Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities.

Key PointsQuestionWhat barriers do American Indian people in rural areas face in accessing dermatological care, and is telehealth compensating for these barriers? FindingsIn this mixed-methods study of 27 dermatology clinics and 49 teledermatological programs, the mean distance between the closest dermatology clinic and a rural Indian Health Service or tribal hospital was 68 miles, 22% of the clinics did not accept any form of Medicaid coverage, and 22% did not accept Indian Health Service referrals for patients without insurance. Of the 303 rural Indian Health Service or tribal facilities in the continental United States, 9% were served by a teledermatological program. MeaningSubstantial geographic barriers to dermatological services exist for patients of American Indian race/ethnicity living in rural communities and this problem appears to be compounded by inconsistent access for those with Medicaid or without private insurance; teledermatological programs may help minimize the disparities in dermatological care access and outcomes. ImportanceUnderstanding geographic and financial barriers to health care is an important step toward creating more accessible health care systems. Yet, the barriers to dermatological care access for American Indian populations in rural areas have not been studied extensively. ObjectiveTo evaluate the driving distances and insurance coverage for dermatological care and the current availability of teledermatological programs within the Indian Health Service (IHS) or tribal hospitals system. Design, Setting, and ParticipantsThis mixed-methods study was conducted from May 7, 2018, to September 1, 2018, and did not take place in any IHS or tribal health care facility in the continental United States. The study design involved a geographic analysis and a cross-sectional telephone survey with brick-and-mortar dermatology clinics (n=27) and teledermatological programs (n=49). Brick-and-mortar clinics were selected for their proximity to a rural IHS or tribal hospital. Main Outcomes and MeasuresMean driving distance from rural IHS or tribal hospital to nearest dermatology clinic, number of dermatology clinics within a 35-mile or 90-mile radius of IHS or tribal hospitals, insurance and referral types accepted by dermatology clinics, and number of teledermatological programs collaborating with IHS or tribal hospitals or health centers. ResultsIn total, 27 brick-and-mortar dermatology clinics and 49 teledermatological programs were identified and contacted for the survey. The median (interquartile range [IQR]) driving distance between rural IHS or tribal hospitals and the nearest dermatology clinic was 68 (30-104) miles. Of the 27 dermatology clinics in closest proximity to rural IHS or tribal hospitals (median [IQR] driving distance, 82.4 [31-114] miles), 25 (93%) responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance. Of the 49 teledermatological programs, 45 (92%) responded and 14 (29%) were no longer active. Ten (20%) teledermatology programs were currently partnering (n=6), previously partnered (n=2), or were setting up services (n=2) with an IHS or tribal site. Only 9% (n=27) of the 303 rural IHS or facility in the continental United States reported receiving teledermatological services. Conclusions and RelevanceSubstantial geographic and insurance coverage barriers to dermatological care exist for American Indian individuals in rural communities; teledermatological innovations could represent an important step toward minimizing the disparities in dermatological care access and outcomes. This study describes the scarcity of dermatological services and practitioners as well as community infrastructures or resources for American Indian people who live in isolated areas in the United States.