Paying Across the Miles: Telehealth Reimbursement and the Dermatology Access Gap

New research shows that the gap between the number of dermatologists in urban and rural areas is widening across the United States, and it seems that only technology—such as the expanded use of telemedicine—will help us effectively bridge this gap and improve access to dermatologic care.

Specifically, dermatologist density increased by 21 percent from 3.02 per 100,000 people to 3.65 per 100,000 people from 1995 to 2013, and the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas, according to a study of county-level data from 1995 to 2013 published in JAMA Dermatology.¹

The ratio of dermatologists older than 55 years to younger than 55 years increased 75 percent in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170 percent in metropolitan areas (from 0.34 to 0.93). Most dermatologists tended to be located in well-resourced, urban communities, the study found.¹

Perspectives

In an accompanying editorial,² Boston dermatologists Martina L. Porter, MD and Alexa B. Kimball, MD, MPH offer some predictions and potential solutions to this problem, including taking steps to engage residents in rural areas and doubling down on technology. “Residency selection, exposure to rural medicine, and targeted financial incentives, such as loan repayment, can all be leveraged to bring about change,” they write. “In parallel, because there appears to be increasing willingness to fund telemedicine, doubling down on training rural physicians and advanced practice practitioners in some areas of dermatology and engaging technology to support them seem prudent and responsible.” These efforts may not modify the overall dermatology workforce imbalance, but they will improve access to dermatologists, they write.

While I agree with many of these points, I don’t envision dermatologists migrating to rural areas in droves in the near future. We need more than a human solution to effectively address these challenges. Dermatologists flock to urban areas for a combination of professional and personal reasons, and even such incentives as loan forgiveness have not seemed to entice us to change course.

The only way to improve access to dermatology in rural areas is through technology. Teledermatology is improving and will continue to do so with the advent of machine learning and artificial intelligence, but its uptake will depend on reimbursement.

The US Centers for Medicare & Medicaid Services’ (CMS) proposed rule has started the conversation about paying for telemedicine (See Sidebar at left). According to the proposal, the CY2019 Physician Fee Schedule would support such access by paying clinicians for virtual check-ins and evaluations of patient-submitted photos, as well as by expanding Medicare-covered telehealth services to include prolonged preventive services.

It’s About to Change

There are many benefits of telemedicine, including delivering quality care at a lower cost and the ability to nip potentially serious skin issues in the bud, and this technology can also improve access to specialty care, regardless of geographic location. The main reason it hasn’t caught on is that insurers are not reimbursing for telemedicine in a consistent fashion… yet. That is all about to change. Keeping your head in the sand is no longer a viable strategy. It is time to buckle up, get familiar with the technology, and develop an implementation strategy. Telemedicine will be ubiquitous in just a few years.

1. Feng H, et al. Comparison of Dermatologist Density Between Urban and Rural Counties in the United States. JAMA Dermatol. Published online September 5, 2018.

2. Porter ML, Kimball AB. Predictions, Surprises, and the Future of the Dermatology Workforce JAMA Dermatol. Published online September 5, 2018.