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The success of telemedicine in managing chronic inflammatory skin conditions including psoriasis during the COVID-19 pandemic “highlighted that teledermatology can be used beyond the context of a global health crisis to provide continuity of care and improve access to health care more broadly,” the task force wrote in a paper published online in JAAD International.
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Co–senior author George Han, MD, PhD, said in an interview that the impetus for the guidelines came from NPF patient advocates, who realized that the organization needed something to take to payers and governmental agencies to advocate for better access to dermatologic care. He is associate professor of dermatology and director of teledermatology at the Hofstra/Northwell department of dermatology, Hyde Park, New York.
“We realized that, in many places around the country, people don’t have access to dermatology.” In upstate New York, said Dr. Han, his anecdotal research has revealed wait times of 6 months or more.
As a guiding principle, the authors pronounce teledermatology “a reasonable alternative for providing long-term management of patients with psoriasis.” Research shows that nearly all dermatologists used teledermatology during the pandemic, the authors noted, and that well-run programs improve Psoriasis Area and Severity Index (PASI) scores and other measures on par with in-person care. Telemedicine may be especially useful for initial visits, they added, particularly when distance, patient incapacity, and circumstances prevent face-to-face evaluation.
Additional position statements emphasize that teledermatology should support rather than supplant in-person visits, and that this balance may be particularly important in cases involving psoriatic arthritis (PsA). “Even though we can’t do a physical exam and palpate some of those joints in person,” said Dr. Han, “tools have been developed that, through a series of questions the patient can answer, can guide you towards whether there is a high index of suspicion for psoriatic arthritis.” Such patients require in-person evaluation with urgency, he said, because delays in PsA diagnosis and treatment can lead to irreversible joint damage and significant functional impairment.
Dr. George Han
Another motivation for producing the guidelines, said Dr. Han, was that, even when underserved patients get a dermatology appointment, some providers may not have all the latest tools or medicines available for treating psoriasis. In such cases, telemedicine may allow dermatologists specializing in psoriasis care to extend their reach in comanaging patients with primary care physicians and community dermatologists.
Before the appointment, guidelines suggest determining what form of teledermatology will best suit each patient. Authors recommended gauging patients’ savviness with computers and cameras, and counseling patients regarding available virtual evaluation tools – such as live video visits, store-and-forward photo strategies, and assessment-tool training videos.
A subsequent guideline underscores the importance of continuously improving technology to support expeditious image capture and workflows that emulate in-person practice. Dr. Han explained, “we wanted to make sure that on the back end there’s adequate support such that – if through teledermatology, we determine that the patient should get, say, a systemic treatment – the patient is able to get the appropriate lab tests, get the medicine, and know how to inject it.”
Regarding reimbursement, Dr. Han said that policies varied prepandemic, but many commercial insurers covered telemedicine at a rate 20% lower than the in-person rate. During the pandemic, he said, insurers shifted to provide the higher rate for telemedicine, consistent with policies adopted by the Centers for Medicare & Medicaid Services.
“There are differences in coverage and reimbursement from plan to plan,” Dr. Han added. “And even within the same plan, there are carve-outs so that some plans don’t allow certain services. The big picture is that for the most part these services are covered at a level comparable to an in-person visit at present.”
With the Department of Health & Human Services’ public health emergency declaration expiring in May, he said, physicians have worried that some of the allowances made by CMS – such as lifting requirements that Medicare patients in rural areas be seen at care sites – will expire. “It seems that some of those limitations have been addressed, and those allowances are going to be extended until Congress is able to pass something that gives us durable access to telemedicine care. We think that based on the current environment telemedicine is here to stay.”
The study was funded by the NPF. Dr. Han has been an investigator, adviser, speaker, or researcher for AbbVie, Amgen, Apogee Therapeutics, Arcutis, Athenex, Bausch Health, Beiersdorf, Boehringer Ingelheim, Bond Avillion, Bristol Myers Squibb, Celgene, CeraVe, Dermavant, DermTech, Eli Lilly, EPI Health, Janssen Pharmaceuticals, LEO Pharma, L’Oreal, MC2 Therapeutics, Novartis, Ortho Dermatologics, PellePharm, Pfizer, Regeneron Pharmaceuticals, Sanofi Genzyme, SUN Pharmaceuticals, and UCB.