Dermatology medications with the highest cost burden on Medicare Part D: Potential implications of the Inflation Reduction Act.

Signed into law in August 2022, the Inflation Reduction Act includes provisions requiring the federal government to negotiate prices for medications covered under Medicare Part D. Initial negotiations will target drugs with the highest total spending and price increases relative to inflation. In this study, we identify dermatology prescriptions with the highest cost burden on Medicare Part D and analyze recent trends in total spending and unit costs.

Comparison of Costs in Teledermatology Using PC and Camera Versus Smartphone.

Introduction: One of the challenges faced by the Colombian Health System is to improve access to health services for the dispersed and isolated rural population, particularly in the field of dermatology. This article examines the implementation of a teledermatology service using a PC and camera versus smartphone technology. Methods: A total of 542 teledermatology visits were conducted, involving 478 patients, in addition to 64 visits for clinical follow-up for patients as per the dermatologist's recommendation. Out of the 478 patients, 461 met the inclusion criteria and agreed to participate in the study. The data collection instrument from the general practitioner or referring provider covered three consultation moments: (1) sending an initial consultation, (2) providing a response to the patient, and (3) sending a follow-up consultation. Seven hundred forty-seven records were completed by the general practitioner for the three consultation moments. Furthermore, 372 consultations were documented by the dermatologist or referring provider for two moments: (1) response to the initial consultation by the dermatologist, and (2) response to the follow-up consultation by the dermatologist. After validating the information reported in the instruments, a descriptive analysis of the data was conducted, utilizing absolute frequencies and percentages for qualitative variables and measures of central tendency (mean, median, standard deviation, and interquartile range) for quantitative variables. The data were analyzed from 747 records of the referring provider instrument related to 461 patients, between 18 and 98 years of age, with a predominantly female representation. Results: The results indicated that for teleconsultations conducted using a mobile device, the average total duration of the teleconsultation was longer on the traditional platform compared with the mobile device (13.03 vs. 8.27 min). Additionally, it was observed that the time taken to store, send, and capture a single image (clinical or dermoscopic) using the mobile device was three times lower than that on the conventional platform (25 vs. 75 s). Similar findings were noted for teleconsultations carried out by the dermatologist, predominantly utilizing a mobile device. The average consultation time was shorter for the mobile device compared with the traditional platform (8.14 vs. 12 min). Conclusions: The cost reduction suggests that the operation of the service is more efficient with smartphone technology in comparison to the use of a PC and camera. Teledermatology with smartphones provides a streamlined, efficient, and technically sound process for obtaining clinical and dermoscopic images.

The Teledermatology Experience: Cost Savings and Image Quality Control.

Introduction: Teledermatology adoption continues to increase, in part, spurred by the COVID-19 pandemic. This study analyzes the utility and cost savings of a store-and-forward teledermatology consultative system within the Veterans Health Administration (VA). Methods: Retrospective cohort of 4,493 patients across 14 remote sites in Tennessee and Kentucky from May 2017 through August 2019. The study measured the agreement between the teledermatology diagnoses and follow-up face-to-face clinic evaluations as well as the cost effectiveness of the teledermatology program over the study period. Results: Fifty-four percent of patients were recommended for face-to-face appointment for biopsy or further evaluation. Most patients, 80.5% received their face-to-face care by a VA dermatologist. There was a high level of concordance between teledermatologist and clinic dermatologist for pre-malignant and malignant cutaneous conditions. Veterans were seen faster at a VA clinic compared with a community dermatology site. Image quality improved as photographers incorporated teledermatologist feedback. From a cost perspective, teledermatology saved the VA system $1,076,000 in community care costs. Discussion: Teledermatology is a useful diagnostic tool within the VA system providing Veteran care at a cost savings.

Role of phototherapy in the era of biologics.

Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of phototherapy in dermatology. Surveys have shown that many dermatology residency programs do not dedicate time to teaching residents how to prescribe or administer phototherapy. Limitations of phototherapy include access to a center, time required for treatments, and insurance approval. Home phototherapy, a viable option, is also underused. However, it should be emphasized that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and does not require laboratory monitoring. It can be safely combined with many other treatment modalities, including biologics and small molecule inhibitors. In addition, phototherapy costs significantly less than these novel agents. Dermatologists are the only group of physicians who have the expertise and proper training to deliver this treatment modality to our patients. Therefore, to continue to deliver high-quality, cost-effective care, it is imperative that phototherapy be maintained as an integral part of the dermatology treatment armamentarium.

