ACR CONVERGENCE 2020—Rheumatology practices nationwide quickly ramped up telehealth in the early days of the COVID-19 pandemic. An ACR Convergence session, Telerheumatology: How COVID-19 Changed It & What’s in the Future, covered recent trends in telehealth usage by rheumatology practices, anticipated regulatory and payer policy changes in the coming year, and provided tips from the director of a large, regional telerheumatology program.
Pre-Pandemic Barriers
Before COVID-19, various barriers limited use of telehealth by many providers, said Christopher Phillips, MD, FACR, a rheumatologist in Paducah, Ky., and chair of the ACR Insurance Subcommittee.
“There were technical barriers, one of which revolved around the need for Health Insurance Portability and Accountability Act (HIPAA)-compliant platforms, some of which were perceived as difficult to use. There was also a need to train employees to use telehealth platforms and lingering questions about internet connectivity,” said Dr. Phillips. “Financial barriers included negative perceptions about the cost of new equipment and which telehealth services and providers would be covered by payers.”
A 2016 American Medical Association survey across all specialties found that only 15% of providers worked in practices that widely used telehealth, and this included remote radiology services, which are more common in rural areas.1 In a recent survey of 45 Veterans Health Administration rheumatologists, providers expressed concerns that telehealth limited their ability to do physical exams and joint counts, as well as collect patient-reported outcomes, and that many patients still need in-person laboratory monitoring.2
Before the pandemic, the Centers for Medicare & Medicaid Services (CMS) not only required HIPAA-compliant platforms, but to cover telehealth services, Medicare patients had to live in an area designated as rural by the agency and visit a designated facility to receive care—they could not receive care from their own homes—and Medicare did not cover audio-only care, Dr. Phillips said.3
Relaxed Restrictions
COVID-19 changed everything. In-person visits across all medical specialties declined by 60% in the U.S. from mid-February through late March, and as of June 1, 32% of respondents reported that most of their patient visits were virtual, according to a survey conducted by The Commonwealth Fund.4
In March, CMS temporarily waived many restrictions to coverage of telehealth services for Medicare patients, using Section 1135 of the U.S. Social Security Act, for the duration of the public health emergency, Dr. Phillips said. Changes included payment parity for virtual and in-person office visits, allowing all patients to receive telehealthcare from their homes instead of just those in rural areas, waiving penalties for using non-secure platforms like FaceTime or Skype and covering brief, telephone-only “virtual check-ins” for existing patients. CMS has renewed these waivers every 90 days since March, and Medicare now provides payment parity for audio-only visits equivalent to a level 2 office visit for the duration of the pandemic. Some, but not all commercial payers have followed suit.
“This is important, as there is data from the FCC [Federal Communications Commission] that suggests that about 14 million Americans lack internet access and about 25 million lack broadband access,” Dr. Phillips said.5 Those numbers may be much higher, as industry data suggest that many people who live in cities still do not use the internet at broadband speeds, and many rheumatologists’ patients may not have access to adequate bandwidth for telehealth visits, he noted.6
Most states have temporarily relaxed cross-border licensure requirements for practicing interstate medicine via telehealth, and most telehealth restrictions on new patient appointments have been waived. However, some commercial plans that must meet minimum standards set by the Employee Retirement Income Security Act of 1974 may allow employers who offer the plans to opt out of telehealth coverage, he added. Updated information on states’ licensure requirements, CMS regulations for telehealth, billing codes, tips for navigating different platforms and other resources for rheumatology practices are available on the ACR website’s COVID-19 page.
Lower regulatory and financial barriers to implementation of telehealth may have helped rheumatology visits nationwide to rebound to 8% below the pre-COVID baseline by late July, mostly because telehealth filled the gaps, according to The Commonwealth Fund data.4 “I believe that many rheumatologists have taken up the mantle of telehealth and we are using it to serve our patients,” Dr. Phillips said.
Telehealth’s Potential Future
What happens after the pandemic hopefully ends? Many payers have arbitrary end dates on telehealth coverage, raising concerns from some ACR members, said Dr. Phillips. “But we’ve also seen those end dates pushed back as they become closer and the pandemic has not, unfortunately, ended. The big question is this: What will happen when the pandemic is over? Some of these relaxed restrictions may roll back.”
Dr. Phillips predicted that coverage for audio-only visits and relaxed restrictions on cross-state telehealthcare will roll back after the pandemic ends. Although CMS can adjust payment levels and the codes that it covers, the agency cannot, by law, permanently waive requirements that covered telehealth visits must be audio-visual or conducted at designed care sites. These changes must be made by Congress, he said. For now, he suggested that rheumatologists who practice telemedicine across state lines obtain permanent licenses and consider investing in HIPAA-compliant secure platforms and developing protocols to collect patient-reported outcomes through telehealth, if required by their states.
