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COVID-19: Important Updates and Developments Edited by Franco Rongioletti, MD, and Leonard J. Hoenig, MD| Volume 40, ISSUE 6, P760-763, November 2022

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Increased utilization of teledermatology among Medicare Part B beneficiaries during the COVID-19 pandemic

      Abstract

      Enhanced telehealth flexibilities in response to the COVID-19 pandemic have prompted heightened use across many physician specialties; yet, national trends have not been assessed within dermatology, specifically. In this longitudinal review of 2017 to 2020 Medicare billing data, we identified a 210-fold increase in teledermatology evaluation and management (E&M) visits between 2019 and 2020, which helped to slightly offset the substantial 20.1% decline in in-person E&M visits. Teledermatology comprised an overall greater proportion of E&M visits in states with the largest declines in in-person visits. Teledermatology E&M visits were primarily comprised by established patient video visits (74.3%); yet, the relatively more substantial role of telephone-only visits in certain rural states may reflect limitations in technologic access in these areas. Asynchronous teledermatology (including store-and-forward dermatology) also increased by 34-fold in 2020, supporting its utility for evaluation of a changing lesion or for triage purposes. The findings underscore the growing role of telehealth in dermatologic care and are important given that certain telehealth flexibilities are set to expire at the end of the public health emergency without additional congressional intervention.

      Introduction

      In March 2020, the Centers for Medicare and Medicaid Services issued enhanced telehealth flexibilities following the COVID-19 pandemic.

      US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

      Recent analyses have thus far demonstrated telehealth increases across all physician specialties in 2020, and survey data suggest that 96% of dermatologists used teledermatology during the pandemic, up from 14% previously;

      US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

      ,
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      however, national and state-specific teledermatology trends have not been assessed,

      US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

      which is important given its potential to aid in common diagnoses,
      • Warshaw EM
      • Hillman YJ
      • Greer NL
      • et al.
      Teledermatology for diagnosis and management of skin conditions: a systematic review.
      increase practice efficiency, reach patients without local dermatologists, and improve care flexibility.
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.

      Methods

      We reviewed the 2017-2020 Medicare Part B Procedure Summary data sets (the most recently available Medicare data) to identify national and state-specific teledermatology trends prior to and during the COVID-19 pandemic.

      Centers for Medicare and Medicaid Services. Physician/supplier procedure summary. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary. Accessed july 5, 2022.

      Consistent with Medicare classifications, teledermatology encounters included (1) synchronous video or telephone-only evaluation and management (E&M) visits and (2) non-E&M asynchronous telecommunications, including “virtual check-ins” and digital “E-visits.” Trends were displayed in aggregate, for each specific teledermatology service type, and within specific states.

      Results

      Overall, 255,656 telehealth E&M visits and 16,849 asynchronous telecommunications were analyzed. Aggregate use of telehealth E&M visits was 210-fold greater in 2020 compared with 2019, whereas in-person E&M visits decreased by 20.1%. Asynchronous telecommunications increased substantially by 34-fold in 2020 (Table 1). Telehealth E&M use was notably higher in Massachusetts (8.3%), Vermont (6.2%), and New York (5.2%), with telephone-only E&M visits more frequently used in Vermont (50.9%), Wisconsin (37.3%), and Alabama (35.2%) (Figure 1).
      Table 1Use of in-person and telehealth E&M visits and asynchronous telecommunications among Medicare Part B dermatology beneficiaries, 2017-2020
      Visit/Interaction typeAnnual volume and proportion of visit typeAverage annual percent change (2017-2019)Annual percent change (2019-2020)
      2017201820192020
      E&M Visits
      All E&M visits11,484,78011,511,09911,723,6769,623,981+1.0%–17.9%
      In-person E&M11,484,46 (100.0)11,510,416 (100.0)11,722,468 (100.0)9,370,529 (97.4)+1.0%–20.1%
       New1,676,225 (14.6)1,628,113 (14.1)1,620,992 (13.8)1,210,571 (12.9)–1.7%–25.3%
       Established9,808,242 (85.4)9,882,303 (85.9)10,101,476 (86.2)8,159,958 (87.1)+1.5%–19.2%
      Telehealth E&M313 (0.0)683 (0.0)1,208 (0.0)253,452 (2.6)+96.5%+20,881%
       Synchronous video (new)189 (60.4)365 (53.4)881 (72.9)24,513 (9.7)+115.9%+2,682%
       Synchronous video (established)124 (39.6)318 (46.6)327 (27.1)188,211 (74.3)+62.4%+57,457%
       Synchronous phone (new or established)40,728 (16.1)
      Asynchronous telecommunications
      All asynchronous telecommunications24026443315,912+34.3%+3,575%
       Virtual check-in (image review)47 (10.9)2,957 (18.6)+6,192%
       Virtual check-in (communication)111 (25.6)4,081 (25.6)+3,577%
       Digital e-visit240 (100.0)264 (100.0)275 (63.5)8,874 (55.8)+7.0%+3,127%
      Note: In-person Medicare E&M visits (HCPCS 99201-99215) performed by dermatologists included those in the office and outpatient hospital facility settings. Synchronous telehealth visits included video (HCPCS 99201-99215 with modifier -95 or place of service: telehealth) or telephone (HCPCS 99441-99443 [established 2020]) E&M visits. Asynchronous telecommunications are patient-initiated and include “virtual check-ins,” potentially with image/media review (HCPCS G2010, G2012 [established 2019]) and digital “E-visits”, typically through portal or email modalities (HCPCS 99421-99423 [2020]; 99444 [2017-2019]). Given data set suppression of small values, a minority (6%) of telehealth visits were estimated from the associated Medicare payment amount provided in the data set.
      HCPCS, Healthcare Common Procedure Coding System; E&M, evaluation and management.
      Fig 1
      Fig. 1State-specific use of in-person and telehealth E&M visits among Medicare Part B dermatology beneficiaries, 2019-2020. The figure illustrates: (A) state-specific percentage change in in-person Medicare Part B E&M visits by dermatologists from 2019 to 2020, (B) state-specific proportions of all Medicare Part B dermatology E&M visits comprised by telehealth in 2020, and (C) state-specific proportions of telehealth E&M dermatology visits that were telephone-only (vs video). Asynchronous telecommunications are not included in the figure.

