The new abnormal: Practice in the COVID-19 era and beyond
There is no question that COVID-19 has changed rheumatology clinical practice. Sanitation and social distancing have become top priorities, practices are operating under financial duress due to lower patient volume and telehealth – once on the fringe in the specialty – has become routine.
What remains to be seen is how long such changes will last, and whether any will endure once the virus is contained.
Many experts view the response to the pandemic in terms of phases. The first phase was the terror that accompanied the initial wave of the infection, when most rheumatology practices all but shut down. This forced rheumatologists to rethink financial structures, apply for assistance and find creative ways to stay solvent.
This ushered in the next phase, when restrictions on telemedicine were lifted, allowing virtual visits that re-established doctor-patient relationships and brought much-needed income to practices that had been forced to furlough staff.
“Early on, it seemed that the amount of evolution that, under normal circumstances, you might see in 6 months or a year, was happening each week,” Max I. Hamburger, MD, founder and executive chairman of United Rheumatology and managing partner at Rheumatology Associates of Long Island, said of those first chaotic days of the pandemic. “There was a rapid period of adaptation.”
The next phase was marked by social distancing, with masked doctors and patients moving through empty hallways and waiting rooms into spotless, sanitized exam rooms.
“You can eat off the floor in our office now,” said Grace C. Wright, MD, PhD, president and CEO of Grace C. Wright, MD, PC, and president of the Association of Women in Rheumatology. “We have had to think hard about what we need to do to keep our physical office safe and clean.”
Then, for a moment in late May/early June, the curve began to flatten, and it seemed possible to look beyond the infection to some approximation of normalcy, perhaps by the turn of the new year. But beaches began to crowd, and shopping malls and restaurants reopened, precipitating a surge in infections.
At the time of writing — late July — all bets are off. COVID-19 cases in the U.S. are upwards of 3.8 million, while fatalities are near 140,000 and rising. Six or seven of these phases may eventuate before the ultimate changes to rheumatology practice will shake out – perhaps even more.
One through-line in all of this was the specter of drug shortages, exemplified by the ongoing drama surrounding hydroxychloroquine. With a number of rheumatology drugs — interleukin (IL)-1, IL-6 and IL-17 inhibitors, along with hydroxychloroquine, to name a few — in clinical trials for COVID-19, the final impact on the armamentarium is unknown.
Another through-line comes back to finance. Rheumatology practices and administrative teams are now operating at minimal or half-capacity. Whether that will, or can, continue without a significant number of practices going under remains to be seen.
“The post-COVID period is a very long ways off, possibly not until the third quarter of 2021,” Hamburger said. “It is difficult to look to that period at this point in time.”
That said, if there is one lasting change that is likely to stay with the specialty long after COVID-19 has been contained, it is an increased use of telehealth.
From Zero to Telemedicine
The short story about telemedicine in rheumatology is that most rheumatologists had failed to make use of this technology prior to the pandemic.
“Telemedicine is one of those rare instances where the government has been two steps ahead,” Herbert S. B. Baraf, MD, FACP, MACR, former managing partner of Arthritis and Rheumatism Associates and clinical professor of medicine at the George Washington University School of Medicine and Health Sciences in Washington, D.C., said in an interview. “Early on in the pandemic, CMS recognized that all outpatient medicine would be in trouble and patient access to care would be seriously hampered. To encourage telehealth, they removed the impediments that had previously encumbered telemedicine allowing it to ramp up rapidly and almost effortlessly.”
Notable obstacles including physician site of service. technology platforms, documentation requirements and fear of audit were all relaxed, according to Baraf, who is also a member of the medical policy committee at United Rheumatology. “HIPAA itself has long been a tremendous impediment to care delivery,” he said. “But waiving HIPAA rules, allowing smart phone use and raising the levels of evaluation and management reimbursements to match in-office services helped to subsidize practices that would have gone under otherwise. Without these changes, patients would have lost their access to physician care during the quarantine and physician practices would not have been able to survive economically.”