UK psychodermatology services in 2019: service provision has improved but is still very poor nationally.

BACKGROUND: Psychodermatology is an emerging subspeciality of dermatology. Psychodermatology clinics use a multidisciplinary approach to deal with psychological or psychiatric elements related to skin disease. Two previous studies in 2004 and 2012 highlighted the deficiency of psychodermatology services in the UK, despite the evidence that these services have high demand and are cost-effective. AIMS: To reassess psychodermatology service provision in the UK and outline the developments that have been made. METHODS: In conjunction with BBC Radio 5 Live, a survey questionnaire was distributed via email to the UK membership of the British Association of Dermatologists (BAD) and Psychodermatology UK. The survey consisted of 13 questions asking about the availability of psychodermatology services. RESULTS: Basic percentages were used to analyse quantitative data, and content analysis was used for qualitative data. Our results showed that less than a quarter of the respondents (24%) have access to a nearby dedicated psychodermatology service. Additionally, the psychodermatology units do not have a unified configuration and clinical provision model differs nationally. Only around 5% of the clinicians have access to a clinic that provides psychology-dermatology-oncology service, and even fewer have access to a paediatric psychodermatology (4.8%). Engagement in psychodermatology research was reported by around 12% of the participants. CONCLUSIONS: The psychocutaneous services in the UK have improved to some extent over the past decade; the service has become more widely available nationally, and the investment in research is promising. However, it is still insufficient and unable to fulfil patient demand, especially for vulnerable individuals such as children and dermato-oncology patients.

Expert Consensus on Nail Procedures and Selection of CPT Codes.

BACKGROUND: Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE: To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS: A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS: Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS: Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION: Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Dermatologists' Perspectives on Defining Moderate Psoriasis: The Canadian Moderate Psoriasis Survey.

BACKGROUND: Psoriasis is commonly classified as either mild or moderate to severe, without specific parameters to differentiate moderate versus severe disease. This may lead to patients with moderate psoriasis being underrecognized and undertreated. OBJECTIVE: An online survey was conducted to assess Canadian dermatologists’ perspectives on the definition and treatment of psoriasis. METHOD: Dermatologists included in the survey were regional and national leaders with expertise in psoriasis. Questions were developed based on feedback from a steering committee of Canadian dermatologists. RESULTS: Of 88 dermatologists contacted, 69 responded; 42.0% were in practice for >20 years. Most dermatologists reported using the percentage of psoriasis-affected body surface area (BSA) to describe disease severity (90.8% for moderate and 87.5% for severe psoriasis). The lower and upper median cutoffs for moderate psoriasis were reported as 5.0% and 10.0% for BSA and 7.0 and 11.5 for the Dermatology Life Quality Index. Most dermatologists also consider psoriasis location (eg, palms, scalp, genital area, face) as an important indicator of disease severity. The majority of Canadian dermatologists (87.5%) identified access to treatment as one of the biggest challenges for patients with moderate psoriasis. Most dermatologists estimated that ≤40% of their patients with moderate plaque psoriasis were being treated with traditional oral systemics, targeted oral systemics, or biologics. CONCLUSIONS: This is the first survey of Canadian dermatologists on moderate psoriasis. Efforts are needed to implement a clinically useful definition of moderate plaque psoriasis to improve patient care and to raise awareness of the definition among regulatory agencies and reimbursement authorities. J Drugs Dermatol. 2021;20(2):126-132. doi:10.36849/JDD.5531.

Inpatient teledermatology: Current state and practice gaps.

