Rheumatology Insights: October 2021 - Cardinal Health Specialty Solutions - Views on industry trends impacting rheumatology practices nationwide
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Cardinal Health Specialty Solutions Rheumatology Insights: October 2021 Views on industry trends impacting rheumatology practices nationwide
A message from the president
Heidi Hunter
Welcome to our second annual edition of Rheumatology Insights, a
research-based report designed to provide perspectives on key issues
and trends affecting rheumatology practices nationwide.
As someone who has spent a good portion of her career working in
rheumatology, I’ve seen firsthand how this therapeutic area has changed.
Over the past decade, the demand for rheumatology care has grown
steeply as the population has aged, while at the same time, the pressures
and complexities facing rheumatology practices have increased.
Our new report seeks to understand how rheumatologists are managing
these changing dynamics. We explored their perspectives on the impact
of COVID-19, how new reimbursement policies are affecting clinical
treatment and practice operations, and the role that technology and AI
may play in the future of rheumatology care.
The research shared in this issue was fielded using web-based surveys
from July through September 2021. Nearly 90 rheumatologists from a
mix of community- and hospital-based practices throughout the U.S.
participated in the research.
At Cardinal Health, we believe that understanding the needs of
healthcare providers is key to the delivery of better patient care. We hope
you find the insights in the enclosed report to be as valuable as we do.
Sincerely,
Heidi Hunter
President, Cardinal Health Specialty Solutions
2 3
COVID-19
At the time our first Rheumatology Insights
report was published in June 2020, COVID-19
was widely viewed as an acute health crisis
that healthcare providers and patients would
need to manage through for several months
until healthcare could return to “normal.”
Today, as the U.S. continues to wrestle with new variants of the virus and resurging
infection rates, there is broad consensus that COVID-19 will have long-term
implications on how healthcare is delivered across all therapeutic areas.
The evidence of COVID-19’s impact on rheumatology was clearly seen during the 2020
American College of Rheumatology (ACR) conference, in which numerous abstracts
examined how rheumatologists’ use of telemedicine has evolved,1 and several posters
explored how smartphone apps have been used to support telemonitoring of
rheumatic disease activity2 during the pandemic.
As COVID-19 continues to create challenges for rheumatology practices, we were
curious to understand rheumatologists’ views on the long-term implications of virus,
Assessing the
and to know how patient needs and care protocols have changed. We also wanted
to learn whether the pandemic is continuing to impact the financial and operational
performance of rheumatology practices.
impacts of COVID-19
on rheumatology
practices and
4
patient care 5
COVID-19 has shifted the paradigm of care for rheumatologists COVID-19
OUR VIEWPOINT
FINANCIAL IMPACT: More than four in 10 rheumatologists
Gordon K. Lam, MD, FACR surveyed said the financial health of their practices is not as strong
Medical Director, Clinical and Translational Research as it was before the pandemic, though new patient referrals are
Arthritis & Osteoporosis Consultants of the Carolinas
stable or increased.
The responses to our COVID-19 survey questions reflect the important
impact the pandemic has had on rheumatologists and their patients over Which of the following best describes the financial health of your practice today?
the past year and a half. The adoption of telemedicine services is perhaps
most notable. According to our survey, only 15% were using telemedicine The financial health of our practice is about the same today as it was before the pandemic
services before the start of the pandemic, but almost all practices adopted
in 2020, and more 93% of surveyed respondents say they expect some 46%
portion of patient visits will continue to be managed via telemedicine after
The financial health of our practice is not as strong today as it was before the pandemic
the end of the pandemic.
Although all rheumatologists would probably agree that in-person 43%
patient visits are always preferrable to virtual appointments, telemedicine
has enabled rheumatologists to maintain continuity of care during the The financial health of our practice is better today than it was before the pandemic
pandemic, has provided a way to see patients who might not otherwise be
able to receive care, and has created a new mechanism for reimbursement. 12%
An overwhelming majority (96%) of survey participants said they expect
to use telemedicine to see patients who lacked transportation, 46% would N = 87
use it to see immuno-compromised patients, and another 41% expect to
use it to triage patients in emergency situations.
