The COVID-19 crisis: A unique opportunity to expand dermatology to underserved populations.

To the Editor: Lee et al recently discussed the 1135 Waiver issued by the Centers for Medicare and Medicaid Services in March, which eliminates many barriers that have prevented widespread teledermatology adoption: reimbursement coverage, out-of-state licensing restrictions, and virtual platform compliance with the Health Insurance Portability and Accountability Act. Dermatologists can now provide teledermatology to Medicare patients, in-or out-of-state, and receive full compensation for their services. Medicaid and private insurers have similarly increased coverage of telehealth visits.

We would like to highlight implications of the authors' commentary on a less discussed but important topic: telehealth expansion during this outbreak presents a unique opportunity to increase access to dermatologic care for underserved populations. Skin cancer mortality and certain disease morbidities are higher among ethnic minorities, the uninsured, and those with lower incomes and less education. These health disparities are partially due to dermatologist maldistribution: 88% of rural counties do not have a single dermatologist, and minority communities—African American, Latin American, and Native American—often have markedly fewer dermatologists. Additionally, 77% of primary care providers for urban, low-income communities report their patients have difficulty obtaining dermatology appointments, and while only 9% of surveyed primary care providers have used teledermatology, 88% were interested in the tool. Underserved populations are particularly vulnerable during this outbreak because many free and student-run safety-net clinics have closed.

It is time to devise strategies to expand care to new, heretofore under-represented populations. Potential efforts include marshaling providers in community health centers to refer their patients to teledermatology services, advertising teledermatology to community organizations serving under-represented populations to publicize services to their members, and outreach through multiple channels, including websites and social media, ideally in multiple languages.

As we expand telehealth to under-represented communities, we will face several challenges. A primary barrier is infrastructural: some patients may lack appropriate technology or broadband services to access the virtual platforms needed for live, synchronous teledermatology. Asking patients to send photographs in advance of telephone consultations—yielding a form of asynchronous teledermatology—may mitigate this barrier; currently, some telephone evaluations can be billed to Centers for Medicare and Medicaid Services as virtual visits.

Another challenge is that some—particularly elderly—patients may find telehealth platforms difficult to navigate. Providing patients with step-by-step instructions for remote visits and phone numbers for technical assistance can mitigate this obstacle. The 1135 Waiver also allows the use of Health Insurance Portability and Accountability Act-noncompliant technologies, such as FaceTime and Skype, with which patients may have baseline familiarity.

A third obstacle is the onboarding of new patients. With the Centers for Medicare and Medicaid Services' waiver of a required initial face-to-face meeting before receiving telehealth care, dermatologists must work to establish efficient onboarding procedures for new patients and work with our colleagues in other disciplines to enhance access for specialty care for the underserved.

We thank Lee et al for highlighting the policy changes accelerating use of telehealth. The dermatology community now has a unique opportunity to close a gap in health care disparities. Let us turn this pandemic into a catalyst for expanding access to dermatologic care for the most vulnerable members of our society.