BACKGROUND: Inpatient dermatology care can be challenging for dermatologists. Currently teledermatology is widely used in the outpatient setting but is not common in the inpatient setting, although it has the potential to reduce wait times and improve access to care. OBJECTIVE: To review the available literature on inpatient teledermatology, assess how teledermatology is currently being used in the inpatient setting, and recommend best practice use of inpatient teledermatology. METHODS: A literature review was performed and dermatology attending physicians were surveyed at the Society for Dermatology Hospitalists annual meeting about their current use of inpatient teledermatology. RESULTS: The majority of attending physicians (80.8%, n = 21/26) responded that their institution uses some form of teledermatology. Approximately half of those using teledermatology used it for both inpatient and outpatient consultations (55%, n = 11/20). For institutions with inpatient teledermatology, attending physicians used teledermatology to remotely staff inpatient consultations (81.8%, n = 9/11), triage consultations (63.6%, n = 7/11), and answer curbside questions from primary teams (18.2%, n = 2/11). LIMITATIONS: The limitations of this study include a limited sample size from a single meeting. CONCLUSION: Inpatient teledermatology is currently under-utilized has the potential to increase access to dermatology care and may be best used for triaging and remote staffing. Additionally, standardization of platforms and reimbursement would allow for increased use of inpatient teledermatology.

The growth of teledermatology: Expanding to reach the underserved.

The regulation of telemedicine in the United States is evolving, with new legislation expanding reimbursement and cross-state licensing capabilities. As telemedicine grows, communities with limited access to traditional dermatologic care may find a solution in teledermatology. A search of the medical literature and online health care law resources published within the past decade was performed to assess the current status of telemedicine availability, health record integration and security, reimbursement policy, and licensure requirements in the United States, with a focus on teledermatology. The majority of states have implemented policies requiring private insurance coverage. Medicaid reimburses some form of telemedicine in all states but restricts which modalities can be used and by which specialties. Medicare places the heaviest limitations on telemedicine coverage. Twenty-four states and Guam are members of the Interstate Medical Licensure Compact (IMLC), and 27 states offer alternative cross-state practice options. With the advent of publicly and privately funded programs, volunteer efforts, and mobile applications, teledermatology is more readily available to rural and underserved communities.

Evaluating the effect of prior authorizations in patients with complex dermatologic conditions.

BACKGROUND: In dermatology, prior authorizations can delay treatment, decrease patient adherence, and deter providers from advocating for their patients. Patients with complex dermatologic conditions, often requiring off-label treatments, may face particularly significant insurance barriers. OBJECTIVE: Evaluate the effect of prior authorizations in patients with complex dermatologic conditions. METHODS: This prospective cohort study assessed patients treated by a dermatologist during 5 months who specialized in complex dermatology. Patients included were older than 18 years, treated at V.P.W.'s rheumatology-dermatology clinic, and prescribed a medication or ordered a diagnostic procedure that elicited an insurance prior authorization. Data on prior authorization outcome, administrative time, and delay to treatment were collected. RESULTS: Of 51 prior authorizations, 51% were initially denied, with systemic medications more likely denied than topical ones (P < .001). Total administrative time spent on 50 prior authorizations tracked was 62.5 hours (median time per prior authorization 30 minutes [interquartile range 17-105 minutes]). Time to access treatment was tracked for 80% of prior authorizations; median delay was 12 days [interquartile range 5.5-23 days]. LIMITATIONS: Single-center, single-provider patient panel. CONCLUSION: Patients with complex dermatologic conditions face a significant barrier to care because of prior authorizations. The administrative burden for provider practices to address these prior authorizations is substantial and may warrant a streamlined system in collaboration with insurers.

Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.

Virtual Clinical Trials: Perspectives in Dermatology.

BACKGROUND: The cost of developing a new drug is approximately USD 2.6 billion, and over two-thirds of the total cost is embedded in the clinical-testing phase. Patient recruitment is the single biggest cause of clinical trial delays, and these delays can result in up to USD 8 million per day in lost revenue for pharmaceutical companies. Further, clinical trials struggle to keep participants engaged in the study and as many as 40% drop out. To overcome these challenges pharmaceutical companies and research institutions (e.g., universities) increasingly use an emerging concept: virtual clinical trials (VCT) based on a remote approach. SUMMARY: VCT (site-less) are a relatively new method of conducting a clinical trial, taking full advantage of technology (apps, monitoring devices, etc.) and inclusion of web platforms (recruitment, informed consent, counselling, measurement of endpoints, and any adverse reactions) to allow the patient to be home-based at every stage of the clinical trial. Studies have shown that VCT are not only operationally feasible, but also successful. They have higher recruitment rates, better compliance, lower drop-out rates, and are conducted faster than traditional clinical trials. The visual nature of dermatological conditions, the relative ease in evaluating skin diseases virtually, and the fact that skin diseases often are not life-threatening and rarely require complex examinations make VCT very attractive for dermatological research. Further, making correct diagnoses based on photographs and patient symptomatology has always been part of the dermatologist's routine. Thus, VCT are in many ways made for dermatology. Herein we describe VCT and their implications in dermatological research.