Andrew L. Concoff, MD, FACR, executive vice president and chief value medical officer at United Rheumatology, offered an explanation as to why the rheumatology community was loath to use telehealth for so long. “We let the perfect be the enemy of the good,” he said in an interview.
The crux of the issue is that rheumatologists rely heavily on the physical exam to make diagnoses and key clinical distinctions, such as differentiating synovitis from arthralgias or tenderness from swelling. “In the past, we said we could never tell as much about a patient without a physical exam, so let’s just not pursue tele-rheumatology,” Concoff said.
Cassandra Calabrese, DO, of the department of rheumatologic and immunologic disease at the Cleveland Clinic, had “reservations” about converting to telehealth visits. “At Cleveland, we were behind,” she acknowledged. “But we converted to a nearly 90% virtual platform pretty quickly, and we were pleasantly surprised at what could be achieved in a virtual visit.”
While many rheumatologists and patients have reported satisfaction with an increased proportion of telehealth visits, the transition has not been smooth, according to Concoff. “At the moment, we are in this awkward hybrid of where we were before the pandemic and making do with whatever platform is fastest and easiest,” he said. “There has not been much thought or guidance about which patients needed priority or how to overcome technical complications. It has been catch as catch can.”
ACR Weighs In
In a move that sought to ease these concerns, the American College of Rheumatology recently published a statement on tele-rheumatology. “The role of telemedicine [is] as a tool with the potential to increase access and improve care for patients with rheumatic diseases, but it should not replace essential face-to-face assessments conducted at medically appropriate intervals,” the statement reads.
However, the ACR acknowledged that telehealth is the new reality for most rheumatologists and their patients, so the authors outlined four key principles for conducting virtual visits.
The first is that the provider-patient relationship, regardless of whether the visit is via telehealth or in person, should follow ethical standards set by the AMA. The second is that patients should be able to choose their providers for telehealth visits. The third is that there should be no drop-off in standard of care during these visits, and that the obvious limitations of telehealth should be mitigated as effectively as possible. The fourth principle is that telehealth visits should be properly documented.
In addition, informed consent mechanisms should be in place, along with protocols to protect patient information, provisions for interstate visits and proposals for outcomes-based research as more visits are conducted.
The stipulations for interstate visits are necessary now, for one important reason highlighted by Concoff. “There is not a single, consistent picture for rheumatology in the pandemic across the country,” he said. “Depending on the state or region, and what the virus is doing, the needs and demands can vary greatly at any given point in time.”
Later in the statement, the ACR supports the opportunity for patients, including those in rural areas, to use telemedicine after the pandemic has subsided. With this provision, the ACR may be positioning itself to stay one step ahead of the reality that telehealth will become part of routine care after COVID-19.
Advantages to Telehealth
There are a number of reasons experts in the specialty believe that tele-rheumatology may be here to stay. “We learned that for patients with stable disease, a short chat on video can be effective,” Calabrese said. “If need be, patients can do maneuvers or show me rashes while I watch on the phone.”
Wright added another component to this advantage. “Another benefit is that I get to see patients in their homes, which means I can see the obstacles and physical barriers that give them trouble on a day-to-day basis,” she said. “I can tailor my advice based on their space, which can impact not only their physical functioning, but their quality of life.”
It is also possible to evaluate soft targets, determine quality of sleep and monitor anxiety and depression, Wright added. “In addition, patients can assess their own pain, regardless of whether they are 100 miles or 100 inches from me.”
One key is establishing strong communication, regardless of the platform. In many cases, this means comfort. With so many people in quarantine regularly using FaceTime, Skype and Zoom to communicate, providers have been able to find a tool for just about everyone.
Another part of comfort pertains to travel. “The burden of commute is particularly stressful for many patients,” Wright said. “Telehealth allows them to stay where they are comfortable and limit the logistical considerations of coming into the office.”