Which of the following best describes your new patient referral volume today compared
In regard to new patient volume, 79% of surveyed rheumatologists say to pre-pandemic?
they are seeing the same amount or more patients than they did before
the pandemic, while 21% say they are seeing fewer patients. The 21% We are seeing similar levels of new patient referrals as before the pandemic
is surprising given that demand for rheumatology services nationwide
has continued to increase. This may reflect the continued impact of 43%
COVID-19 and could suggest that some patients may be continuing to
delay healthcare needs that are not viewed as urgent – or that referring We are seeing more new patient referrals today than before the pandemic
physicians are simply too busy treating COVID patients to refer patients for
other types of treatment. 37%
One important trend that is not reflected in the research is how We are seeing fewer new patient referrals today than before the pandemic
rheumatology treatments may shift due their possible interaction with
vaccines. Research has shown that several commonly used treatments, 21%
such as methotrexate, rituximab, and mycophenolate, may affect a
patient’s humoral response to the COVID-19 vaccine9. These findings N = 87
may affect rheumatologists’ treatment decisions, as well as their
recommendations on the timing of the vaccine doses10. Clearly, this will
be an important trend to watch over the coming months. 80% of participating rheumatologists
said new patient referrals are the same or greater
than before the pandemic.
6 7
COVID-19 COVID-19
TELEMEDICINE: Nearly two-thirds of participating rheumatologists For what purposes will you use telemedicine in the future?
said the pandemic caused them to adopt new approaches they will To see patients who lack transportation to appointments 90%
continue to use long term, such as telemedicine. To see patients who are immunocompromised 46%
Which of the following most aligns with your view on how the COVID-19 pandemic To triage patients who may need emergency care 41%
impacted patient care in your practice?
N = 87
The pandemic led us to adopt new approaches to patient
care, some of which we will maintain over the long term 58%
The pandemic had a temporary impact on how we
treated patients, but it has not had a long-term impact 39%
The pandemic had very little impact on patient care
3%
N = 87
Before the COVID-19 pandemic, what percentage of your patient visits were conducted
via telemedicine? After the end of the pandemic, what percentage of your patient visits
do you anticipate will be conducted via telemedicine?
Before pandemic
After pandemic
3%
84% 7% 10% 45% 26% 1% 14% 1% 8% While few practices were using telemedicine before the pandemic,
N = 87
0 1-10% 11-20% 21-30% 31% or more
93% 93% of participating rheumatologists
said they will continue to use it in the future, particularly with
patients who lack transportation to appointments.
8 9
COVID-19
IMPACT ON PATIENT CARE: Over 90% of rheumatologists surveyed
said the social and economic challenges posed by COVID-19 have
negatively impacted patients, with mental health support cited as
the most pressing unmet patient need.
Please indicate your degree of agreement with this statement. Social and economic
challenges created by the COVID-19 pandemic (including higher unemployment, social isolation,
etc.) have had a negative impact on the health of my patients.
N = 87
31% 59% 9% 1% 0%
Strongly agree Agree Neither agree Disagree Strongly disagree
nor disagree
What gaps or unmet needs in patient care have been revealed by the COVID-19
pandemic? Please select all that apply.
Mental health support 83%
Medication adherence support 61%
Support navigating insurance coverage/managed care 55%
Support with managing the cost of their therapy 52%
Caregiver support 43%
Other 5%
I do not see any significant gaps/unmet needs in patient care 1%
N = 87
10 11
INDUSTRY DYNAMICS
Although the COVID-19 pandemic created
unique challenges for rheumatology
providers, the landscape for rheumatology
practices has also been complicated by
new clinical developments and changes in
reimbursement policies.
The continuing shift from fee-for-service reimbursement to value-based reimbursement has
been a significant challenge for rheumatology practices for several years, as demonstrated
by our 2020 Rheumatology Insights survey. This year, to add to the complexity, the Centers
for Medicare & Medicaid Services (CMS) released a new ASP calculation methodology for
self-administered drugs,3 resulting in reimbursement decreases for several therapies that are
commonly prescribed by rheumatologists.
