cross-state licensing options in different states and territories, as of
544
October 201918,35,45 Cross-State Licensing Type
States/Territories
IMLC member issuing licenses only (non-SPL)
AL, AZ, CO, IA, ID, IL, KS, MD, ME, MI, MS, MT, ND, NE, NH, NV, SD, TN, UT, WA, WI, WV, WY, and Guam MN
IMLC implementation in process
GA, KY, OK, PA, VT, and District of Columbia
IMLC legislation introduced License to practice across state lines may be granted for fully licensed out-of-state providers License to practice across state lines for fully licensed providers practicing in adjoining states, as long as similar privileges are extended to their own physicians Special purpose license for licensed out-of-state providers Telemedicine license
NJ, SC
Telemedicine certificate Consultation services as requested by in-state provider only Physician-to-physician consultation Infrequent consultation
OHj
IMLC member serving as state of principal licensure (SPL) and issuing licenses
CT, INa, MNb, NDc, NM, ORd, SD, UTe
MDf, PAg
AL, NV LA, OKh, TNh, TXi MEb, MS HI, NH, OK, VA AZk, AR, KYl, MOl, RIm, TX
545 546
_______________________________________
547
a. As long as the licensed out-of-state provider and their employer/contractor file for certification
548
of compliance with the courts of IN
549
b. Must register with the state board and agree not to open an office, meet patients, or receive
550
calls in the state
551
c. Per the state medical board’s discretion
552
d. Must establish a patient-physician relationship, and cannot write prescriptions based on online
553
consult only
24
554
e. Only if services are rendered as a public service and for noncommercial purpose
555
f. Cannot open an office in the state
556
g. Based on availability of medical care in the area involved
557
h. Osteopathic board only
558
i. Must have passed the Texas Medical Jurisprudence Examination
559
j. Must also possess a special activity certificate, which can be converted to a license by written
560
request
561
k. Physician-to-physician only
562
l. If their service was requested by an in-state licensed physician with an established relationship
563
with the patient
564
m. For no more than 7 days unless extended with written permission from the director
565 566 567 568 569 570 571 572 573 574 575 576
25
S0190-9622(19)33147-0
DOI:
https://doi.org/10.1016/j.jaad.2019.11.055
Reference:
YMJD 14038
To appear in:
Journal of the American Academy of Dermatology
Received Date: 3 October 2019 Revised Date:
17 November 2019
Accepted Date: 26 November 2019
Please cite this article as: Chuchvara N, Patel R, Srivastava R, Reilly C, Rao B, The growth of teledermatology: expanding to reach the underserved, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/j.jaad.2019.11.055. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Article Type: Health Policy & Practice Title: The growth of teledermatology: expanding to reach the underserved Authors: Nadiya Chuchvara, BA1; Rachel Patel, BA1; Radhika Srivastava, BA1; Catherine Reilly, BS1; Babar Rao, MD, FAAD1,2 1. Center for Dermatology, Rutgers Robert Wood Johnson Medical School at 1 Worlds Fair Drive, Somerset, NJ 08873. 2. Department of Dermatology, Weill Cornell Medical Center at 1305 York Avenue, New York, NY 10021. All correspondence to: Nadiya Chuchvara, BA Center for Dermatology Rutgers Robert Wood Johnson Medical School 1 Worlds Fair Drive Somerset, NJ 08873 Email: [email protected] Capsule Summary Word Count: 46/50 Abstract Word Count: 165/200 Text Word Count (excluding references, figures, and tables): 2491/2500 Table Count: 2 Figure Count: 3 Reference Count: 54 Keywords: dermatology, teledermatology, telemedicine, telehealth, underserved, rural, live video, store-and-forward, reimbursement, private payer, parity, Medicare, Medicaid, cross-state licensing, Interstate Medical Licensure Compact, IMLC Funding sources: None Conflicts of interest: The authors do not have any conflicts of interest to disclose.
