ACR: Telehealth could offset dwindling access to rheumatology care
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The recent explosion in the use of telehealth may compensate for ongoing trends in rheumatology — such as a worsening workforce shortage and rising patient costs — that stifle access to care, according to the American College of Rheumatology.
A 2020 survey conducted by the ACR found that approximately 66% of rheumatic disease patients reported having a rheumatology telehealth appointment within the last year, primarily due to COVID-19-related office closures. However, aside from its benefits during a pandemic, officials at the ACR said telehealth may prove valuable in countering nationwide workforce shortages in rheumatology, particularly for children and patients in rural areas.
“Telemedicine can indeed help to alleviate access problems in rheumatology which are already an ongoing issue,” Suleman Bhana, MD, FACR, chair of the ACR’s Communications and Marketing Committee, told Healio Rheumatology.
Despite research showing that as many as one-quarter to one-third of people in the United States have a rheumatic disease, there is, on average, just one practicing rheumatologist for every 40,000 people. The numbers are even more dire for juvenile care, with only 300 pediatric rheumatologists practicing in the entire United States, with demand projected to double the current supply by 2030. According to Bhana, there will be a further contraction in the rheumatology workforce over the next 10 years, due to retiring physicians and a lack of new training programs.
“Telemedicine can help ensure patients who are disabled or in remote areas and still have some access to rheumatology care,” he said. “Telemedicine can also help ensure the financial viability of independent rheumatology practices that are under heavy assault from increasing costs and high administrative burden. Through telemedicine, many more important patient discussions can be had than through an office billed visit.”
The ACR detailed these and other trends affecting rheumatology in a new white paper entitled, “Rheumatic Diseases in America: Confronting the Challenge.” The paper, released May 11, includes data from the ACR’s 2020 National Patient Survey and various studies, as well as analysis and commentary on what the numbers mean for the future of the field.
According to the document, 60% of respondents who said they had been referred to seek rheumatology care reported that they had to wait more than 30 days to secure an appointment — if they could get one at all. To meet this growing demand, the paper states that thousands more adult rheumatologist will be needed by 2030.
However, telehealth may be able to address these workforce and wait-time issues, the white paper argues.
“For patients living in rural areas, telehealth is a valuable option for those who would otherwise have to travel long distances to see a rheumatology health professional,” reads the document, in part. “Children with rheumatic diseases in particular could benefit from increased access to telehealth in that they may no longer have to miss school or extra-curricular activities to attend a rheumatology appointment.”
In addition, although the changes made by insurers and CMS that allowed providers the flexibility to expand telehealth services had been the product of the COVID-19 emergency, policymakers are currently mulling whether to make them permanent.
However, telehealth is far from a cure-all. According to Bhana, there are several inequities built into its use, chief among them being the uneven distribution of high-speed internet across the country, and the ability to access and use the required devices.
“There are barriers to a ubiquitous use of telemedicine. Some of those barriers include things on the patient side — access to broadband and high-speed internet, access to electronic device that can support a video call, and needing the technical acumen to operate a video call and navigate through difficult user interfaces,” Bhana said. “Other barriers are restrictions on interstate licensure to allow physicians in one state to see patients across state lines. Another would be making sure payers have parity in reimbursements for video and audio telehealth appointments compared to in person visits.”
He added: “It is my expert opinion that to maintain a robust telehealth environment, there has to be national and state policy changes that ensure the technological access to telehealth for all patients, as well as to maintain the financial stability of independent practices that rely on these visits as part of regular operating income.”
Racial/gender Disparities, Increasing Costs
The ACR white paper outlines numerous other trends in rheumatology, including the ever-increasing economic toll these diseases have on patients, both in terms of medical costs and lost wages. According to the document, rheumatic diseases account for $140 billion in medical costs each year. Patients with these diseases have also reported an additional $164 billion in lost wages and productivity. This combined figure of $304 billion is greater than the cost of cancer in the United States, according to the ACR.
In all, median annual out-of-pocket spending for patients receiving rheumatic treatment amounted to $1,000 in 2020, a two-fold increase from when the ACR surveyed out-of-pocket costs in 2019, according to the paper.
In addition, rheumatic diseases do not affect all Americans equally. According to the white paper, approximately one in 12 women will develop an autoimmune or inflammatory rheumatic disease in their lifetime. For men, that figure is one in 20. Women are two to three times more likely to be diagnosed with rheumatoid arthritis, and nine out of every 10 people with lupus are women.
Meanwhile, Black, Latino and Indigenous Americans demonstrate a significantly higher prevalence of activity limitations due to arthritis, compared with non-Hispanic whites, despite the overall prevalence of arthritis being similar across all groups.
Veterans also have a significantly higher prevalence of rheumatic disease, with one in three veterans diagnosed with arthritis, compared to one in five among the general population. Arthritis is the second leading cause of discharge from the U.S. Army, according to the paper.
Biosimilar Education, Notification
According to the ACR’s National Patient Survey, 29% of rheumatic disease patients were unsure of whether they had been prescribed a biosimilar drug. The white paper argues in favor of expanded patient education regarding the use and safety of biosimilars.
In addition, the paper reports that, between 2013 and 2019, a total of 48 states have enacted laws requiring patients to be notified when their drugs have been substituted for biosimilars. Only Oklahoma and Mississippi, alongside Washington, D.C., and the territories of American Samoa, Guam, the U.S. Virgin Islands and the Northern Mariana Islands, have no biosimilar notification laws on the books.
Impacts of Formulary Structure
According to the ACR, 47% of patients receiving treatment for a rheumatic disease were subject to a step therapy requirement. Another survey, from the Arthritis Foundation, found that more than half of patients who went through step therapy reported having to try two or more different drugs before ultimately receiving the one their physician had originally ordered. That same survey also reported that step therapy had to be stopped in 49% of cases because the drugs were ineffective, while they had to be ceased in 20% of cases due to worsening conditions.
Meanwhile, a survey 2017 from the AMA found that 92% of physicians reported that prior authorization caused delays in their patients’ care, according to the ACR. The survey also found that 78% of physicians reported that prior authorizations sometimes led to patients abandoning their treatment.
Lastly, the white paper cites a report released by the Texas Department of Insurance that analyzed 19 pharmacy benefit managers (PBMs) operating in the state, and found that PBMs collected more than $350 million in revenue between 2016 and 2019, compared with just $16 million in savings passed on to patients during that time.
“The fact that PBMs pocket a significant portion of the rebates they negotiate can also cause drug prices to rise,” reads the white paper, in part. “This is because the profit incentive motivates PBMs to demand higher rebates from manufacturers in exchange for preferred status in PBM formularies. To pay these higher rebates, drug manufacturers may in turn raise their list prices.”
According to the ACR, several states have enacted legislation requiring disclosures of discounts and rebates, and disallowing “claw-back” provisions from being inserted into PBM insurer contracts. In addition, the federal government in 2018 banned “gag clauses” that prevented pharmacists from informing patients about lower-cost alternatives.
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