At the same time, rheumatologists are seeing shifts in the mix between infused therapies
and oral therapies. This impacts reimbursement because infused medicines are purchased
on a “buy and bill” model, meaning providers are reimbursed for the average sales price
of the therapy plus 6%. During the COVID-19 pandemic, some rheumatologists shifted
immunocompromised patients to oral therapies to avoid unnecessary clinic visits. However,
a new FDA black box warning on some oral therapies for arthritis4 and recent shortages of
other medications5 may result in a shift back to infused medicines.
Our survey sought to understand how rheumatologists are thinking about these issues, and
Responding to
what steps they are taking to help their practices respond to the challenges.
changing industry
and reimbursement
12
dynamics 13
Declining reimbursement continues to challenge rheumatologists,
and many do not have a plan for replacing lost revenue INDUSTRY DYNAMICS
OUR VIEWPOINT
CRITICAL CHALLENGES: Value-based care and changing
Gordon K. Lam, MD, FACR reimbursement models were cited as the biggest challenges
Medical Director, Clinical and Translational Research facing rheumatology practices, with the growing demand for
Arthritis & Osteoporosis Consultants of the Carolinas
care among an aging population and the growth of oral therapies
The rheumatology landscape has shifted over the past year – but the results
among key concerns.
of our survey show the rheumatologists’ perceptions about challenges are As you think about your practice, which of the following do you consider to be the biggest
largely the same as they were in 2020 with value-based care and changing challenge facing your practice?
reimbursement viewed as the top challenge by 28% of respondents vs. 29%
in 2020. Interestingly, fewer survey participants said they see increasing
2021 2020
administrative duties as a top challenge: 24% in 2021 vs. 33% in 2020.
N = 87
Although declining reimbursement is seen as a top challenge, it is not clear
that many rheumatologists have a clear plan on how to effectively respond
or counteract the trend. More than 59% said reimbursement changes
to self-administered drug products would have a significant negative or
somewhat negative impact on their practice, yet more than a third of
respondents (38%) said they were either unsure how they would mitigate
the impact or would not take steps to mitigate.
The survey also indicated that many rheumatology practices may be
missing opportunities to strengthen their financial performance by adding
new revenue streams. Expanding infusion services to therapeutic areas
outside of rheumatology has become an increasingly recognized revenue-
generating strategy for many practices, yet nearly half of our participants
28% 29% 18% 15% 24% 33%
said they infuse rheumatology patients only (48%) and another 14% said Value-based care and the changing Lack of providers to support the Increasing administrative and
they do not have an infusion center. reimbursement landscape growing number of patients practice management duties
Perceptions about the impact of oral therapies on rheumatology practices
was mixed with 28% saying they do not expect much impact, 46% saying
they expect to do fewer infusions, and 26% saying they are unsure what
the impact will be. While research shows that patients prefer oral therapies
over infused therapies11, the recent FDA announcement about black box
warnings for JAK inhibitors12 and the shortage of tocilizumab due to the
pandemic surge13, both of which occurred after this survey was completed,
will likely affect rheumatologists’ treatment decisions in the near term.
10% 8% 15% 10% 5% 5%
On the whole, the survey results indicate that rheumatologists and their
administrators may need to put more focus on revenue management to Increasing healthcare Lack of time to spend on Competition
maintain financial performance, as reimbursement pressures are likely to costs for patients patient care
intensify in the future.
14 15
INDUSTRY DYNAMICS INDUSTRY DYNAMICS
As the U.S. population ages, demand for rheumatology services is expected to grow while A growing number of oral therapies for rheumatology are in the drug development pipeline.
the number of practicing rheumatologists is expected to decrease. How does your practice As more oral therapies come to market, how do you see your practice changing?
expect to manage these changing dynamics? Please select your top 3.
