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
INSIDE CMS CY2019
“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” said Administrator Seema Verma in a statement about CY2019.
CMS says provisions in the proposed CY2019 Physician Fee Schedule would support access to care using telecommunications technology by implementing proposed new services:
- Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code GVCI1)
- Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (HCPCS code GRAS1)
Practitioners could be separately paid for the Brief Communication Technology-based Service when they check in with beneficiaries via telephone or other telecommunications device to decide whether an office visit or other service is needed. This would increase efficiency for practitioners and convenience for beneficiaries. Similarly, the Remote Evaluation of Recorded Video and/or Images Submitted by the Patient would allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.
CMS is also proposing to pay separately for new coding describing Chronic Care Remote Physiologic Monitoring (CPT codes 990X0, 990X1, and 994X9) and Interprofessional. Internet Consultation (CPT codes 994X6, 994X0, 99446, 99447, 99448, and 99449).
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.
Mark D. Kaufmann, MD is an associate Clinical Professor of Dermatology, Dept. of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.
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.
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