Live interactive teledermatology compared to in-person care - a systematic review.

Teledermatology is a rapidly developing field of dermatological care, giving the opportunity to deliver more efficient healthcare to patients in remote areas. Live interactive (LI) teledermatology uses videoconferencing and, hence, allows for direct communication. A current overview on effectiveness, costs, feasibility and accuracy of LI applications compared to standard care is missing. The present systematic review provides this overview on LI teledermatology. Two databases were searched until April 2019, followed by title, abstract and full-text screening. Additionally, reference lists of the detected eligible articles were screened for further eligible studies. Studies comparing LI applications with standard care were included. Data on study design, sample size, country, objectives, main findings and characteristics of LI applications were extracted. Results on time effectiveness, costs, accuracy and feasibility of LI applications were synthesized. Additionally, the quality of included studies was assessed. Twenty-three publications were included in the final analysis: seventeen case-control studies and six randomized controlled trials. Included studies were published between 1997 and 2017. Study quality differed across studies. The studies were carried out in eight different countries. Eleven studies focused on patient consultation, three on patient organization and nine on combined applications of the aforementioned. Nine studies investigated applications facilitating patient-provider interaction. Fourteen studies evaluated applications combining patient-provider and provider-provider interaction, meaning the patient sits next to one provider while using LI applications to interact with another provider. This review reveals that LI applications can be a time effective substitute of or supplement to standard dermatological care. Results demonstrated that LI and standard care are comparable with regard to feasibility and accuracy. No clear tendencies can be reported with regard to costs. However, there is a lack of current comparative studies.

Teledermatology: Improving Access or Widening Healthcare Disparities?

Teledermatology, the form of telemedicine directed toward dermatology patients, is one of the earliest technological innovations that advanced remote medical care. Developed in 1995, teledermatology was established with the mission of increasing healthcare access among patients in rural geographic locations who had limited access to specialist care.1.

Understanding economic evidence for the prevention and treatment of atopic eczema.

BACKGROUND: Atopic eczema is an inflammatory skin condition, with a similar impact on health-related quality of life as other chronic diseases. Increasing pressures on resources within the National Health Service increase the importance of having good economic evidence to inform their allocation. OBJECTIVES: To educate dermatologists about economic methods with reference to currently available economic evidence on eczema. METHODS: The role of different types of economic evidence is illustrated by evidence found in a systematic literature search conducted across 12 online databases up to 22 May 2017. Primary empirical studies either reporting the results of a cost-of-illness study or evaluating the cost, utility or full economic evaluation of interventions for preventing or treating eczema were included. Two reviewers independently assessed studies for eligibility and performed data abstraction, with disagreements resolved by a third reviewer. Evidence tables of results were produced for narrative discussion. The reporting quality of economic evaluations was assessed. RESULTS: Seventy-eight studies (described in 80 papers) were deemed eligible. Thirty-three (42%) were judged to be economic evaluations, 12 (15%) cost analyses, six (8%) utility analyses, 26 (33%) cost-of-illness studies and one a feasibility study (1%). The calcineurin inhibitors tacrolimus and pimecrolimus, as well as barrier creams, had the most economic evidence available. Partially hydrolysed infant formula was the most commonly evaluated prevention. CONCLUSIONS: The current level of economic evidence for interventions aimed at preventing and treating eczema is limited compared with that available for clinical outcomes, suggesting that greater collaboration between clinicians and economists might be beneficial.

Augmented reality in dermatology: Are we ready for AR?

Augmented reality (AR) refers to a group of technologies that capture, analyze, and superimpose digital information onto the real world. This information gives health care providers unique and useful perspectives that can enhance patient care. AR has been utilized in selected scenarios in health care for several decades, notably laparoscopic surgery and vein finding. In recent years, improved wireless technologies, computing power, and analytics are leading to rapid growth in the AR industry. Novel health care-specific use cases are rapidly being introduced with the potential to widely affect clinical care, particularly in dermatology because of the visual nature of the field. In this article, we define AR, profile clinical and educational uses of AR in dermatology, and discuss key policy considerations for the safe and appropriate use of this emerging technology.

