Jane’s* hands and wrists had been swollen and painful for about eight weeks. Lab findings in the ambulatory consult that came to our office revealed a cyclic citrullinated peptide antibody count >250 u/mL. We all know where this story goes, including how important the early treatment window is.
Chris Phillips, MD
Our clinic reviews all consults and tries to expedite those with findings such as these. A certain virus affected our plans this time, though. Due to the COVID-19 pandemic, an executive order in our state allows us to see only urgent and emergent cases in clinic. Although Jane may qualify, a second catch was her report that the chicken plant where she worked had recently seen several COVID cases. So our first meeting occurred with the help of a high-speed internet connection.
Because Jane’s astute referring physician had obtained all the necessary labs and because our audiovisual connection allowed me to see the synovitis in her hands clearly, I promptly started her on disease-modifying anti-rheumatic drug (DMARD) therapy. Our next visit may also be virtual, depending on how the pandemic progresses.
As I disconnected, it struck me that several months ago, telehealth a) sounded like something that would only be useful in central Montana and b) would require too much in start-up cost and technical know-how with too little opportunity for reimbursement. Several months ago, COVID-19 also sounded like a good name for the NASA Mars project.
Acute Practice Impacts
Times are changing rapidly. The negative economic effects of the COVID-19 pandemic on rheumatology practices have been well documented.1,2 For many of us, the day-to-day operation of our practices scarcely resembles what it looked like just a few months ago. My pre-COVID practice comprised five or six new patients and 20–22 established patients per day, and 14–18 established patients per day for my physician assistant.
As our patients began to recognize the reality of the crisis, but before we optimized telehealth, I nadired at three visits in one day. Currently, using doxy.me (and FaceTime as a backup), I am seeing 10–14 telehealth patients per day and between two and eight urgent, in-person patient visits per day.
Different parts of the country have had different impacts. From western Kentucky, I cannot pretend to comprehend the life of a New York rheumatologist. Employed and academic rheumatologists face salary reductions, while independent rheumatologists worry about having to close their practices if the crisis continues. What can we learn from this crisis, how can we survive it, and where will the dust settle when it’s over?
In general, we need to consider the possibility that this crisis may lead to a winter or even a mini-ice age, in which the economic impact may last several years, as opposed to a blizzard that we can weather and clean up from in a few months.3 Until there is sufficient herd immunity, an effective vaccine or both, we should expect viral circulation that may lead to ongoing regional outbreaks, leading in turn to regional re-introduction of distancing protocols, even after initial restrictions are lifted.
Mitigating Losses & Planning for Post-COVID Remote Care
What factors may impact current practice health and what lingering impacts may ACR member practices see when the COVID-19 crisis abates? The ability to continue providing evaluation and management (E/M) services through the crisis is critical.
Many of us have learned telehealth on the fly. We all have frustrating stories, which usually revolve around poor internet connections or dropped calls. However, I suspect many of us, if we are honest, would admit we have learned this skill more easily than we imagined.
We have the aid of the Centers for Medicare & Medicaid Services (CMS), which is reimbursing for audiovisual telehealth visits conducted with the patient in their home, across state lines and even with non-HIPAA-compliant modalities.4 (How many iPhone users have fallen back on FaceTime when the default platform failed? I am guilty as charged.)
Fortunately, most commercial payers have followed suit and are paying for these services at office visit rates. The ACR and other groups have advocated coverage for audio-only encounters at standard E/M rates during the current crisis, because so many of our patients lack internet connectivity to support a video feed. Just as I finalized this document, word came that CMS has listened and is providing audio-only payment parity. (Reminder: Advocacy works!)
The U.S. Department of Health & Human Services (HHS) has given guidance to states suggesting they eliminate barriers to interstate telehealth services.5,6 However, state regulations remain a patchwork quilt, with some allowing carte blanche interstate care, some denying it and others requiring emergency licensure.7
Getting a taste of telehealth, some of our patients like it. When this crisis is over, be prepared for some patients to continue to request remote service. Will it be available to them? If CMS and commercial payers continue to reimburse telehealth at standard E/M rates and allow patients to be seen from their home, expect telehealth to remain popular.8
When, or if, we return to normal, recognize that some of the current emergency leniencies in telehealth regulation (i.e., HIPAA restrictions) may also revert to normal. Are you currently seeing patients across state lines due to the emergency regulations? Consider obtaining licensure in those states for future care. (Some states require full licensure; some states offer telehealth licenses; some states have reciprocity agreements for telehealth.)9
What about the ability to offer telehealth services after hours or on weekends? If you’re independent, entrepreneurial and/or looking to make up lost revenue, this option could sound great. If you are employed with a family at home and your employer sees this as a way for you to make up lost revenue, this option may not sound so great.
