Singer Jimmy Dean reportedly once said, “I can’t change the direction of the wind, but I can adjust my sails to always reach my destination.” The COVID-19 pandemic has required us as rheumatologists to adjust our sails multiple times. We have had to rethink many of the ways in which we interact with our worried patients to provide the highest quality care, along with practical and emotional support, and to do it all safely during these extraordinary times.
At the ACR, we have been searching for ways to help our members adjust their sails and assist them in navigating these challenges. I would like to underscore some of the resources that have been developed and are currently available on the ACR website, and highlight the ways in which the ACR has been advocating on behalf of patients and providers.
Early in the COVID-19 crisis, the ACR Executive Committee established two task forces to support our members and the entire rheumatology community. These are the Practice and Advocacy Task Force (Chair: Kelly Weselman, MD, FACR; Executive Committee liaison: Douglas White, MD, PhD) and the Clinical Guidance Task Force (Chair: Ted R. Mikuls, MD; Executive Committee liaisons: Kenneth Saag, MD, MSc, and me). These two groups have worked tirelessly to provide information for members and address ongoing needs posed by the pandemic.
Practice & Advocacy Resources
The ACR advocacy team has done a tremendous amount of work in advocating for the availability and proper use of hydroxychloroquine, a drug that is essential for the treatment of lupus and is also used in other rheumatic diseases. Some early evidence suggested this medication holds potential as a possible treatment for COVID-19. This position has led to drug shortages and decreased drug availability for some of our patients. As rheumatologists and rheumatology professionals, we need to advocate for our patients’ access to the drug while clinical trials establish whether hydroxychloroquine is truly effective to treat COVID-19.
Working in conjunction with the American Academy of Dermatology, the Arthritis Foundation and the Lupus Foundation of America, the ACR has released a statement to the White House Coronavirus Task Force and the nation’s governors highlighting issues critical to hydroxychloroquine access. The ACR has also provided a template that medical providers can use to help advocate for appropriate use of hydroxychloroquine during this time.
The Practice and Advocacy Task Force has provided a great deal of information covering specific guidance on practice management issues, including guiding principles for proper resource allocation of medications that may be in high demand during the COVID-19 crisis. In addition to hydroxychloroquine, these include rheumatic disease drugs with potential applications in COVID-19, such as drugs inhibiting interleukin (IL) 1 and IL-6.
The ACR is aware the physical distancing measures implemented to reduce transmission of the SARS-CoV-2 virus place many rheumatology practices under financial strain. On the ACR website, we have compiled resources to help you sustain your practice financially. We also provide information about the Coronavirus Aid, Relief and Economic Security (CARES) Act and the federal paycheck protection program, including detailed information about how rheumatologists can apply.
To further assist our members in continuing to serve their patients, the ACR has provided several resources regarding telehealth, which presents a new avenue to meet patient needs. We recognize that telehealth has posed a challenge to many of our members, some of whom had not previously integrated this into their practices and many of whom have patients who cannot participate in telehealth in an ideal way.
The resources available through the ACR website also include coding and practical guidance to help ensure proper reimbursement for both video and phone-based telehealth services, as well as information about telehealth vendors, commercial health payers, Medicare reimbursement and potential malpractice concerns. The ACR has also provided a template that members can use to send letters to their state medical boards to advocate for clearer guidance about practicing telehealth across state lines. At the federal level, we are advocating for proper reimbursement for telehealth services, even for medical appointments that need to occur over the phone.
On a related note, the ACR is also reaching out to insurance companies to encourage them to expand access to telehealth services. We have also advocated for relief from potentially avoidable administrative challenges, such as those mandating prior authorization of treatments before prescribing. With members of other specialty societies, the ACR wrote a letter urging the Centers for Medicare & Medicaid Services to waive prior authorization requirements for Medicare Advantage plans during this time. The ACR has also provided a comprehensive position statement regarding the detrimental problems prior authorization causes for both rheumatologists and their patients.
Finally, the ACR has developed documents centered on practice guidance, including information about how to best handle treatment infusions and principles for helping decide which patients may need in-person services vs. telehealth monitoring. We have also created guidance on advising patients as to how they might best seek care during this time, including their telehealth options.
The Practice and Advocacy Task Force continues to meet virtually to gather new resources that will provide further guidance.
The Clinical Guidance Task Force has assembled best practices to help inform treatment decisions during this pandemic. Clinicians understandably have questions about the best way to manage their patients on immunosuppressive drugs, questions about how these agents might impact the likelihood of contracting COVID-19 or of having a poor outcome. Clinicians may have questions about how to handle unexposed patients, exposed patients without confirmed disease, as well as patients with mild or severe forms of COVID-19.
The data available on these topics are limited and complex. However, members of this task force include infectious disease experts and experts in biologic and non-biologic therapies, and they have compiled a guidance document for clinicians that is now available on the ACR website. This document contains recommendations for adult patients with rheumatic disease and will be updated as new data become available. More detailed information about the modified Delphi methodology used to create these recommendations will be published soon.
Ongoing Guidance & Support from the ACR
The ACR encourages all members to submit data on their rheumatology patients with COVID-19 to the Global Rheumatology Alliance, which is sponsoring an international, case-reporting registry. Data from this registry will ultimately provide insights into outcomes for rheumatology patients in the setting of COVID-19. The ACR has played a critical role in spreading the word about the Alliance, helping disseminate data and performing other key functions, and the Alliance has recently become a section of the ACR.
The ACR will continue to provide ongoing guidance on this rapidly evolving situation via its website, which contains documents updated in real time. Documents are being added almost daily, so please check the website regularly. New documents are clearly highlighted, making them easier to find. Please also check your email frequently, as the ACR is sending regular updates to members as new resources become available. Also, do not hesitate to contact us with your concerns by emailing COVID@rheumatology.org. We will get back to you quickly.
The ACR is exploring the format for all future meetings and events, including this year’s annual meeting, ACR Convergence 2020. We will update you as information becomes available.
This is a time that requires resiliency, courage and a steadfast response. I have been so impressed and inspired by the dedication and teamwork demonstrated by so many members of the rheumatology community. I want to personally thank all my colleagues at the ACR—the chairs, the board of directors and the executive committee—for their tremendous work in this effort. I also want to thank the amazing ACR staff, who have worked such long hours to make up-to-date information available to our membership. I would like to thank the task forces for their formidable work in preparing guidance documents for the rheumatology community.
Most importantly, I would like to thank all of the rheumatologists and rheumatology professionals around the globe for continuing to do their best for their patients during this very challenging time. Please stay safe and well.
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.