To bring all of it back to the question of whether these changes are likely to remain after COVID-19, Baraf was clear. “The horse is out of the barn with telehealth,” he said. “Hopefully, the government will take this reality check to heart and allow physicians and patients to use their own devices and communicate in any way they can. Lowering these barriers will be critical to patient care.”
Focus on Finances
The primary focus of all of this, of course, is maintaining patient outcomes through and after the public health crisis. But rheumatologists, and rheumatology practices, need an income for this to happen.
With this in mind, in another part of its statement, the ACR advocates for parity of reimbursement for in-office visits, audio-visual visits and audio-only visits, both by CMS and by commercial payers, after the public health emergency has ended.
The ACR also opposes “payer policies which dictate use of specified telemedicine platforms, use telemedicine services to construct restrictive networks, or which use telemedicine as a means to divert patients to their preferred” providers, according to the authors of the statement.
Reimbursement is critical because patient volume is low. Meaning: Every penny counts. Wright believes that the new normal in most rheumatology practices is somewhere around 60% of previous patient capacity. A combination of lingering patient fears, increased use of telemedicine and the necessities of social distancing and sanitation in the clinic may keep that number around 60% for quite some time, even after the virus has been controlled.
The financial impact of this is obvious. “Depending on how flush the practice is, it is likely that most practices are going to have to cut clinical or support staff,” Wright said.
Conversely, though, the demands of sanitation may force practices to make at least one new hire. “It may be necessary to have a staff member who just runs around cleaning,” Wright said. “I honestly think it will be a while before we forget about the horror of the pandemic, and the idea that touching a contaminated surface can lead to infection. It is going to require time.”
A companion consideration is that most practices will have to keep a room empty for cleaning at all times in order to move patients most efficiently through exams. This alone will reduce the capacity for patient volume.
As so many rheumatology practices consist of only one or two rheumatologists, the threat of closure is real. But organizations like United Rheumatology exist to advocate, to bring payers to the table, to ensure that these small practices stay afloat regardless of patient numbers. “We are working with payers and tech companies, we are looking at clinical and financial data and analyzing it,” Hamburger said. “The hope is to help practices learn from their peers and adapt.”
Baraf noted a final financial consideration that is likely to impact rheumatology practice moving forward. “Rheumatology is a specialty that relies heavily on ancillary services like imaging, infusions and joint injections,” he said. “Ultimately, telehealth has been a very good stop-gap measure, but rheumatology is a hands-on specialty and face-to-face visits will remain the preferred mode of care. Delivery of these ancillary services are part and parcel of how we ideally manage patients and are also critical to the economics of rheumatology practice. In the years ahead, telehealth will play an important role, for the infirm, for patient’s who can’t travel and in other special circumstances. It will not, nor should it, go away but it is not a true substitute for hands-on treatment.”
Shifting from ancillary services to pharmacotherapeutics, if there is an area where the ultimate impact of the pandemic is least clear, it is the possibility of drug shortages. “There are thousands of studies underway on ClinicalTrials.gov,” Calabrese said. “The drug shortage questions are apt to change pending these data.”
If a certain drug is proven to be a game-changer, there may be shortage concerns about that drug, according to Calabrese. “For now, we just have to wait and see what looks promising,” she said.
The good news is that most of the experts who spoke to Healio Rheumatology did not report difficulties in acquiring medications, even hydroxychloroquine. But given the rapid pace at which the pandemic is moving, the possibility of the emergence of positive trial results and the unpredictable information on drug efficacy emerging from the White House and other sources, that could change again.
The question of possible shortages aside, Hamburger sees this moment as an opportunity for rheumatology to improve as a field. “Since 2010-2011, we have moved toward a treat-to-target approach, aiming for widely accepted composite indices of disease activity in many of the conditions we treat,” he said. “But many rheumatologists are not measuring disease activity frequently enough.”