2021 2020
N = 87
37% 28% 26% 9%
We expect to perform fewer We do not expect any I am not sure how more We expect to perform fewer
infusions and subcutaneous major impact over the oral therapies will impact infusions and subcutaneous
injections and expect to see next several years my practice injections and will explore
in-practice dispensing or
a decrease in revenue
adding a specialty pharmacy
47% 57% 31% 20% 32% 34% 30% 34%
Hire more advanced Hire more Expand patient care Invest in technology/
practice providers/ administrative staff with telemedicine tools to enable providers
clinicians (APPs) to spend more time on
patient care
16% 14% 15% 23% 10% 8% 8% 11%
Extend hours to provide Postpone retirement Use consulting services Sell or merge the practice
patient services on evenings to aid with practice
and/or weekends management
of participating rheumatologists said they plan More than four in 10 participating rheumatologists said
15% to postpone retirement due to the demands they expect to perform fewer infusions and injections
of an aging patient population. as more oral therapies arrive on the market.
16 17
INDUSTRY DYNAMICS INDUSTRY DYNAMICS
DECLINING REIMBURSEMENTS: About 60% of rheumatologists This year, the Centers for Medicare & Medicaid Services (CMS) announced reimbursement
changes for certain Medicare Part B drugs (such as Orencia® and Cimzia®) that have self-
surveyed said reimbursement has declined, though some have administered formulations. How much of a negative impact will this adjustment have on
adapted by adding new sources of revenue. your practice this year?
Which of the following best describes your view of the reimbursement landscape
in rheumatology?
14%
47% 37% 2%
Reimbursement for my
practice has declined over
We have not seen a
significant change
Reimbursement has
declined, but my practice
Reimbursement for my
practice has increased
20% 39% 17% 12% 13%
the past year in reimbursement has counterbalanced over the past year
these changes by adding Significant Somewhat Very little No impact Not sure
over the past year
new sources of revenue negative impact
negative impact negative impact
N = 87
N = 87
What strategies will you implement to mitigate this negative impact? Please select all that apply.
Explore other new revenue streams 33%
Start new patients on different drug therapies 27%
Move existing patients to different drug therapies 23%
I do not anticipate making any changes to mitigate the impact 20%
Unsure 18%
Change my payer mix/Limit the number of Medicare patients 11%
N = 87
18 19INDUSTRY DYNAMICS INDUSTRY DYNAMICS
MULTI-SPECIALTY PRACTICES: About one in three rheumatologists PATHWAY PROGRAMS: Only about one in four rheumatologists
surveyed said they care for patients treated for other diseases, surveyed said their practices participate in commercial payer or
primarily to address community need. health plan-sponsored pathway programs, but 22% said they are
considering it for the future.
Which of the following best describes your current practice?
Does your practice participate in any commercial payer or health plan-sponsored
pathway programs?
62 % 24 % 14 %
5%
46% 35% 15%
No, we do not currently participate Yes, we currently participate in No, but we plan to participate in
We infuse rheumatology We are a multi-specialty We don’t have our own We currently infuse in pathway programs pathway programs pathway programs in the future
patients only infusion practice, infusing infusion center; we refer rheumatology patients
both rheumatology and our patients to a multi- only, but are considering
N = 87
specialty infusion center expansion into other
patients treated for other
specialties
diseases
N = 87
83% of “Supports a need in
rheumatologists my community” (35%)
with multispecialty was the most cited reason
practices said they for expanding into other Among practices in pathway programs,
provide infusions for specialties. participating rheumatologists
cited limited availability of programs (28%), finding
gastroenterology
the patients to participate (26%) and managing data
patients. and reporting (20%) as the biggest challenges.
Dermatology (47%),
immunology (43%) and
neurology (40%) were
also commonly cited.
20 21AI / MACHINE LEARNING
As the industrywide shortage of rheumatologists
continues to challenge both patients and
providers, there has been increased focus on the
role that technology and artificial intelligence
(AI) can play in reducing the resources burden
and helping to support diagnosis and patient
treatment decisions.
