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Teledermatologic Care, the Affordable Care Act, and 20 Million New Patients Picturing the Future

Courtney B. Rubin, BS1,2; Carrie L. Kovarik, MD3,4
[+] Author Affiliations
1Perelman School of Medicine at the University of Pennsylvania, Philadelphia
2Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
3Department of Dermatology, University of Pennsylvania, Philadelphia
4Department of Medicine, University of Pennsylvania, Philadelphia
JAMA Dermatol. 2014;150(3):243-244. doi:10.1001/jamadermatol.2013.9603.
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There is considerable concern as to whether the current number of dermatologists in the United States can meet the needs of a growing patient population. The average wait time to see a dermatologist is already more than 30 days for new patients, and many practices are hiring nonphysician clinicians to fill the gap.1 Within the next 2 years, the Affordable Care Act’s individual health care mandate is expected to increase the number of nonelderly people with health insurance by more than 20 million, and this number could be substantially higher if many states elect to expand their Medicaid programs.2 Dermatologists will be faced with additional pressure to expand their practices and see more patients while the newly insured may be faced with a shortage of appointment availability and long wait times. The inability to access a board-certified dermatologist in a reasonable amount of time may force the newly insured to seek care from alternate providers or overburdened emergency departments or not receive care at all. Alternatively, these patients may use direct-to-patient teledermatologic services through the Internet or mobile devices that offer to evaluate skin issues quickly but may be unable to provide the continuity of care afforded by a physician-patient relationship. Newly insured patients, who are likely to be more racially diverse, less educated, and non-English speaking compared with the currently insured, may receive substandard dermatologic care from these alternative resources.3 These differences may ultimately lead to an increase in dermatologic health disparities and barriers of access in minority and vulnerable populations.

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Realistic Teledermatology
Posted on March 19, 2014
Christopher Schmidt, MD
Internet Dermatology Network
Conflict of Interest: I am one of the founders of the Internet Dermatology Network.
To The Editor. In their Viewpoint article, Rubin and Kovarik recommend classic teledermatology conducted between two medical professionals, as a way to solve the looming shortage of dermatologic services. At the same time, they criticize direct-to-patient teledermatology systems, stating that they are unable to provide clinical context or continuity of care. Unfortunately classic teledermatology has already proven itself too impractical and poorly reimbursed to gain widespread use. Worse, it usually does not allow for physician continuity when the patient needs follow up in the office. Usually the consulting dermatologist is at a tertiary care center, far removed from the patient and the referring physician. Contrary to Rubin and Kovarik’s argument, the direct-to-patient method offers a more effective approach to increase dermatologic capacity and maintain quality. The practicality of a direct-to-patient teledermatology consultation is undeniable. Current store-and-forward systems obtain patient history, allow two way communication and are adequately reimbursed. With pre-loaded diagnoses and order sets, they are also extremely efficient. When these systems are used to connect patients with their local or closest dermatologist, in-office follow up with that physician is just part of the practice. The weak link in teledermatology is diagnostic accuracy. For that reason, in-office follow up with physician continuity should be an essential part of a teledermatology practice. Direct-to-patient teledermatology systems, that allow any dermatologist to participate, provide appropriate clinical context and better continuity of care than classic teledermatology systems. Their exceptional efficiency is what will make them the most likely solution for any future shortage of dermatologic services. Christopher Schmidt, MD1. Rubin CB, Kovarik CL. Teledermatologic care, the Affordable Care Act, and 20 million new patients. Arch Dermatol. 2014; 150(3):243-244.
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