Teledermatology Most dermatologists reside in metropolitan areas, so teledermatology should be considered as an access option for individuals living outside these areas. However, two questions must be answered. How much does it cost? How valuable is it? A team of Veterans Administration researchers attempted to answer these questions (Datta et al. 2015). The team used two cost perspectives. One examined costs from the perspective of the Veterans Administration, estimating how much it costs to produce teledermatology care and how much it costs to produce a face-to-face visit. Two challenges emerged from this effort. First, costs varied considerably. From the Veterans Administration perspective the average cost of a teledermatology consult was $308, but the standard deviation was $298. The average cost of a face-toface consult was $338, but the standard deviation was $291. Second, the authors chose not to include the cost of equipment used to take images of the patient's skin, arguing that the incremental cost of an image was negligible. In looking at costs from a societal perspective, the team added spending for dermatologic care from providers who did not work for the Veterans Administration, travel costs, and patient time costs. From a societal perspective the average cost of a teledermatology consult was $460, but the standard deviation was $428. The average cost of a face-to-face consult was $542, but the standard deviation was $403. This study was a CUA, so the team measured utility before and after treatment. They used a time trade-off technique to measure patients' quality of life. This technique presents respondents with directions such as "Imagine that you have ten years left to live. You can choose to live these ten years in your current health state, or you can choose to give up some life years to live for a shorter period in full health. Mark the timeline with the number of years in full health that you think is of equal value to ten years in your current health state." 1 2 3 4 5 6 7 8 9 10 At baseline, average quality of life was 0.90 for both samples. Over nine months the teledermatology groups' average increased by 0.03 and the face-to-face visit groups' average increased by 0.02. Discussion Questions Would you be willing to use teledermatology? Why or why not? Which perspective on costs seems more valid to you? Do you think that the costs of the imaging equipment should have been included? Did the team use the right approach to evaluation? Would a CMA have been acceptable? What is your reaction to the time trade-off technique? What is your recommendation for assessing the value of teledermatology? Would you be willing to adopt teledermatology for your health system? Should Medicare use economic evaluation in making coverage decisions? Congress has largely banned considering costs in making coverage decisions. Do you agree? Can you find published examples of CMA? CEA? CBA? CUA?