      Discussion

      The analysis indicates substantial growth in teledermatology in 2020, closely reflecting the average for other medical specialties (2.6%).

      US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

      This expansion was likely facilitated by temporary government waivers, which increased the Medicare payment rate for telehealth services (audio and video) to the non-facility in-person rate across all regions.

      US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

      Previously, Medicare telehealth was only reimbursed in specified rural regions and at the lower facility rate.

      US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

      Despite teledermatology growth, aggregate E&M visits still decreased in 2020, underscoring the importance of careful monitoring for patients with suboptimal follow-up during the pandemic.
      Although teledermatology increased across all states, greater use in states with more substantial in-person visit declines suggests its role in addressing care gaps. Although telephone-only E&M visits were infrequently used, they comprised a significant proportion of teledermatology in certain rural states (Vermont, Wisconsin, Alabama), potentially reflecting less developed rural technologic infrastructure in these areas.
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      Importantly, older patients, minorities, and those with disabilities also have decreased digital access,
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      and mitigation of these disparities is therefore critical to promote equitable teledermatology use moving forward.
      There are shortcomings to teledermatology, including reliance on digital technologies, potential exacerbation of language barriers,
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      lack of suitability for full-body examinations,
      • Kennedy J
      • Arey S
      • Hopkins Z
      • et al.
      Dermatologist perceptions of teledermatology implementation and future use after COVID-19: demographics, barriers, and insights.
      and potentially inferior diagnostic accuracy for malignant lesions;
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      still, it offers acceptable diagnostic accuracy for a number of common of skin conditions.
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      ,
      • Warshaw EM
      • Hillman YJ
      • Greer NL
      • et al.
      Teledermatology for diagnosis and management of skin conditions: a systematic review.
      Surveyed dermatologists are comfortable using live teledermatology for dermatitis and follow-ups,
      • Kennedy J
      • Arey S
      • Hopkins Z
      • et al.
      Dermatologist perceptions of teledermatology implementation and future use after COVID-19: demographics, barriers, and insights.
      as reflected in these data by the disproportionate use among established patients. Stored digital photography also increased to a significant degree in these data and may offer specific utility for the evaluation of a single changing lesion and assist in triaging patients for in-person evaluation.
      • Yeboah CB
      • Harvey N
      • Krishnan R
      • Lipoff JB.
      The Impact of COVID-19 on teledermatology: a review.
      ,
      • Kennedy J
      • Arey S
      • Hopkins Z
      • et al.
      Dermatologist perceptions of teledermatology implementation and future use after COVID-19: demographics, barriers, and insights.
      Conclusions
      Limitations to this analysis include the reliance on Medicare data given that commercial payors were not required in many states to implement telehealth reimbursement parity. Additionally, these data are not available at the provider level, beyond 2020, and cannot be correlated to diagnoses. Despite teledermatology expansion, the lower facility payment rate and geographic telehealth restrictions are set to have returned in October 2022. As such, additional congressional legislation may be required to support long-term use, and further longitudinal assessments will be essential.

      Financial Disclosures

      Dr. Grant-Kels serves as Deputy Editor of Journal of the American Journal Academy of Dermatology and is Chief Medical Officer, member of the Board and stockholder of VeraDermics, Inc; Consultant and stockholder for DermaSensor, Inc. Hao Feng is a consultant for Cytrellis Biosystems, Inc and for Soliton, Inc.

      References

      1. US Department of Health and Human Services. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location. Available at: https://www.aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf?_ga=2.263152908.1288477598.1638811694-1417522139.1637192937. Accessed july 5, 2022.

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        • Lipoff JB.
        The Impact of COVID-19 on teledermatology: a review.
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        Teledermatology for diagnosis and management of skin conditions: a systematic review.
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      2. Centers for Medicare and Medicaid Services. Physician/supplier procedure summary. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary. Accessed july 5, 2022.

        • Kennedy J
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        Dermatologist perceptions of teledermatology implementation and future use after COVID-19: demographics, barriers, and insights.
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