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Telemedicine Success Often Hinges on Aligning Providers and Payers

A Massachusetts telemedicine program used collaboration and creativity to get off the ground — and likely saved lives.

Source: ThinkStock

By Eric Wicklund

- Sometimes a telemedicine service can offer too much value to let a little thing like reimbursement stand in the way.

For a group of seven community health centers in Massachusetts, that service is teledermatology. Faced with an average wait time of four months to see a dermatologist, these CHCs, serving about 100,000 Bay State residents, had to find a way to improve access. And they had to do it without Medicare assistance, and in state that doesn’t reimburse through Medicaid for remote image reads.

So they negotiated their own reimbursement with four health plans.

“This was a critical service,” says Carla Bettano, a healthcare consultant who helped launched the teledermatology program in 2016. “It was all about access, and we knew that access could mean the difference” between life and death.

Bettano and the health centers first secured a two-year Partnership for Community Health grant to create a teledermatology service at 22 remote sites. They also joined forces with 3Derm, a Boston-based telemedicine company spun out of Yale University in 2013, to provide the store-and-forward technology to enable remote clinics to send dermatology images to a separate site for reading and evaluation.

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Bettano then connected with four health maintenance organizations (HMOs). They were willing to cover the service during its pilot phase, agreeing rather quickly on a reimbursement rate for the dermatologists (3Derm charges on a per-read basis).

“They were receptive,” she said, adding that it became easier once the first health plan joined up. “Everybody’s looking for alternative means of delivering care, especially better way to deal with access issues.”

The telemedicine system designed by 3Derm uses a handheld scanner to capture three different views of the lesion in the doctor’s office – an overview, a 2D and 3D image and a polarized and magnified dermatoscope image – then uploads those images and necessary patient information to a cloud server for review by a specialist. The specialist can then determine whether the patient needs follow-up care, and notify both patient and primary care provider within 48 hours.

Typically, a PCP or clinic doctor will take a look at a lesion and refer the patient to a dermatologist if there is any visual cause for concern, a process that takes, on average, 29 days but could take months. Of the 14 million “new issue” dermatology appointments scheduled each year, studies estimate that only 20 percent actually require an in-person visit with a specialist and less than 1 percent result in a positive melanoma diagnosis.

Following a three-month training period, two health centers went live with the telederm platform last November. It didn’t take long to make an impact.

READ MORE: In the Northeast, Telehealth Gets Creative - With Good Results

“Immediately from the time we launched this project, we were saving lives,” said Bettano, who presented the program during a telehealth workshop at last week’s Xtelligent Media Value-Based Care Summit in Boston.

According to Bettano, one of the first patients to be seen presented with a severe rash that looked to all the world like excema – and would likely have been diagnosed as such had she been examined at a busy health center. A teledermatology read, however, confirmed within days that she had T-Cell Lymphoma, the most common form of blood cancer, and she was able to begin treatment immedicately.

In the year that the program has been live, Bettano says more than 112 cases have been expedited, with roughly 60 percent referred back to the primary care physician without need for a dermatologist visit. She estimates the service has saved 30 percent in a health systems annual dermatology costs by cutting out unnecessary specialist consults.

“What we’re also seeing is the primary care [providers] becoming more efficient and effective,” she added, noting they aren’t reimbursed for the telederm service.

Those types of outcomes are making teledermatology popular to both PCPs and specialists.

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“It’s a much more efficient to take these images and have a dermatologist interpret them than it is to schedule an office visit,” says Tom Scornavacca, MD, a family practice physician and Senior Medical Director of UMass Memorial Health's Office of Clinical Integration and Population Health program in Worcester, Mass. “Until now, there hasn’t been a good way to filter out who they see and who they don’t.”

Scornavacca and Mary Maloney, MD, chair of the University of Massachusetts Medical School’s Dermatology Department, presented the results of their study of the 3Derm platform at the 2016 American Telemedicine Association conference in Minneapolis, shortly before the service was rolled out to Bettano’s health centers. According to the study, the teledermatology platform identified cases of skin cancer with the same rate of success as an in-person visit, while reducing the number of cases referred from a PCP or clinic to a specialist by some 57 percent.

“This platform is designed to replicate what a dermatologist would see in person,” says Liz Asai, 3Derm’s CEO. “What we’re trying to do is give (PCPs and other front-line doctors) the technology they need to help make that diagnosis. You can’t do that with an iPhone.”

With the two-year window afforded by the grant coming to a close, Bettano and the health centers are now waiting to see whether the program can continue.

They’re waiting for the Centers for Medicare & Medicaid Services to loosen Medicare telemedicine restrictions, or for Massachusetts legislators to come to agreement on telemedicine legislation that would open Medicare’s pursestrings to these types of programs. With Medicaid-based Accountable Care Organizations scheduled to debut next year, their fingers are crossed.

With that uncertainty overhead, the best course of action is still to approach individual health plans and look for partnerships, as Bettano did.

“You have to be out there, and you have to find the right payer,” says Alexis Bortniker, senior counsel and healthcare lawyer with Foley & Lardner, who also spoke at the VBCS workshop. “You have to do your homework and be prepared to convince them.”

It’s not a new concept. Bortniker’s colleague, Nathaniel Lacktman, presented on this topic at this year’s ATA conference in Orlando, Fla.

“There’s been some deliberate efforts … to align with [payers] and embrace cooperation on coverage and reimbursement,” Lacktman, chairman of the firm’s Telemedicine Industry Team and co-chair of its Digital Health Work Group, told prior to the ATA conference. “We’re noticing movement toward that now.”

“Too many sit back on their heels and say ‘We’re not getting reimbursed,’” he added. “But by communicating with [commercial payers], they have a chance to align their visions.”


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