If you routinely provide uncompensated care via a patient portal (answering unsolicited patient questions not associated with an encounter in the previous seven days or the next 24 hours), the service may qualify for reimbursement as an e-visit.4
Could increased use of remote care dovetail with care coordination protocols we see as part of value-based care initiatives? Will this crisis propel us further down a value-based care pathway, and if so, how may our members best position themselves in contract negotiations?
What about the physical exam? One of the joys of rheumatology is that the physical exam still matters. Don’t we take pride in palpating synovitis the referring provider could not appreciate? How much of our diagnostic acumen is lost in an audiovisual meeting? Members will have different opinions on this matter, and we may find over time that certain circumstances are better suited for telehealth than others. A policy requiring in-person evaluation at least every other visit may be appropriate, for example.
I look forward to seeing research regarding best practices in rheumatology telehealth diagnostics in the next few years.
Concerns about Immune Suppression
What about our patients on biologics, and specifically infusions, during this difficult time? These patients are between a rock and a hard place, knowing their treatment may somewhat increase their risk for infection, but also knowing that stopping treatment may lead to disease flares, immune dysregulation and the need for steroids, which may be equally troublesome when considering COVID-19 complication risks.
The ACR has published guidance for safe infusion practices during COVID-19.10 Local COVID-19 prevalence, patient-specific risk factors and patient-specific disease features may guide decisions regarding treating or delaying. Practices continuing to infuse should be sure to consistently confirm that insurance coverage is active at the time of service in light of the economic situation. Some insurers may try to hijack the COVID-19 crisis as an excuse to move patients onto home infusions or other treatments that are preferred by the insurer but may not be in the patient’s best interest. We need to advocate for our patients, regardless of what treatment they are on, rather than let insurers dictate terms of treatment to us, couched in concern about patient safety during the pandemic.11
Economic Considerations
When this crisis abates, who will be coming into our clinics? We may have the same clinic panel, but their insurance status may have changed. Some may be uninsured; some may be on Medicaid rather than commercial insurance.12 These numbers will depend on how deeply the economy contracts and how quickly it bounces back.
Do you accept Medicaid or self-pay patients? Do you have an up-to-date pay scale for self-pay patients that is fair to them and to you? If you haven’t previously accepted Medicaid patients, will this crisis change your view? There are no right or wrong answers; the mistake would be not to prepare.
Have you considered the potential burden on your pre-certification staff related to new drug prior authorizations for patients on new insurance?
If you offer health insurance, consider projections of up to a 40% increase in insurance premiums next year due to COVID-19-related costs.13 Although that’s a high-end projection, give some thought to budgeting healthcare costs.
What about volume? Due to pent-up demand, you may have a surge in patients. Do you have a staffing plan for providers and staff that may allow for increased access? Have you evaluated vacation schedules and considered adjusting them? Again, there are no right or wrong answers; it’s only wrong not to think about these possibilities. For many of us, an already long backlog of new-patient referrals will be only longer. Creative re-thinking of how we use extenders, when applicable, may be warranted and will likely play a larger role in the post-COVID-19 era.
Government Relief
Some private clinics may have applied for and obtained Small Business Association (SBA) forgivable loans. Most private clinics and larger employed groups received a share of $50 billion in HHS relief funds distributed in mid-April. The HHS funds must be used in response to COVID-19 pressures (e.g., loss of E/M and/or infusion revenue; information technology/telehealth costs related to COVID-19; staffing costs, such as staff kept on payroll who may have otherwise been furloughed, hazard and/or overtime pay, and/or training costs related to COVID-19; costs related to cleaning and personal protective equipment; fees paid to consultants, accountants or billing services related to your COVID-19 response).
If you received more than $150,000, you will need to provide an accounting each quarter of how these funds were spent. At least 75% of the SBA loan funds must be used for payroll-related expenses; the other 25% may be used for rent and utilities. Use of the funds for other purposes is not precluded, but the funds may need to be repaid at a 1% interest rate.14,15 Be sure not to double count any expenses toward both SBA and HHS funds.
In sum, these government relief programs provide needed assistance to keep our practices open, but the expenses need to be tracked and could be audited, so account for them closely. For those in employed or academic practices, the HHS relief funds were paid to your employer. This could be multiple degrees of separation upstream, maybe even paid in a different state for large healthcare systems. Know that these funds are intended to maintain employment and payroll, although we don’t know how larger employers may direct them. Open lines of communication with administration regarding how they use these funds may be helpful for employed rheumatologists.