1
47 48
Abstract: The regulation of telemedicine in the United States is evolving, with new legislation
49
expanding reimbursement and cross-state licensing capabilities. As telemedicine grows,
50
communities with limited access to traditional dermatologic care may find a solution in
51
teledermatology. A search of the medical literature and online healthcare law resources
52
published within the past decade was performed to assess the current status of telemedicine
53
availability, health record integration and security, reimbursement policy, and licensure
54
requirements in the United States, with a focus on teledermatology. The majority of states have
55
implemented policies requiring private insurance coverage. Medicaid reimburses some form of
56
telemedicine in all states, but restricts which modalities can be used, and by which specialties.
57
Medicare places the heaviest limitations on telemedicine coverage. Twenty-four states and Guam
58
are members of the Interstate Medical Licensure Compact (IMLC), while 27 states offer
59
alternative cross-state practice options. With the advent of publicly and privately funded
60
programs, volunteer efforts, and mobile applications, teledermatology is more readily available
61
to rural and underserved communities.
62 63 64 65 66 67 68 69
2
70 71
Capsule Summary: •
a deficit of dermatologists.
72 73
Teledermatology is a promising method of delivering specialty care to communities with
•
This study describes the current state of teledermatology in the United States as it relates
74
to utilization, accessibility, health record integration, security, as well as state-specific
75
reimbursement and licensing legislation.
76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 3
94 95
Introduction: Telemedicine is defined as, “the remote diagnosis and treatment of patients by means of
96
telecommunications technology.”1 The concept originated as early as the 1940s, when radiology
97
images were first sent 24 miles over a telephone line for remote evaluation.2 In subsequent
98
decades, multiple US government-funded initiatives provided telemedicine services to special
99
populations, such as astronauts and residents of isolated reservations.2 The rise of the Internet—
100
along with improving communication speeds, information storage, and encryption—has since
101
paved the way for further expansion. Today, physicians from various specialties have adopted
102
telemedicine into their practice, and dermatologists are no exception.3
103
The term “teledermatology” was coined by two dermatologists, Perednia and Brown, in
104
1995.4 Upon observing the shortage of dermatologists in rural Oregon, they investigated
105
teledermatology as an alternative to traditional care.4 The distribution of dermatologists
106
continues to disproportionately favor urban areas in the US. Between 1995 and 2013, the number
107
of dermatologists per 100,000 residents increased from 3.41 to 4.03 in metropolitan areas and
108
from 2.63 to 3.06 in rural areas.5 Patients from rural communities traveled an average of 2.4
109
miles farther to see a dermatologist than patients from metropolitan areas, with some venturing
110
over 200 miles.6 Additionally, patients from rural areas were more likely to be older and
111
impoverished, further compounding the disparity in access.6 Teledermatology provides a time-
112
effective, cost-conscious solution for patients who would otherwise undertake laborious travel to
113
visit a dermatologist.
114
The benefits of teledermatology implementation are supported by the literature. By
115
practicing tele-triage, which prioritizes in-person clinic visits for patients with conditions
116
associated with greater morbidity or mortality—while using telemedicine for the rest—,
4
117
providers can better manage the delivery of specialty dermatologic care to resource-limited
118
settings.7,8 Pilot studies demonstrated a decrease in time-to-consultation for patients—from
119
months/weeks to days/hours—, expediting treatment as a result.9-15 Some studies showed
120
applicability to pediatric populations, as well.16,17
121
The Center for Connected Health Policy (CCHP) classifies telemedicine into three types:
122
live video, store-and-forward, and remote patient monitoring. Live video telemedicine is
123
synchronous, consisting of a real-time interaction between the healthcare provider and the patient
124
using video-conferencing software.18 The remaining two forms of telemedicine, store-and-
125
forward and remote patient monitoring, do not occur in real-time and are therefore asynchronous.
