Improving Access to Care for Patients with Psoriasis and Psoriatic Arthritis: The Impact of the Temporary Reciprocity to Ensure Access to Treatment Act and Remote Care Policy Reform

Many patients with psoriatic disease continue to suffer from deficits of access to care. Specifically, patients with more severe and generalized disease lack access to dermatologists willing to prescribe adequately aggressive therapeutic options, including biologics and other systemic therapies. ¹ A study conducted by Armstrong et al in 2017 showed that only 40.9% of 1.7 million patients with moderate-to-severe psoriasis were receiving therapy. Within this 40.9%, nearly half (42%) were receiving topical therapy only. Moreover, psoriatic arthritis, one of the most common comorbidities of psoriasis, requires an evaluation by a rheumatologist. In 2015, a workforce study conducted by the American College of Rheumatology cited national shortages of rheumatologists and anticipated even greater shortages by 2030. ² Compounding this issue, Schmajuk et al described barriers patients requiring a rheumatology evaluation face, including significant travel distance burdens. ³ The debilitating nature of psoriatic joint disease can also make traveling physically difficult. Concerningly, patients may wait months for an evaluation despite the fact that delays in diagnosis of only 6 months has been shown to result in permanent joint damage, including peripheral joint erosions and deficits in long-term physical function. ⁴ Overall, remote medical care helps connect physicians to patients with severe psoriasis who require aggressive therapies and reduce the travel burden for patients with debilitating comorbidities, including psoriatic arthritis.

Brought to the forefront by the COVID-19 pandemic, concerns over state medical licensure regarding remote medical care have intensified. Prior to the onset of the pandemic, each state’s Medical Practice Act determined licensing restrictions for physicians, stating that any patient care, including telemedicine, can only occur in the state where physicians are licensed. Many of these state-level licensure-restrictions were lifted early in the pandemic, including the Medicare requirement that a clinician must be licensed within the state where the patient is located. However, state-by-state variability of emergency legislation has caused delays in care and administrative burden, ⁵ leading to proposed legislations to address the issue on a nationwide scale. New federal legislation, the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act [H.R.708, S.168], ⁶ introduced by a bipartisan group of lawmakers, is currently pending approval by Congress. This legislation would enable licensed healthcare professionals in good standing to provide care for patients, through telemedicine or in-person, across state borders during and 180 days after the pandemic. Healthcare professionals would be able to practice without facing penalties for the unauthorized practice of medicine across state borders, which would otherwise threaten their state licensure. While it is only temporary, the TREAT Act may serve as the start of more long-lasting reform, eventually eliminating practice limitations based on state borders. Numerous organizations have supported the legislation, including the Association of American Medical Colleges (AAMC). The AAMC joined more than 50 associations for higher education, writing a letter of support for the act on March 8, 2021. ⁷ Inter-state reciprocity has also garnered support from the dermatology community. On their position statement for teledermatology, the American Academy of Dermatology supports efforts by state medical boards to facilitate and lower burdens for physicians obtaining licensure in multiple states. ⁸

Remote care can provide an effective avenue to increase access to care and improve care coordination for patients, particularly in underserved areas, long after the public health emergency. Policy changes inspired by COVID-19 may expand the role of remote medical care, potentially mitigating this issue. While the TREAT Act serves as a temporary fix, attention and momentum brought to the issue of inter-state licensure reciprocity by the pandemic should not be wasted. Further legislation should be developed to allow interstate medical practice to proceed unencumbered by state border restrictions, allowing patients with psoriatic disease to access care wherever care is offered.

This paper has not been previously published or posted and is not under consideration elsewhere.

ORCID iDs

Edward Hadeler https://orcid.org/0000-0002-3005-6529

Nicholas Brownstone https://orcid.org/0000-0002-1187-1712