‘Medicine is in crisis’: Future of dermatology relies on telehealth
Key takeaways:
- Private practices face current and looming challenges of limited reimbursements, physician shortages and administrative burdens.
- Telehealth may alleviate these pain points.
It has been 5 years since the start of the COVID-19 pandemic, which forced many providers to embrace telehealth.
In the fall of 2019, Rachel Day, MD, FAAD, chief medical officer of Zest Health and founder of OneSkin Integrative Dermatology, decided to open her own brick-and-mortar clinic after building a dermatology practice within a small community hospital. Little did she know that the world would go into lockdown a few months later and that the experience would lead her to the career she has today.
“In March 2020, I first recognized telemedicine as a potential career path. I saw how it could address many of the challenges medicine faces today — improving access, reducing barriers to care and enhancing efficiency,” Day told Healio. “While I truly loved my private practice, I felt limited in my ability to drive meaningful, system-wide change. That desire to shape broader impact is what led me to join a health tech startup”
That health tech startup, Zest Health, is the first value-based virtual care company focused on treating patients with inflammatory skin diseases, according to Day, specifically eczema and psoriasis. While the COVID pandemic may have prompted Day’s shift toward telehealth, it is not the sole reason why she, and other providers, have maintained this new medium of health care.
The decline of brick-and-mortar private practices
According to Day, telehealth has become a driver of additional or alternative revenue for private practices and dermatologists who continue to face “many challenges,” with one of the biggest being a “consistent reduction in reimbursement under the fee-for-service model,” she said.
On Nov. 1, 2024, the CMS finalized cuts to the 2025 Medicare Physician Fee Schedule for the fifth year in a row — a move Seemal R. Desai, MD, FAAD, president of the American Academy of Dermatology, labeled as “catastrophic.”
According to a press release from the AAD, the cuts are “further hindering patient access to care as practice expenses increase and payments decrease.”
In a statement to the House Ways and Means Committee in May 2024, the AMA also told Congress to take “immediate and decisive actions” to the burdens driving physicians away from private practice.
“The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations and systemic inequalities,” the association wrote in its statement.
According to one of the association’s surveys, private practices have been on the decline for years, with 46.7% of physicians working in a private practice in 2022 — a decrease of 13 percentage points from 2012.
“Medicine is in crisis,” Day said, “it's like trying to put on an oxygen mask while the building is already on fire.”
According to Day, the only “lever that most practices have to pull” to compensate for the decreasing reimbursements is to increase volume, but this too has proven to be a struggle.
“Many dermatology providers in nonacademic settings are just seeing a lot of patients, over 40 patients a day,” she said. “So, there is a huge cognitive load and burnout to the shifts that are happening around the dermatology community in brick-and-mortar practice. It’s one of the reasons we have focused on creating better aligned payment models with our partners at Zest Health”
A 2024 survey by The Physicians Foundation found that six in 10 physicians reported often feeling burnout — an increase from four in 10 in 2018. Dermatologists are no exception, with over 50% reporting burnout in a 2014 Mayo Clinic survey.
“Breathing room has largely been removed from practice,” Day said. “But teledermatology brings some diversity of options where it can feel like maybe there aren’t great options right now.”
Types of teledermatology
There are many ways dermatologists can engage with telehealth.
According to Day, dermatologists can work for a separate telehealth platform while keeping their private practice on the side with relative ease. Dermatologists can pick up telehealth hours as a 1099 contractor with the only administration burden being paying for and maintaining a license to practice.
Anna Chacon, MD, FAAD, a dermatologist that offers both in-person and telehealth appointments at her private practice as well as sub-contracts for telehealth platforms and major medical centers that need teledermatology assistance, explained that a career in teledermatology for her includes “conducting virtual consultations, reviewing patient-provided images, diagnosing conditions and prescribing treatments — all through a secure platform,” she told Healio.
“My day typically starts with logging into the telehealth system, reviewing the list of patients and preparing for consultations,” Chacon explained. “I interact with patients via video calls or ... messaging, depending on the video platform.”
For dermatologists who would like to offer telehealth appointments as part of their own private practice, there are platforms that provide solutions. An example of one such platform is Miiskin.
According to the company website, Miiskin is a HIPPA-compliant platform that facilitates asynchronous, also known as store-and-forward or photo-based virtual care and administration. Miiskin and similar platforms offer dermatologists the ability to provide care to their own existing patient base as well as service patients acquired through the platform.
Jon Friis, MSc, founder and CEO of Miiskin, believes that this asynchronous, virtual approach to care holds the most “promise” for the future of teledermatology.
“During COVID, telehealth started with video consultations,” Friis told Healio. “But I think what people are realizing is that video consultations for dermatologists are less effective.”
According to Friis, the synchronous nature of video calls is a pain point for both patients and providers as it means both parties must be present during the appointment simultaneously. Additionally, the quality of videos may be inadequate to effectively examine skin issues, and the documentation of the appointments may prove difficult through video, Friis explained. But with asynchronous telehealth, patients can submit photos of their skin diseases to dermatologists for diagnostic and treatment guidance at any time.