126
Store-and-forward involves the acquisition and storage of clinical information, which is then
127
forwarded for evaluation.18 Remote patient monitoring allows providers to track patient health
128
data over time for those with chronic diseases.18 Due to its heavy reliance on visual data,
129
teledermatology most often utilizes the store-and-forward modality, particularly with clinical and
130
dermoscopic images.19,20 Second to store-and-forward are live video interactions, and third is a
131
hybrid of the two modalities.20 The location of the patient where the telecommunication is
132
initiated is termed the “originating site”, while the dermatologist is at the “distant site”.
133 134 135
Methods: A review of the medical literature was conducted, using the keywords, “telemedicine,”
136
“telehealth,” and “teledermatology” in PubMed, EMBASE, Cochrane Library, and JAAD
137
databases. Additionally, online healthcare news databases, such as mHealthIntelligence and
138
Health Care Law Today, were searched using the same keywords. Articles were chosen based on
139
relevance to the topic of teledermatology and date published (between 2009 and 2019). We
5
140
searched the references of articles for primary sources and additional publications that did not
141
populate in our initial search. For individual state legislation on Medicaid and private payer
142
reimbursement, information was collected from the CCHP Fall 2019 State Telehealth Laws and
143
Reimbursement Policies report and cross-checked with the eVisit and VisuWell state-by-state
144
telemedicine policy resources. Information on Medicare legislation was collected from the
145
Medicare Learning Network Telehealth Services report. Cross-state licensing legislation was
146
determined by the IMLC, CCHP, eVisit websites.
147 148
Results:
149
Utilization and Accessibility
150
According to the US Department of Health and Human Services (HHS), 60% of all US
151
healthcare institutions, and 40% to 50% of hospitals, incorporated some form of telemedicine in
152
their practice in 2016.21 In the American Medical Association’s 2016 Physician Practice
153
Benchmark Survey, it was found that 15.4% of US physicians—and 15% of dermatologists—
154
work in practices that utilize physician-to-patient telemedicine.3 Of the specialist subgroups,
155
dermatologists were in 11th place, well behind the top three users: radiologists (39.5%),
156
psychiatrists (27.8%), and cardiologists (24.1%).3 Still, the number of US teledermatology
157
programs rose from 37 in 2011, to 102 in 2016.20
158
Efforts have been made to expand the use of telemedicine—particularly to benefit the
159
underserved. In 2016, the US Health Resources and Services Administration (HRSA) announced
160
funding for sustainable telehealth programs as part of a multimillion dollar grant package to
161
increase healthcare access in rural and underserved areas.22 Funded by the HHS and HRSA, 12
6
162
regional and 2 national Telehealth Resource Centers provide resources, education, and technical
163
assistance to support these efforts.23
164
Through both public and private funding, teledermatology has paralleled this national
165
movement. The American Academy of Dermatology (AAD) developed AccessDerm as a
166
philanthropic teledermatology platform in 2016, where volunteer dermatologists provide free
167
store-and-forward consultations to patients at Federally Qualified Health Centers in underserved
168
communities.24 In 2016 alone, 62 facilities of the Veterans Health Administration performed
169
101,507 teledermatology consultations.20 The University of Missouri has offered
170
teledermatology services with the Missouri Telehealth Network for over 20 years, expanding
171
care to rural Missourians as one of the longest-running telemedicine programs in the nation.25,26
172
In a younger pilot program, seven Massachusetts community health centers serving low income
173
populations partnered with remote dermatologists for store-and-forward tele-triage.15
174
While most literature describes a “hub-and-spoke” model, where “spokes” of specialist
175
care are initiated from the “hub” of a general practitioner’s office, direct-to-consumer
176
teledermatology is a growing phenomenon. The development of mobile teledermatology
177
applications allows patients to connect with dermatologists more easily than ever, offering a
178
direct-care platform for remote diagnosis and management of skin conditions. These
179
teledermatology consultations are accessible to the uninsured, with fees ranging from $25-60—
180