Cost analysis of a store-and-forward teledermatology consult system in Philadelphia.

BACKGROUND: Store-and-forward (SAF) teledermatology (TD) has the potential to increase access to timely, high-quality care for underserved populations. However, the cost-effectiveness of TD for underserved populations is uncertain. OBJECTIVE: This study evaluates the potential cost savings associated with an SAF TD program implemented for an underserved population in the city health clinics of urban Philadelphia. METHODS: We performed a retrospective analysis of SAF TD consultations for 700 outpatients managed in 12 Philadelphia primary care clinics. Primary care providers were asked to specify a treatment plan, as well as the type of care for the patient, in the absence of the TD service. Analysis compared the cost of each patient case with use of the TD consult model versus with conventional care. RESULTS: In all, 27% of in-person dermatology clinic visits (189 of 700) and 3.29% of emergency room visits (23 of 700) were avoided by using TD. Compared with conventional care, TD had a mean expected cost savings of $10.00 to $52.65 per TD consult. In sensitivity analyses, these estimated savings remained positive across a range of parameters. LIMITATIONS: The cost analysis relies on several assumptions regarding the cost of care, and indirect costs were not included. CONCLUSION: TD can be a cost-saving model while increasing access to dermatologic care.

The national burden of inpatient dermatology in adults.

BACKGROUND: Management of inpatient skin disease represents a unique subspecialty within dermatology. OBJECTIVE: To assess the national burden of inpatient dermatology in adults. METHODS: Using the 2014 National Inpatient Sample, we performed a retrospective cohort study of adults hospitalized for dermatologic conditions. RESULTS: In 2014, there were 644,320 weighted hospitalizations principally for skin disease in adults, which cost the health care system $5.04 billion. Overall, skin disease was diagnosed in 1 in 8 hospitalized adults. Dermatologic hospitalizations were associated with a lack of medical insurance (odds ratio [OR], 2.27; 95% confidence interval [CI], 2.20-2.34), residence in a low-income community (OR, 1.10; 95% CI, 1.07-1.13), and small (OR, 1.27; 95% CI, 1.23-1.32) or rural hospitals (OR, 1.38; 95% CI, 1.32-1.44). Racial minorities were less likely to be hospitalized for skin disease than were whites (for blacks: OR, 0.77; 95% CI, 0.75-0.79; for Hispanics: OR, 0.85; 95% CI, 0.83-0.8; for Asians: OR, 0.59; 95% CI, 0.55-0.64). Only 0.47% of patients admitted for skin disease experienced in-hospital mortality; however, mortality rates were high in hospitalizations for cutaneous lymphomas (9.19%) and malignant melanoma (6.54%). LIMITATIONS: We could not assess the impact of inpatient dermatology consultations on hospitalization outcomes. CONCLUSIONS: Skin disease is highly prevalent among hospitalized patients.

Public Perception of Ethical Issues in Dermatology: Evidenced by New York Times Commenters.

BACKGROUND: A 2017 New York Times (NYT) article questioning the appropriateness of skin cancer treatment modality by dermatology providers stimulated discussion among the public pertaining to ethics in the current state of dermatologic practice. OBJECTIVE: The purpose of this study is to characterize issues raised by the comments on the NYT article, discuss strategies to address these concerns, and encourage reflection on ethics in dermatologic care. MATERIALS AND METHODS: A qualitative analysis was performed on the 309 comments on the NYT article. General themes were identified, resulting in the inclusion of 222 comments. These comments were reviewed and characterized by the type of commenter, his or her stance on health care, and what issues they raised. RESULTS: Providers interested in "profit over patient" was the most common theme, followed by mistrust of APPs, health care system interested in "profit over patient," inadequate supervision by advanced practice providers (APPs), finding the "right" provider, support for coordinated APP and physician care, support for APP credentials, and finally inappropriate elderly care. CONCLUSION: The NYT article raises the concern of identifying quality care and choosing the "right provider"-one who successfully balances the various incentives affecting skin cancer management including appropriate usage of APPs.