However, when the end goal is patient connection, Day says that video consultations are a great care option, especially as private practices struggle to meet high-volume demands.
“We are not trying to recreate the environment of care that we think needs to be improved,” Day said about Zest Health. “I don’t think it’s good for a dermatologist or provider to have 3 or 4 minutes with their patient, so we have intentionally chosen to have longer appointment times, unlimited access and value-based payment models.”
According to Day, these longer appointment times, although over video, bring “so much value” to building a relationship with patients.
“I was personally surprised at how much connection you can build with someone that you’ve never met in person,” she said. “The therapeutic relationship can be so strong even, in many cases, as strong as in-person care delivery.”
Benefits
In addition to patient connection, there are many benefits to utilizing both synchronous and asynchronous teledermatology. For starters, patients are “overwhelmingly” satisfied with telehealth offerings, according to Chacon.
“Patients appreciate the convenience of telehealth, especially for follow-ups or conditions that don’t require in-person care,” Chacon said. “Many patients have expressed gratitude for being able to consult a dermatologist without needing to take time off work or travel long distances.”
According to the J.D. Power 2022 U.S. Telehealth Satisfaction study, 94% of patients that previously used telehealth stated they would use it again. In fact, most patients reported preferring telehealth over in-person care for prescription refills (80%), reviewing medication options (72%) and discussing test results (71%).
According to the survey, the key drivers for using telehealth among these patients were convenience (61%), rapid care (49%) and ease of access to health information (28%).
“The convenience of being able to access expert dermatology care from the comfort of your home without taking any time off from work is better than traveling and waiting in line,” Friis added, “especially in the U.S. where the wait can be anything from 4 to 6 months for dermatology care.”
According to the 2022 Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates, the average wait time for a dermatology appointment is 34.5 days — a 7% increase since 2017. In contrast, patients utilizing teledermatology can receive results much sooner.
“Looking at the data, I think it’s 98% of patients receive an answer within 48 hours,” Friis said about teledermatology. “It is fast and efficient, and I think that is what is attracting patients and consumers to go this way.”
According to Friis, involving patient documentation in an asynchronous digital space not only benefits patients, but also providers.
“Patients could offload the providers and staff burdens by documenting everything at home by themselves before engaging with the health care system,” he said.
According to Chacon, this system could also promote a better work-life balance among dermatologists.
“Flexibility is a significant advantage, as I can create a schedule that works best for me while reaching patients nationwide,” she said. “This has allowed me to balance my professional and personal life better.”
But perhaps the greatest benefit of teledermatology, according to Day and Chacon, is the ability to help those who historically face health care barriers.
A 2023 study in SKIN The Journal of Cutaneous Medicine showed that only 1.6% of dermatologists practice across the 100 most rural areas of America — a decrease from the 1.8% in 2016, indicating that “initiatives aimed at redistribution of dermatologists have not made a major difference,” the authors wrote. This type of situation is what the medical community terms the “rural mortality penalty,” where residents in these areas experience escalating morbidity and mortality.
“That is what brought my husband and me to this area,” Day said, referencing her small-town residence. “At the time I was the only dermatologist in the community after there hadn’t been one for 6 years.”
After utilizing telehealth, Day said she realized how much it reduces barriers for accessing expert care.
“You can really impact so many people that live in remote or resource-poor areas,” she said. “Like the community that I’m in.”
Prior to the COVID pandemic, a study in the Journal of Rural Health found that rural Medicaid beneficiaries were more likely to use telehealth services than their urban counterparts. Further, in a survey-based study in Health Psychology Research, 88% of residents in rural areas reported they were open to using telehealth.
“Many rural areas lack specialists, and telehealth bridges that gap by bringing care directly to the patient,” Chacon said. “Teledermatology eliminates geographical barriers, making it possible for patients in remote or underserved areas to access dermatologic care.
The future of teledermatology
In addition to the reduction in reimbursements, the health care system is set to face another challenge — a physician shortage.
According to the Association of American Medical Colleges, the U.S. will face a physician shortage of up to 86,000 physicians by 2036.
“Digital technologies will need to bridge this gap,” Friis urged. “Doctors will need to be performing extremely efficiently and that is what I believe digitalization can help them do.”
Friis said the future of dermatology embraces a hybrid model that incorporates teledermatology for triage and follow-up purposes and in-person visits for physical examinations, biopsies and procedures.
“In the future, starting digital should be an improvement for both the patient and the providers, knowing that for some issues, you need to have a physical consultation, but you have already completed the clinical pathway and the triaging of the patients with a digital, well documented workflow, instead of going down to a physician consultation,” Friis said. “Doctors supported by technology can be very efficient if they have access to all the patient information before they spend any time with the patient. I think that would be a really big win and enable efficient digital workflow initiated by the patient at home.”
However, the question remains if telehealth will even be an option for many patients.
On March 15, Congress voted to pass a federal government spending bill that included extensions for telehealth Medicare provisions. Previously set to expire March 31, Medicare’s coverage of telehealth flexibilities will now last through Sept. 30, 2025.
Kyle Zebley, BA, senior vice president of public policy at the American Telemedicine Association and executive director of the association’s ATA Action affiliated advocacy organization, told Healio he is “happy to see” the deadline extended.