The 2020 American College of Rheumatology meeting featured several abstracts and posters
exploring the use of technology in practice, including studies using AI-driven methodologies for
X-ray data analysis6 and a study that examines whether machine learning can more effectively
identify clinical features and biomarkers to predict response to key treatments.7
In addition, as remote monitoring of rheumatology patients has become more common during
the COVID-19 pandemic, some researchers are studying the role that digital health technology,
such as wearables and apps, can play in supporting better health.8
The emerging research around these technologies and the early adoption of AI-based tools in
other therapeutic areas suggests there could be a significant opportunity to use AI to enhance
care of rheumatology in the future. Our survey is intended to gauge whether rheumatologists are
following these technology trends and if they see the same potential for AI in the years ahead.
Technology use
and the future
outlook for AI in
22
rheumatology 23Rheumatologists lack familiarity with artificial intelligence and
machine learning and are skeptical about the value of these tools AI / MACHINE LEARNING
OUR VIEWPOINT
CURRENT TECHNOLOGY USE: Nearly all rheumatology practices
Amy Valley, PharmD surveyed use electronic health records (EHRs), and participating
Vice President, Clinical Strategy and Technology Solutions, GPO rheumatologists said they are likely to make further investments in
EHRs in the coming year.
Advances in technology may have the potential to significantly alleviate Which of the following technology solutions do you currently use in your practice? Which
some of the pressures facing rheumatologists. Yet our survey shows most of the following technology solutions do you expect to invest in during the coming year?
rheumatologists have low awareness of these innovations and limited Please select all that apply.
confidence in the ability to drive change.
Despite increased use of artificial intelligence (AI) in rheumatology, more Electronic health records
than half of survey respondents (55%) said they are not very familiar with
the use of AI and machine learning in healthcare, and only a quarter of 97%
respondents believe AI will have a significant impact on rheumatology 40%
care over the next three years. In addition, less than one third (32%)
say they can envision AI playing an important role in informing their Inventory management system
treatment decisions in the future. These results are somewhat surprising
when considering the growing body of research showing the application 13%
of AI to evaluate rheumatologic disease and to predict how it will progress.
10%
In addition, when asked about future applications of AI and machine
learning, less than half (45%) say it is likely or very likely that they will drive Practice management system
operational efficiencies for rheumatology practices, and far fewer say it is
likely that AI and machine learning will help to improve the quality of care 25%
(36%) or lower healthcare costs (27%). 24%
Interestingly, many of the challenges facing rheumatologists today may
eventually be addressed by AI-powered solutions. As our survey shows, Infusion management tool
rheumatologists continue to cite declining reimbursement as their
top challenge, and AI is increasingly being used within revenue cycle 17%
management tools to increase efficiency and make financial management 19%
more predictable. We are also seeing a growing use of AI in population
health tools, which can be used to guide clinical decisions, such as which Analytics and reporting tools
patients are likely to be adherent to their treatment plan or to experience
clinical deterioration. These tools may help providers to identify patients 25% Solutions in place
that need proactive interventions or additional supportive services.
24% Likely to invest in coming year
Overall, our survey suggests there is a need for more education around
the role that technology can play in supporting rheumatologists. Those N = 87
providers who embrace the opportunities early may see advantages in
both clinical care delivery and the financial performance of their practice.
About 40% of participating rheumatologists
plan to invest in EHRs in the coming year though nearly all
have a system in place.
24 25AI / MACHINE LEARNING
NEAR-TERM OUTLOOK ON AI: Most rheumatologists surveyed
said they have limited familiarity with artificial intelligence (AI)/
machine learning in healthcare and see minimal impact over the
next three years.
How familiar are you with the use of AI/machine learning in healthcare?
10 %
Very familiar
33 %
Moderately familiar
56 %
Not very familiar
N = 87
What impact do you expect AI/machine learning to have on rheumatology care over the
next three years?
53% 24% 23%
Over 75% of rheumatologists surveyed predicted Limited impact. We may see some Significant impact. A considerable No impact. The promise of AI is
mostly theoretical at this point.
limited or no impact of AI and machine adoption of AI tools among select
rheumatology practices.
number of practices are likely to adopt
AI tools over the next three years.
learning on care in the next three years.
N = 87
26 27AI / MACHINE LEARNING
THE LONGER VIEW: Looking longer-term, participating
rheumatologists are generally pessimistic about the potential
of AI/machine learning, with less than half believing it is likely
or very likely to improve quality of care, drive operational
efficiencies, enhance clinical outcomes or lower costs.