With fewer opportunities to see patients and the possibility of drug shortages looming, Hamburger believes that rheumatology should refine both targets and treat-to-target strategies. “COVID has forced us to utilize these measures more consistently,” he said. “A move toward a more precision medicine approach will not only help us separate which patients can be seen at home and which need to come into the office, but also help us use drugs more judiciously in the event of shortages.”
Patient Behavior Post-COVID
Drug shortages and risks associated with entering the clinic are just two of the fears that patients have voiced throughout the pandemic. It is critical to address these and other fears head on, with accurate information, according to the experts.
“Some degree of patient fear is good,” Calabrese said. “Of course, there are a lot of people who are not scared, and that is obviously a separate issue, but because their conditions tend to be chronic, our rheumatology patients are attuned to their health.”
Calabrese suggested that fear of acquiring COVID-19 has forced rheumatology patients to pay even closer attention to their health-related behaviors. She believes that rheumatologists can, and should, capitalize on this. “Anything that leads our patients to want to increase their health literacy can be a positive.”
The downside is that many patients remain terrified of even setting foot outside of their homes, much less into a health care facility. “They are not even getting routine issues taken care of, like dental visits, so many of our patients are definitely not getting appropriate labs or imaging analyses done,” Calabrese said.
It is with patients like this in mind that Concoff suggested that the field needs to get creative. “It is more than telehealth,” he said. “We need to find different ways of connecting with patients. One way to do that is with mobile phlebotomy, where the lab can come to your door to draw blood to monitor medicines.”
Another way to connect is to pay closer attention to mental health parameters. “Rheumatologists have traditionally performed poorly in assessing the psychological status of their patients,” Concoff said. “Anxiety and depression are present in many of our patients even without the pandemic. This is something we are going to have to think about moving forward.”
Psychological comorbidities are associated not only with rheumatologic diseases, but with the virus, as well, according to Concoff. “We still do not know which of our patients may experience long-term complications from COVID-19,” he said. “Plus, you have to consider lockdown fatigue and anxiety, social isolation, all of these unique factors that we have all been dealing with. As rheumatologists, we are going to have to do a better job of understanding the total and behavioral health status of our patients.”
It is with all of these factors in play that Concoff sees this moment as an opportunity for rheumatologists to elevate their game. “There has been a lot of talk about value-based care,” he said. “This pandemic may give us the chance to really put that into action. In short, if we can find a way to start paying rheumatologists to make the right choice at the right time, it can save money and improve patient outcomes.”
For Hamburger, there is an analogy to be drawn between the immune system and the response to the pandemic. “The immune system must react and adapt,” he said. “That is what we must do.”
While clinicians, researchers and payers work out the details of what “react and adapt” will entail through the next phases of COVID, Wright encouraged her colleagues to keep talking to patients, and focus on the basics. “I tell my patients: Stand outside your building and breathe fresh air,” she said. “Work in the garden if you have one. Touch the greenery. Go for a walk. And then I tell them: We can get through this.”
Calabrese expressed a similar sentiment. “I do not lie to my patients about COVID,” she said. “I tell them that it is likely not going anywhere for a while. But whether I see them in the clinic or on their phone, I make sure one message is clear: We will take care of you.”
- For more information:
- Herbert S. B. Baraf, MD, FACP, MACR, can be reached at 2730 University Blvd. W # 310, Silver Spring, MD 20902; email: firstname.lastname@example.org.
- Cassandra Calabrese, DO, can be reached at 9500 Euclid Ave., Desk A50, Cleveland, OH 44195; email: email@example.com.
- Andrew L. Concoff, MD, FACR, can be reached at 2355 Westwood Blvd., Suite 1808, Los Angeles, CA; email: firstname.lastname@example.org.
- Max I. Hamburger, MD, can be reached at 150 Motor Pkwy., Suite 108E, Hauppauge, NY 11788; email: email@example.com.
- Grace C. Wright, MD, PhD, can be reached at 345 East 37th St., Suite 303C, New York, NY 10016; email: firstname.lastname@example.org.