comparable to a copay.27 As of 2017, there were 106 teledermatology applications available on
181
Apple, Android, and Windows platforms, triple in number since 2014.27
182 183 184
7
185 186
Electronic Health Record Integration and Security Though convenient for the patient, external direct-to-consumer teledermatology
187
platforms can lead to fragmented care, since records of consultations are rarely sent to the
188
patient’s primary care provider.28 Internal teledermatology programs that merge with a patient’s
189
electronic health record (EHR) ensure continuity of care and proper record-keeping.11 Two
190
health systems have published their experiences on teledermatology compatibility with their
191
existing Epic EHR (Systems Corporation, Verona, WI), the most widely used EHR in the US.11
192
Carter et. al. successfully integrated store-and-forward teledermatology with Epic at Parkland
193
Health and Hospital System in Dallas.11 Similarly, dermatologists at Stanford Health Care
194
demonstrated Epic integration with both consultative and patient-initiated teledermatology.10,14
195
The use of mobile applications for teledermatology may pose security risks related to
196
Health Insurance Portability and Accountability Act (HIPAA) compliance. In an analysis of 29
197
direct-to-consumer applications in 2014 by Peart and Kovarik, only 69% were found to be
198
HIPAA compliant.29 If a healthcare provider is a HIPAA-covered entity, it is their responsibility
199
to use a secure platform with data encryption, login controls, and other features listed in the
200
American Telemedicine Association (ATA) Practice Guidelines.30,31 Commonly used
201
applications were evaluated by Armstrong et. al. in 2010 and Ho et. al. in 2013, but there is a
202
need for newer studies to keep up with the rapidly-changing landscape of application
203
development.32,33
204 205 206 207
Reimbursement: Private Payer, Medicaid, and Medicare One point of regulation for telemedicine is reimbursement.34 Since individual states hold autonomy over laws governing private payer and Medicaid coverage, discrepancies are
8
208
prevalent.18 As of October 2019, 36 states and the District of Columbia have passed parity
209
laws.18,35 Coverage parity laws and payment parity laws require private payer insurances to cover
210
and reimburse telemedicine services, respectively, at the same rate as traditional, in-person
211
services (Figure 1).36
212
Medicaid reimbursement plays an important role in telemedicine expansion for
213
underserved patients. All states and the District of Columbia require coverage for live video
214
services, although Massachusetts only reimburses mental/behavioral healthcare delivered in this
215
way (Figure 2).18,35,37 Only 20 states cover store-and-forward teledermatology services (Figure
216
3).18,35,37 While 23 states and the District of Columbia have restrictions on originating and/or
217
distant sites, patients are explicitly allowed to initiate the interaction from home in 19
218
states.18,35,37 Additionally, Medicaid will reimburse a facility fee for eligible originating sites in
219
34 states.18
220
Medicare regulations are by far the most restrictive. The telehealth service must consist
221
of real-time audiovisual communication, barring coverage for asynchronous telemedicine, except
222
for a store-and-forward demonstration program in Alaska and Hawaii.38,39 The originating site
223
must be in a qualifying health center within a rural Health Professional Shortage Area or a
224
county outside a Metropolitan Statistical Area.39 This excludes a patient’s home as a permissible
225
originating site in all cases save for substance use disorder treatment.39 The HRSA provides an
226
online Medicare Telehealth Payment Eligibility Analyzer tool to determine whether a location
227
qualifies.40
228
In order for a telemedicine service to be reimbursed through Medicare, The Current
229
Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS) code
230
must be on the list of covered Medicare telemedicine services (Table I).38 Additionally, the
9
231
originating site can bill a facility fee for the telemedicine visit using the code Q3014.39
232
Regardless of insurance type, a provider must bill with the proper modifiers: GT for live video,
233
and GQ for store-and-forward.18,37
234
When insurance coverage persists as a barrier to telemedicine utilization, an up-front fee
235
can be charged directly to the patient—generally ranging from $30-75—, with the caveat that the
236
patient must sign a waiver not to use insurance for their telemedicine visit if the provider is in-
