These are difficult times for rheumatologists. We have seen sharp declines in face-to-face patient visits since the COVID‑19 pandemic began. Many of us have questions about the best ways to maintain employee and patient safety while keeping our practices afloat and continuing to provide optimal care.
The volunteer leaders at the ACR continue to care for patients in settings from private practices to academic centers. We are in constant contact with our rheumatologist and health professional colleagues across the U.S. to stay abreast of the evolving concerns of our community. In response to member needs and in collaboration with the tireless staff at the ACR, we have generated many resources and documents on clinical guidance, practice management, ongoing advocacy and the most up-to-date information about COVID-19. I would like to highlight some of the key points in these documents, but I also encourage you to explore them on the ACR website.
The necessary rapid adoption of telemedicine by many rheumatologists over the past several months has presented both opportunities and challenges. Although this technology provides better access to care for many patients virtually, obvious inherent limitations exist. Thus, the ACR recommends telemedicine be combined with periodic in-person visits.
Earlier existing barriers to telemedicine included poor and inconsistent reimbursement, challenging Health Insurance Portability and Accountability Act (HIPAA) regulations, and requirements for licensing, credentialing, malpractice coverage and informed consent laws, which often differ among states. Fortunately, some of these barriers have been waived for the duration of this public health crisis. For example, even non-rural patients may now participate in telemedicine from their homes.
As of March 1, the Centers for Medicare & Medicaid Services (CMS) increased reimbursement for virtual audiovisual visits to match that of in-person visits. The CMS later agreed to reimburse audio-only visits at the same level, backdated to this same date. Many commercial insurers soon followed suit. We are advocating at both the regulatory and legislative level to keep these changes in place long term to make it feasible for more practitioners to offer telemedicine as a permanent component of their practices. Currently, resubmission of telemedicine claims is required for reimbursement. However, as part of our advocacy initiatives, the ACR is lobbying to correct this and asking that these claims be paid without requiring resubmission, thus reducing paperwork for providers.
Some restrictions to telemedicine still apply, particularly at the state level, and we recommend checking your state’s regulations. The ACR has been supporting legislative initiatives to help streamline telemedicine services across state lines. On the COVID-19 section of our website, we provide detailed information about telehealth service requirements, billing codes and reimbursement practices.
Reopening Practices During the Pandemic
Many practices have continued seeing urgent patients via in-person visits during the pandemic, including patients with acute disease flares and those with active, high-risk disease. The ACR has provided guidance for deciding which patients need to be seen in person and which can be accommodated via telemedicine. We have also issued guidance for best practices for necessary in-office infusions, including disinfection, hygiene and screening procedures. We have argued against indiscriminate expansion of home infusions, which pose safety concerns for some patients.
As stay-at-home orders have lifted, many rheumatology practices are beginning to reopen and are scheduling a higher percentage of patients for in-
person and non-urgent visits. Although we lack hard and fast rules for best practices, an advisory document on reopening is now available on the ACR website. In making such decisions, practitioners should consider regional prevalence and new infection rates of SARS-CoV-2 on an ongoing basis. Clinics should also plan for the possibility that scaling back may again be necessary if there is a resurgence of disease locally.
Following guidance from the Centers for Disease Control & Prevention, practitioners may contemplate reopening in stages, screening employees for symptoms, requiring mask use by patients and staff, and employing strict infection-control measures. Many physical arrangements can facilitate appropriate distancing, such as using Plexiglas barriers and having patients wait in their cars for appointments, if feasible. Clinicians may also want to consider proactively developing a plan to be used if an asymptomatic patient tests positive after a clinic visit.
We also recommend clinicians consult the clinical guidance documents provided by the ACR. In addition to a document addressing the care of adult rheumatology patients, two new documents have been prepared by the ACR’s COVID-19 Pediatric Rheumatology Clinical Guidance Task Force. The first addresses the care of pediatric rheumatology patients in during the COVID-19 pandemic. The second document takes on the identification and management of the newly described multi-system inflammatory syndrome (MIS-C) seen in children with COVID-19.
Continued Advocacy & HCQ Recommendations
At the ACR, we have been advocating for our patients for appropriate use of hydroxychloroquine (HCQ) since the drug came to public attention in March. Fortunately, shortages have abated. However, HCQ use in the setting of COVID-19 has brought safety concerns into the public spotlight, particularly regarding possible cardiac toxicity. Providers in clinical practice may be uncertain as to what to tell patients who express anxiety about taking this drug.
Practitioners can highlight that the cardiac risks reported in recent studies are rare in rheumatology patients taking standard doses, although the risk may be higher in COVID-19 patients for reasons including the use of higher dosages of hydroxychloroquine; drug-drug interactions, especially with azathioprine; and the effects of SARS-CoV-2 on the heart. Clinicians should also emphasize that HCQ is the only drug known to reduce death rates in patients with lupus.
Financial Support Advocacy
Providers are grateful for the funds made available through COVID-19 financial relief programs legislated by Congress. However, many clinicians have expressed concerns about the possibility of future audits and potential penalties, given the lack of clear guidance around fund use in the original legislation. We are actively working with the U.S. Department of Health & Human Services to try to clarify these issues and allay member concerns.
The ACR continues to actively advocate for the financial needs of its members at the federal level. A fourth COVID-19 relief package is expected over the summer, and we have been reaching out to communicate the needs of the rheumatology community. We are urging more direct financial support for vulnerable rheumatology practices and lobbying for such funding to be specifically tailored to help address staff and provider furloughs and salary reductions.
We will continue to reach out via focus groups, surveys, town halls and private communications to better understand the needs of our members in practice. Continue to share your concerns and questions via COVID@rheumatology.org, and we will get back to you quickly. We will use what we learn from members to influence legislative and regulatory processes and help meet our members’ needs.
We are joining the American Medical Association, as well as rheumatology organizations, advocacy organizations and specialty societies, to bring greater power to these efforts. As I have stated in prior columns, these times require resilience and fortitude. We are working to serve our members as we navigate these challenging times together.
Ellen M. Gravallese, MD, is chief of the Division of Rheumatology, Inflammation and Immunity at Brigham and Women’s Hospital, Harvard Medical School, Boston. She is the 83rd president of the ACR.