COVID-19: Practical Tips for Practices

On July 13, the ACR held a town hall-style webinar, COVID-19 Guidance for Community Practices, in which a panel of rheumatologists answered questions submitted by ACR and ARP members on telehealth, clinic safety precautions and grants from the Department of Health & Human Services (HHS) CARES Act Provider Relief Fund.

The ACR will continue to advocate for enhanced financial support from future stimulus funding, said Kelly Weselman, MD, a rheumatologist at Wellstar Rheumatology, Smyrna, Ga., and co-chair of the ACR COVID-19 Practice and Advocacy Task Force.

“We are working for more direct financial support to preserve vulnerable specialty practices. The ACR was also a vocal advocate for audiovisual and audio-only payment parity with both CMS [Centers for Medicare & Medicaid Services] and private insurers, and this will remain an advocacy priority,” Dr. Weselman said. “We also continue to advocate for regulatory policies that reduce the burden for telemedicine.”

Telehealth Tips
Rheumatologists and patients can have positive experiences with telehealth examinations, said Aruni Jayatilleke, MD, MS, a rheumatologist at Temple University Hospital, Philadelphia. The ACR posted a fact sheet with useful tips.

“From my personal experience, patients whose conditions are in a low disease activity state without frequent flares can be safely monitored remotely. Many patients were not coming in frequently for in-person visits prior to COVID-19 and were also capable of and comfortable with self-monitoring their illnesses,” she said. “Most patients seem comfortable with these visits for diagnosis and treatment.”

In a recent survey of 2,000 patients, 72% reported being somewhat or very satisfied with telehealth appointments. Kaleb Michaud, MD, a rheumatologist at the University of Nebraska Medical Center, Omaha, said, “Patients reported that [telehealth visits] were safer, involved less travel time and continued access to care, which was most important to them, mainly access to their medications. However, their overall perception was that telehealth visits were less effective than in-person visits.”

Payment Parity
The CMS currently reimburses telehealth video and telephone-only visits at the same rate, and HHS is expected to extend this policy, said Chris Phillips, MD, a rheumatologist at Paducah Rheumatology, Kentucky, and chair of the Insurance Subcommittee of the ACR’s Committee on Rheumatologic Care.

“Many of us hope that payment parity for audio-visual appointments may persist, although audio-only parity may be a stretch,” said Dr. Phillips. “Private payers are making their own policies. The majority, especially large payers, are following CMS on audio-visual and many on audio-only payment parity.”

The HHS has directly asked states to remove barriers to interstate practice to accommodate telehealth visits across state lines. However, some states still require providers to have full licensure in their state to conduct telehealth visits or do not allow providers to render new diagnoses via telehealth, Dr. Phillips said. “We expect that once the crisis is over, prior licensure requirements probably will resume.”

CMS waivers for telehealth platforms that are not HIPAA-compliant may not continue after the pandemic, so practices should invest in at least one compliant telehealth platform if possible, and use platforms like FaceTime as a backup, said Dr. Phillips.

The day before a telehealth appointment, panelists suggested that a staff member should:

• Call the patient to check video compatibility and connections;
• Ask the patient to email photos of their joint in different positions;
• Prepare charts and medication lists; and
• Email the link to log onto the telehealth platform.

Safe Reopening
The ACR posted strategies to help rheumatology practices safely reopen for in-person visits, said Virginia Reddy, MD, a rheumatologist in Dallas. Ensure clinic waiting rooms allow for people to stand six feet apart, ask patients to check in from their cars and wait there until an exam room opens, and require masks or provide them at check-in. Her clinic removed chairs from the staff break room and emailed reminders to employees to stay home if they have possible COVID-19 symptoms or may have been exposed to infection. At her clinic, all staff must wear surgical masks and, when in close contact with patients, a face shield or goggles as well. Providers who are in exam rooms for prolonged periods wear N-95 masks.

Follow the CDC’s updated guidelines to guide staff on when to stay home, said Angus Worthing, MD, a rheumatologist in Washington, D.C. Symptom-based strategies may be more practical than test-based strategies due to limited testing availability or long delays in getting results, he said.

Social distancing tips for rheumatology clinics include:

• Ask patients to come alone to clinic appointments unless they require help, such as understanding the doctor’s recommendations;
• Limit time spent in the exam room in close contact and the number of people in these rooms. Trainees may examine patients without supervision and report their findings to the rheumatologist outside the room. Save any typing for after the exam; and
• Consider keeping the exam room door open and increase privacy with a curtain or a noise machine.

For adult patients who test positive for COVID-19, the ACR posted updated clinical guidance on when they may safely restart immunosuppressive therapy, said Dr. Worthing. Recommendations cover patients with both complicated and asymptomatic COVID-19 infections. Clinical guidance is also available for pediatric patients.

CARES Act Funds
Rheumatology practices that received CARES Act grants must submit reports on how they used these funds. HHS has relief funding information posted online, but the ACR shared members’ concerns about unclear reporting and audit requirements, said Dr. Phillips.

“They want to ensure that funds were used to keep practices open and allow us to continue caring for our patients,” Dr. Phillips said. HHS will not require grant recipients to report on a quarterly basis, but its inspectors will monitor for fraudulent activities and may contact recipients for tax documents or proof of loss of income.

Although the HHS has indicated it will develop a reporting template for providers who receive funding, the ACR suggests keeping detailed ledgers of COVID-related expenses and losses in case of an audit. Any funds not spent by the end of the pandemic emergency must be returned to HHS. Currently, loans are taxable income, but the HHS is expected to change these to non-taxable grants, said Dr. Phillips.

COVID-related alerts are updated regularly on the ACR website at https://www.rheumatology.org/Announcements/COVID-19-Practice-and-Advocacy. ACR and ARP members may send individual questions to covid@rheumatology.org.

Susan Bernstein is a freelance journalist based in Atlanta.