237
network.41 There is evidence to support that patients are willing to pay median values of $25-
238
48.84 out-of-pocket for teledermatology services, especially for the benefit of shorter wait time
239
to consultation.42-44
240 241 242
Licensure In most cases, physicians are legally allowed to practice telemedicine only in the state in
243
which they are licensed, posing a barrier to cross-state telemedicine. The Interstate Medical
244
Licensure Compact (IMLC) offers a solution by expediting the process of licensure for qualified
245
physicians who wish to practice in multiple states.45 According to the IMLC, all physicians who
246
possess a full and unrestricted medical license are eligible to apply for expedited licensure in
247
participating states. Currently, 24 states and Guam are members of the IMLC agreement and 5
248
states and the District of Columbia are in the process of joining.45 As of 2019, IMLC legislation
249
has been introduced in New Jersey and South Carolina.45 Beyond the IMLC, some states have
250
special provisions which allow out-of-state physicians to practice telemedicine without acquiring
251
an additional full medical license (Table II).18,35,45
252 253
10
254 255
Discussion: As with most technologies involving remote interaction, there are some drawbacks to
256
teledermatology. Essential elements of the physical examination, including palpation of the skin
257
and lymph nodes, cannot be performed. Lack of in-person interaction can potentially erode the
258
patient-provider relationship, leading to incomplete histories or imprecise communication. Poor
259
quality videos and images can compromise a diagnosis. A combination of these factors might
260
explain why—despite multiple studies demonstrating adequate diagnostic and management
261
concordance in teledermatology—, one weak point is skin cancer.46,47 Diagnostic accuracy of
262
cutaneous malignancies may improve by incorporating teledermoscopy, in which the referring
263
provider sends dermoscopy images for interpretation.31,48 For high-risk patients who require
264
serial lesion surveillance and prefer the direct-to-consumer model, smartphone-attachment
265
dermatoscopes like the DermLite HÜD (3Gen Inc., San Juan Capistrano, CA) and
266
Molescope/Molescope II (Metaoptima Technology Inc., Vancouver, BC, Canada) can be
267
purchased for $79.95-299.49-51
268
Ultimately, the responsibility and potential liability falls on the teledermatology provider
269
in a direct-care interaction and is shared with the referring provider in a teleconsultation.52 It is
270
prudent for providers to determine coverage of telemedicine under their medical liability
271
insurance policy, including cross-state telemedicine, prior to initiating these services.52 The ATA
272
and AAD provide expert guidelines that facilitate the creation of quality teledermatology
273
programs, both in technical caliber and clinical excellence.31,52
274
Despite expansion of telemedicine and teledermatology, most physicians and
275
dermatologists do not see patients via telehealth. Without a standardized definition of
276
telemedicine, variations can lead to vague interpretations of the law, and consequent legislative
11
277
barriers to wider implementation. In states like Colorado, Michigan, and Minnesota, the private
278
insurer decides what qualifies as telemedicine.18 While the 12 states have mandated payment
279
parity by private insurances—making telemedicine a financially practical alternative for
280
providers—, more states have implemented coverage parity instead, which alone does not
281
guarantee equal reimbursement. Despite the fact that store-and-forward is the most-studied and
282
most-practiced modality of teledermatology—used independently in 72% of programs and in
283
combination with live video in another 35%—, it is met with the steepest reimbursement
284
challenges.20 Medicaid in the majority of states, and Medicare as a whole, strictly define
285
telemedicine as a two-way, real-time interaction between patient and provider, preventing
286
coverage for store-and-forward. Still, many states have progressed their legislation to expand
287
Medicaid reimbursement for telemedicine, and Medicare recently approved new CPT codes for
288
prolonged telehealth interactions. Unfortunately, the restrictive nature of Medicare coverage to
289
specific originating sites and geographical locations overlooks the potential benefits of telehealth
290
to all elderly beneficiaries, who often experience challenges with transportation.