Therapeutics
What can be said about our therapeutics during and after this crisis? Several of our drugs (hydroxychloroquine [HCQ], tocilizumab, sarilumab) have received attention as potential COVID-19 treatments. Hype seems to outpace science, especially concerning HCQ, while we await randomized study results.
How will these drugs weather this crisis? How many of us are guilty of having described HCQ to our patients as the safest drug in our armamentarium? Will the previously smooth feathers of HCQ be ruffled by our president’s descriptions of it as a “very powerful drug” or by the observation of arrhythmia and death, especially in older patients when co-administered macrolide antibiotics?16,17 How many of us obtain a baseline electrocardiogram before starting HCQ? (Hint: Not many.) Will we start doing so? I’m not sure yet, but hopefully science will guide us and maybe we will learn something new about an old drug.
Conclusion
Crises bring change. Legislative and regulatory fallout from COVID-19 will continue to impact us long after the virus is gone. Never has the adage, “You’re either at the table or you’re on the menu,” been more germane. We need to advocate on the federal level to maintain the rollback of sequester cuts. We need to advocate on state and federal levels for Medicaid and commercial policies to grandfather patients who are stable on treatment but transitioning from different insurance. We must advocate for CMS and commercial payers to continue to allow telehealth access from home, as well as for payment parity to in-person visits.
As commercial payers look to pass COVID-related losses on to our patients, we need to advocate against the higher out-of-pocket costs, premium increases, specialty tiering and higher deductibles they may seek to implement.
We are living in a unique time. The ways in which we adapt our practices to the current economic and healthcare environment, as well as how we plan for potential changes in the post-COVID world, will be critical to the sustainability of our practices and to our ability to care for the patients who desperately need our care today—and who will still need it tomorrow.
Christopher Phillips, MD, balances time with his solo private practice in Paducah, Ky., to help rheumatologists fight insurance battles for their patients in his role as chair of the ACR’s Insurance Subcommittee (ISC).
References
- Hamburger MI. COVID-19 threatens rheumatology practices amid plunging patient volume, revenue. Healio Rheumatology. 2020 Apr 17.
- COVID-19 financial impact on medical practices (survey). MGMA. 2020 Apr 7–8.
- Feuer W. US isn’t prepared for outbreak. This is a ‘coronavirus winter, and we’re in the first week,’ disease specialist says. CNBC. 2020 Mar 10.
- Medicare telemedicine health care provider fact sheet. CMS.gov. 2020 Mar 17.
- Guidance to states: Lifting restrictions to extend the capacity of the health care workforce during the COVID-19 national emergency. National Council of State Boards of Nursing. (no date)
- Azar AM II. Letter to governors. Secretary of Health and Human Services. 2020 Mar 24.
- States waiving of modifying licensure requirements for telemedicine in response to COVID-19. American College of Rheumatology. 2020 Apr 24.
- Hollander JE, Sites FD. The transition from reimagining to recreating health care is now (letter). NEJM Catalyst. 2020 Apr 8.
- Telemedicine policies: Board by board overview. Federation of State Medical Boards. 2019 Nov.
- Guiding principles from the American College of Rheumatology for home infusion during the COVID-19 pandemic. American College of Rheumatology. 2020 Apr 11.
- ACR infusion guidance during COVID-19 crisis. American College of Rheumatology. 2020 Apr 11.
- Minemyer P. COVID-19 job losses could drive down employer plan enrollment by as much as 35M, report shows. Fierce Healthcare. 2020 Apr 3.
- Livingston S. COVID-19 could prompt higher 2021 insurance premiums, benefit cuts. Modern Healthcare. 2020 Mar 23.
- Paycheck protection program overview. American College of Rheumatology. 2020 Apr 24 (updated).
- HHS emergency fund disbursements to practices. American College of Rheumatology. 2020 Apr 20 (updated).
- Lane JCE, Weaver J, Kostka K, et al. Safety of hydroxychloroquine, alone and in combination with azithromycin, in light of rapid wide-spread use for COVID-19: A multinational, network cohort and self-controlled case series study (preprint). medRxiv. 2020 Apr 10.
- FDA cautions against use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk of heart rhythm problems. FDA Drug Safety Communication. U.S. Food & Drug Administration. 2020 Apr 24.
*Name changed to preserve anonymity