“It’s not as long an extension as we’d like,” he said, “but it’s far better than allowing these flexibilities to lapse at the end of March.”
While certain provisions including the Acute Hospital Care at Home Program were included in the spending bill, many items were not, including the first-dollar coverage for High Deductible Health Plan-Health Savings Accounts — an action Zebley states is disappointing.
However, Zebley expressed hope for the future of telehealth as he stated the country is currently in “a rarefied place of bipartisan agreement on a major area of health care.”
“Telehealth is a way to deliver health care to every American where appropriate in the country, regardless of where they might reside,” Zebley said. “Favorable public policies that have been put in place since the pandemic have ensured that in some way, shape or form, virtually every American can have access to clinically appropriate care where and when they need it.”
Resources
There are many ways dermatologists can get involved with telehealth if they decide it is a path they would like to take, according to Chacon and Day.
“My advice is to start by researching telehealth platforms to find one that fits your needs and integrates seamlessly with your workflow,” Chacon said. “Familiarize yourself with state licensing requirements as well, as teledermatology often involves practicing across multiple states.”
Both Day and Chacon recommend practitioners take advantage of the resources provided by the AAD and American Telemedicine Association, which offer guidance on getting started.
Most importantly, Day urges dermatologists to take a moment of reflection and identify their “personal motivator.”
“What is your purpose?” she asked, “How does engaging in telehealth align with that purpose or advance your career goals? Understanding your aspirations and then connecting with others who are doing what you envision is a powerful first step.”
For dermatologists interested in trying teledermatology, the AAD has a philanthropic teledermatology program that accepts clinician volunteers.
“Give it a try and see how it feels for you,” Day encouraged. “Stay curious and connect with others to explore careers in teledermatology. Dermatologists are a welcoming community, and many are eager to support and guide those interested in this path.”
For more information:
Anna Chacon, MD, FAAD, can be reached at support@drannachacon.com.
Jon Friis, MSc, can be reached at jon@miiskin.com.
Kyle Zebley, BA, can be reached at info@ataaction.org.
Rachel Day, MD, can be reached at rachel.d@joinzest.com.
References:
- 2022 survey of physician appointment wait times and Medicare and Medicaid acceptance rates. https://www.wsha.org/wp-content/uploads/mha2022waittimesurveyfinal.pdf. Accessed March 5, 2025.
- 2024 survey of America’s current and future physicians. https://physiciansfoundation.org/wp-content/uploads/2024-Survey-of-Americas-Current-and-Future-Physicians.pdf. Accessed March 5, 2025.
- AAD’s Teledermatology Program. https://www.aad.org/member/career/volunteer/teledermatology. Accessed Mar. 5, 2025.
- American Academy of Dermatology Association statement on final 2025 Medicare physician fee schedule. https://www.aad.org/news/president-statement-final-2025-medicare-physician-fee-schedule. Published Nov. 1, 2024. Accessed March 5, 2025.
- Brumbaugh B, et al. Dermatol Online J. 2024;doi:10.5070/D330564425.
- Kolluri S, et al. Health Psychol Res. 2022;doi:10.52965/001c.37445.
- Miiskin pricing for healthcare providers. https://miiskin.com/pro/plans-pricing/. Accessed March 5, 2025.
- Nguyen CN, et al. SKIN The Journal of Cutaneous Medicine. 2023;doi:10.25251/skin.7.3.9.
- No shutdown for telehealth as congress passes spending bill to keep the government open, including critical telehealth extensions, ATA Action celebrates vote. https://www.americantelemed.org/press-releases/no-shutdown-for-telehealth-as-congress-passes-spending-bill-to-keep-the-government-open-including-critical-telehealth-extensions-ata-action-celebrates-vote/. Published March 15, 2025. Accessed March 17, 2025.
- Recent changes in physician practice arrangements: Shifts away from private practice and towards larger practice size continue through 2022. https://www.ama-assn.org/system/files/2022-prp-practice-arrangement.pdf. Accessed March 5, 2025.
- Shanafelt TD, et al. Mayo Clin Proc. 2015;doi:10.1016/j.mayocp.2015.08.023.
- Statement for the record of the American Medical Association to the Committee on Ways and Means. https://searchlf.ama-assn.org/letter/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2Flfste.zip%2F2024-5-23-Statement-for-the-Record-The-Collapse-of-Private-Practice-Examining-the-Challenges-Facing-Independent-Medicine.pdf. Published May 23, 2024. Accessed March 5, 2025.
- Talbot JA, et al. J Rural Health. 2019;doi:10.1111/jrh.12324.
- Telehealth. https://www.medicare.gov/coverage/telehealth. Accessed March 5, 2025.
- Telehealth emerges as preferred channel for routine care while increasing access to mental health treatment, J.D. Power finds. https://www.jdpower.com/business/press-releases/2022-us-telehealth-satisfaction-study. Published Sept. 29, 2022. Accessed March 5, 2025.
- The complexities of physician supply and demand: Projections from 2021 to 2036. https://www.aamc.org/media/75236/download. Published March 2024. Accessed March 5, 2025.