291
Regarding cross-state licensing, the IMLC increases the pool of physicians available to
292
patients in rural communities, which is particularly important for delivery of specialty care. In
293
states like Kansas, the number of dermatology providers ranges from 0-1 to 3-4 per 100,000
294
people in the majority of 3-digit ZIP code regions, limiting the extent to which teledermatology
295
can be delivered from within the state.53 Contrast this to states like Florida and Hawaii, where
296
most regions have from 3-4 to 10-plus dermatology providers per 100,000 people.53 Through
297
cross-state licensing, Kansas residents would gain access to out-of-state dermatologists.
298
However, neither Florida nor Hawaii are currently members of the IMLC.45 To optimize this
299
system, more states with a high proportion of dermatologists must join the compact.
12
300
As new legislation expands reimbursement and eases cross-state practice,
301
teledermatology will become more appealing to the provider. More than ever, teledermatology
302
has shown potential as a beneficial and accessible method of delivering care. The growth of
303
mobile applications makes participation easier than ever. Volunteer efforts and pilot programs
304
have demonstrated that telemedicine services can address the barrier between underserved
305
populations and specialty dermatologic care. Government agencies are subsidizing telemedicine
306
as they did many decades ago, allowing for the development of new programs—from schools, to
307
community hospitals, to academic centers.54 Teledermatology stands as a viable option to
308
provide dermatologic care for individuals who would otherwise go without.
309 310 311
Conclusion: Teledermatology is expanding, as evidenced by increased accessibility and functionality,
312
legislative support of insurance coverage, and expedited cross-state licensing. Private payer
313
reimbursement is growing secondary to parity laws. Medicaid reimburses live video
314
teledermatology in nearly all states, and store-and-forward services in nearly half. Medicare
315
reimbursement is the most restrictive. Dermatologists may practice telemedicine across state
316
lines using special licenses and the IMLC in participating states. With growing availability,
317
teledermatology expands access to specialty dermatologic care.
318 319
Acknowledgements:
320
We would like to thank Trilokraj Tejavsi, MD, Chair of the ATA Teledermatology Special
321
Interest Group, for his insight on teledermatology in the US.
322
13
323
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Warshaw EM, Hillman YJ, Greer NL, et al. Teledermatology for diagnosis and
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465 466
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Position Statement on Teledermatology. American Academy of Dermatology;2016.
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Glazer AM, Rigel DS. Analysis of trends in geographic distribution of US dermatology
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workforce density. JAMA Dermatol. 2017;153(5):472-473.
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Case studies of how hospitals and health systems are using telehealth to expand access
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473
health-systems-members-action. Accessed August 26, 2019.
474 475 476 477 478 479 480
20
481
Figure Legends:
482
Figure 1. Private payer parity laws. Map of the United States colored according to the status of
483
individual state private payer telemedicine parity laws, with a focus on teledermatology.18,35,37
484
_______________________________________
485
Current through October 2019. Created with mapchart.net.
486
* No coverage parity until January 1, 2021, but requirement for telehealth coverage in
487
dermatology and other conditions/settings
488
† Effective January 1, 2021. Does not apply to Medi-Cal Managed Care.
489
‡ Effective January 1, 2020
490
§ Unless the health provider and payer contractually agree to a lower reimbursement rate
491
| Payment must be at least 75% of traditional services
492
¶ Coverage parity for live video, but not store-and-forward
493 494
Figure 2. Medicaid live video coverage. Map of the United States colored according to the
495
status of individual state Medicaid live video coverage, with a focus on teledermatology.18,35,37
496
_______________________________________
497
Current through October 2019. Created with mapchart.net.
