For health care to work for all Californians, people in every corner of the state need prompt access to the right kind of care. In rural and underserved communities, telehealth can offer just that. A recent RAND evaluation found that teledermatology company DirectDerm led to a nearly 50% increase in visits, some of them literally lifesaving. Take the case of Andrea Nielsen.
Andrea Nielsen considers herself pretty lucky that her father noticed the odd-looking mole on the back of her right arm. It was in a place she never looked. Nielsen visited the clinic near her home in Escalon, a small town surrounded by peach, walnut, and dairy farms a half-hour north of Modesto. The clinic's nurse practitioner knew the mole should be examined by a dermatologist, but that might involve a six- or nine-month wait for an appointment.
Months-long wait times to see specialists are not atypical in rural and underserved areas in California, particularly for those covered by Medi-Cal or who are uninsured. Nielsen, a 43-year-old cafeteria worker and mother of three covered by Medi-Cal, faced long and potentially dangerous delays in accessing care.
To avoid delays in care, the clinic nurse arranged for Nielsen to visit a technician in Modesto who took images of the mole using a web-based technology platform developed by Bay Area company DirectDerm. DirectDerm enables same-day and next-day virtual consultations by US board-certified dermatologists. Known as teledermatology, the process involves a digital camera, a computer, and internet service. The initial scan prompted an in-person visit with a dermatologist participating in Medi-Cal for a biopsy, and soon after that Nielsen learned she had malignant melanoma that required prompt surgery.
Through its Health Innovation Fund, the California Health Care Foundation invested in DirectDerm in 2011 to expand access to specialty care among the state's traditionally underserved populations. The technology has allowed thousands of patients from across the state to be examined by specialists from remote locations. The results thus far have been impressive.
Last month JAMA Dermatology published a study by researchers from RAND who found DirectDerm demonstrated dramatic improvements in the availability of lifesaving dermatological services for patients in the safety net. "The offering of teledermatology appeared to improve access to dermatology care among Medicaid enrollees and played an especially important role for the newly enrolled," the RAND researchers wrote.
DirectDerm provides its teledermatology services for Medicaid plans in California, Arizona, Hawaii, and New Mexico. Patients have convenient access to DirectDerm at many primary care provider clinics, select Safeway clinics, and online. RAND's evaluation shows DirectDerm's effectiveness and significant role in increasing access and the quality of dermatology services to underserved populations. DirectDerm achieves accurate results and high patient satisfaction — and for those most in need.
RAND analyzed utilization at the Health Plan of San Joaquin (HPSJ), the Medi-Cal managed care provider in San Joaquin and Stanislaus Counties, from July 2011 to December 2014. As detailed in the JAMA Dermatology article, in the 19 months following the introduction of teledermatology to the HPSJ network, RAND tallied 7,287 teledermatology visits across 4,515 patients, an average of 1.6 visits per patient. This represented 21% of all visits with dermatologists and served 49% of patients who interacted with a dermatologist. The number of dermatologist visits per 1,000 enrollees increased 46%.
The research also delved into the characteristics of telederm users versus in-person visit users. More Latinos — in general, an underserved population in California — used teledermatology services versus in-person visits, and DirectDerm generally served a healthier, younger population with potentially less severe skin conditions than in-person dermatologists. For the newly enrolled members of HPSJ, dermatological services were 75% more likely to occur via DirectDerm than at an in-person visit.
Nielsen is relieved that her skin cancer was caught early. "It was very scary when I heard the diagnosis was malignant melanoma," Nielsen said. "I don't know how long I had it, but if it took six months to see a dermatologist, that might have been the difference in going to Stage 2 and needing to have chemotherapy."
Now Nielsen faces a new complication. During a post-op scan, her oncologist found a different cancer that is not melanoma. She will require further care for that. Without her initial biopsy, though, she might never have known.