Improve quality of care Drive operational efficiencies
8% 15%
Very likely Very likely
25% 26%
Likely Likely
40% 43%
Somewhat likely Somewhat likely
21% 12%
Unlikely Unlikely
6% 5%
Very unlikely Very unlikely
Enhance clinical outcomes Lower costs
13% 10%
Very likely Very likely
21% 15%
Likely Likely
40% 36%
Somewhat likely Somewhat likely
20% 32%
Unlikely Unlikely
7% 7%
Very unlikely Very unlikely
N = 87
28 29AI / MACHINE LEARNING
POTENTIAL AI BENEFITS: Only one-third of participating
rheumatologists can envision AI playing an important role
in treatment decisions, but 46% say it could provide value in
automating administrative tasks.
When it comes to using AI/machine learning to support treatment decisions, which of
the following best reflects your view?
64% 26% 9%
AI tools may provide some useful I can envision AI playing an important I would not use an AI tool to support
information, but ultimately, I would rely role in informing my treatment my treatment decisions
on my own training and judgment to decisions, particularly as treatment
guide treatment decisions options grow more complex
N = 87
Which of the following would be the most valuable benefit that AI/machine learning
could deliver to your practice?
Automating administrative tasks
so I can focus on patients 46%
Identifying best treatment path so patients
get the right drug the first time 18%
Predicting patients most likely to develop
complications or experience adverse events 13%
Accelerating diagnosis so patients
can start treatment sooner 12%
Automating functions that are currently staffed
by people, allowing my practice to save money 9%
Predicting patients most likely to be
non-adherent to therapy 2%
N = 87
30 31Contributors References
Gordon K. Lam, MD, FACR 1 https://acrabstracts.org/abstract/lasting-covid-19-impacts-on-us-rheumatology-
practices/
Medical Director, Clinical and Translational Research
Arthritis & Osteoporosis Consultants of the Carolinas 2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057822/
3 https://www.cms.gov/files/document/mm12244.pdf
Amy Valley, PharmD
Vice President, Clinical Strategy and Technology Solutions 4 https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-warnings-
about-increased-risk-serious-heart-related-events-cancer-blood-clots-and-death
Cardinal Health Specialty Solutions
5 https://www.cnn.com/2021/08/27/health/actemra-shortage-rheumatoid-
arthritis-covid/index.html
A note from our medical team 6 https://acrabstracts.org/abstract/an-artificial-intelligence-ai-assistant-
identifying-spinal-diffuse-idiopathic-skeletal-hyperostosis-on-plain-x-rays-a-
Duis aliquam tellus elementum tortor cursus, quis dictum pilot-deep-learning-study/
ipsum efficitur. Aliquam elementum ultricies semper. Nulla 7 https://acrabstracts.org/abstract/identification-of-a-rule-to-predict-response-to-
semper mattis elit, sed imperdiet lectus dictum eu. In ut magna sarilumab-in-patients-with-rheumatoid-arthritis-using-machine-learning-and-
in est condimentum condimentum. Vestibulum lacinia gravida clinical-trial-data/
sapien eu vestibulum. Mauris id bibendum purus. Donec 8 https://acrabstracts.org/abstract/development-and-preliminary-validation-of-
sollicitudin euismod mollis. smartphone-sensor-based-measurement-tools-for-psoriatic-arthritis/
9 https://ard.bmj.com/content/early/2021/08/22/annrheumdis-2021-220597
10 https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1159
Methodology 11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6124803/#:~:text=The%20
The research was fielded using web-based surveys in July survey%20revealed%20that%2064,no%20preference%20(Table%202).
through September 2021. Nearly 90 rheumatologists from a 12 https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-warnings-
mix of community- and hospital-based practices participated about-increased-risk-serious-heart-related-events-cancer-blood-clots-and-death
in the research. 13 https://www.cnn.com/2021/08/27/health/actemra-shortage-rheumatoid-
arthritis-covid/index.html
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