498
* Professional relationship must exist between the patient and the distant site provider
499
† If deemed by the commissioner as appropriate, cost effective, and likely to expand access
500
‡ When services are ongoing, the patient should receive a traditional clinical evaluation at least
501
once per year; the distant site provider should coordinate with the primary care physician
502
§ Mental/behavioral health only
503
| Some restrictions apply (beneficiary cannot travel, imminent health risk)
21
504
¶ Must be at an eligible site, in a rural area with a health professional shortage (same as
505
Medicare)
506
** Distant site must be of a sufficient distance from originating site; prior approval required in
507
some cases
508
†† Only for initial and follow-up inpatient telehealth consultation
509
‡‡ Only by TN Managed Care
510 511
Figure 3. Medicaid store-and-forward coverage. Map of the United States colored according
512
to the status of individual state Medicaid store-and-forward coverage, with a focus on
513
teledermatology.18,35,37
514
_______________________________________
515
Current through October 2019. Created with mapchart.net.
516
* Teledentistry only
517
† Only in the case of provider-to-provider communication (electronic consults)
518
‡ Teledermatology only
519
§ Teleradiology only
520
| Effective January 1, 2020
521
¶ Teledermatology, teleophthalmology, and teleradiology only
522
** Patient must be notified of the right to interactive communication with the distant site
523
provider, who must respond within 30 days of the patient’s request
524
†† Not explicitly included, but may be covered under the definition of telemedicine
525
‡‡ Only by TN Managed Care
526
§§ Outpatient teledermatology, teleradiology, and diabetic retinopathy screening only
22
527
Table I. Covered Medicare telemedicine services (and their CPT/HCPCS codes) of relevance to
528
teledermatology39 Service Telehealth consultations, emergency department or initial inpatient Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs Office or other outpatient visits Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service
CPT/HCPCS Code G0425–G0427 G0406–G0408 99201–99215 99354-99355*
99356-99357*
529 530
_______________________________________
531
* New codes for 2019
532 533 534 535 536 537 538 539 540 541 542
23
543
Table II. Summary of cross-state licensing options in different states and territories, as of
544
October 201918,35,45 Cross-State Licensing Type
States/Territories
IMLC member issuing licenses only (non-SPL)
AL, AZ, CO, IA, ID, IL, KS, MD, ME, MI, MS, MT, ND, NE, NH, NV, SD, TN, UT, WA, WI, WV, WY, and Guam MN
IMLC implementation in process
GA, KY, OK, PA, VT, and District of Columbia
IMLC legislation introduced License to practice across state lines may be granted for fully licensed out-of-state providers License to practice across state lines for fully licensed providers practicing in adjoining states, as long as similar privileges are extended to their own physicians Special purpose license for licensed out-of-state providers Telemedicine license
NJ, SC
Telemedicine certificate Consultation services as requested by in-state provider only Physician-to-physician consultation Infrequent consultation
OHj
IMLC member serving as state of principal licensure (SPL) and issuing licenses
CT, INa, MNb, NDc, NM, ORd, SD, UTe
MDf, PAg
AL, NV LA, OKh, TNh, TXi MEb, MS HI, NH, OK, VA AZk, AR, KYl, MOl, RIm, TX
545 546
_______________________________________
547
a. As long as the licensed out-of-state provider and their employer/contractor file for certification
548
of compliance with the courts of IN
549
b. Must register with the state board and agree not to open an office, meet patients, or receive
550
calls in the state
551
c. Per the state medical board’s discretion
552
d. Must establish a patient-physician relationship, and cannot write prescriptions based on online
553
consult only
24
554
e. Only if services are rendered as a public service and for noncommercial purpose
555
f. Cannot open an office in the state
556
g. Based on availability of medical care in the area involved
557
h. Osteopathic board only
558
i. Must have passed the Texas Medical Jurisprudence Examination
559
j. Must also possess a special activity certificate, which can be converted to a license by written
560
request
561
k. Physician-to-physician only
562
l. If their service was requested by an in-state licensed physician with an established relationship
563
with the patient
564
m. For no more than 7 days unless extended with written permission from the director
565 566 567 568 569 570 571 572 573 574 575 576
25