‘I believe that many rheumatologists have taken up the mantle of telehealth & we are using it to serve our patients.’ —Christopher Phillips, MD, FACR
In September 2020, ACR’s Committee on Rheumatologic Care issued a position statement on telehealth supporting audio-only and audio-visual visit payment parity, and protocols to protect patient data security while balancing the need for patient access, including a deeper look at HIPAA-compliant platforms, and proposals that facilitate cross-state practice of telemedicine.7 The ACR opposes restrictions on where patients may receive telehealthcare.
“The role of telehealth in rheumatology will continue to grow whether we like it or not. Patient expectations to utilize telehealth services will linger, so I think it’s important that we plan now, as part of a good business strategy to manage what our telehealthcare will look like post-pandemic,” Dr. Phillips concluded.
Rural Rheumatology
Telehealth may be a viable way to provide rheumatology care to patients who live in rural areas that not only lack a rheumatologist, but many other physicians, said Christine Peoples, MD, clinical assistant professor of medicine and director of the telerheumatology program at the University of Pittsburgh Medical Center (UPMC), which currently cares for patients in three rural Pennsylvania communities: Everett, Seneca and Hermitage. Patients visit a small teleconsult center in their community, where a registered nurse (RN) works with the rheumatologist in Pittsburgh to perform the physical examination over a secure video connection.
“In rural areas, primary care is also changing. There is a workforce shortage and primary-care providers are retiring. There’s a lack of recruitment to these areas, and clinics, community health centers and hospitals are closing,” Dr. Peoples said. In January 2016, UPMC’s rheumatology teleconsult centers began conducting and billing for remote visits, and the program now performs more of these appointments than any other internal medicine specialty in the network.
The scheduling and check-in processes are exactly the same as in-person visits, said Dr. Peoples. Each teleconsult center is staffed and includes a telepresenting RN whom she has trained. At check-in, all rheumatoid arthritis patients fill out a RAPID3 questionnaire, which the nurse scans and sends to her in Pittsburgh. If needed, UPMC orthopedists based at the regional hospitals can perform arthrocentesis injections. “The elephant in the room is the physical exam. We can do a lot by visual inspection, and seeing the patient on different types of cameras, or with different lighting and patient positioning.” The nurse places patients’ hands against different backgrounds to make them easier to see.
UPMC now offers a telehealth elective to its rheumatology fellows, where they train to care for patients in different locations using traditional secure video, telephone and home video over a four-week rotation.
“They can see both new and follow-up patients and have their precepting with me. Thus far, we have had one fellow rotate through, and both the patients and our fellow really enjoyed the experience,” Dr. Peoples said.
Pandemic Paradigm Shift
Demand for telerheumatology services at UPMC has grown steadily since its launch, but the pandemic changed many aspects of the program.
“When COVID-19 happened earlier this year, we had to respond. I had to keep in mind that our teleconsult centers were located in rural areas. Many primary-care physicians’ offices closed. We became a main source of information for patients about COVID-19,” Dr. Peoples said. “There was also a shift from patients going into teleconsult centers to receiving care at home through telephone visits or home video visits through an app in our EMR [electronic medical record] interface.”
Dr. Peoples acknowledged telerheumatology’s limitations in her program, including the inability to perform procedures or infusions, and it may not be appropriate for diagnosis or new patient visits. New equipment or platforms may be costly for practices or even large systems. However, it has been a helpful option for delivering care to both rural patients and those who need to stay home due to the risk of COVID-19 exposure. Rheumatologists who are considering ramping up their telehealth services must consider the investments in equipment or staff training required, as well as the telehealth coverage policies of payers in their region, she said.
“Is telerheumatology sustainable where you are? Remember that it’s a dynamic process. You collect regular feedback about your program and adjust workflows as needed. Think about clinical support you may need, such as where patients will go for diagnostic testing or infusions.” Consider how to coordinate multidisciplinary televisits with other specialists if needed for complex cases, she said.
Rheumatology programs must train more fellows in telehealth to prepare for the growing demand for remote care, Dr. Peoples said. “In the future, telerheumatology will be one of many options to provide the right care to the right patient at the right time and place.”
Susan Bernstein is a freelance journalist based in Atlanta.
References
- Kane CK and Gillis K. The use of telemedicine by physicians: Still the exception rather than the rule. Health Aff (Millwood). 2018 Dec;37(12):1923–1930.
- Matsumoto RA, England BR, Mastarone G, et al. Rheumatology clinicians’ perceptions of telerheumatology within the Veterans Health Administration: A national survey study. Mil Med. 2020 Aug 13;usaa203.
- S. Centers for Medicare & Medicaid Services. Medicare telemedicine health care provider fact sheet. 2020 Mar 17.
- Mehrotra A, Chernew M, Linetsky D, et al. The impact of the COVID-19 pandemic on outpatient care: Visits return to pre-pandemic levels, but not for all providers and patients. The Commonwealth Fund. 2020 Oct 15.
- Federal Communications Commission. 2018 Broadband Deployment Report. 2018 Feb 2.
- Microsoft on the Issues blog. It’s time for a new approach on mapping broadband data to better serve Americans. 2019 Apr 8.
- Committee on Rheumatologic Care, American College of Rheumatology. Position Statement on Telemedicine. 2020 Sep.
