Rheumatology as a primary inpatient service essentially is a thing of the past, but that doesn't mean the service line deserves short shrift.

Twenty years ago, it wasn't unusual for patients with rheumatoid arthritis to be admitted because their joint problems grew severe enough to require inpatient care. However, in the late 1990s and early 2000s, development of biologic medications revolutionized treatment for rheumatoid arthritis and other autoimmune diseases. Among them were the first TNF blockers. These drugs suppress the immune system, thus preventing inflammation and the resulting damage that once landed patients in the hospital.

Now, patients rarely are hospitalized because of rheumatologic diseases, of which there are 100. Admission typically is for a severe flare-up of an autoimmune condition, says David A. Fox, M.D., chief of the division of rheumatology at the University of Michigan, Ann Arbor. So, rheumatology in the inpatient setting typically is a consult service.
However, patients need a host of outpatient services to keep these diseases in check. Arthritis or another rheumatic condition was the principle or secondary diagnosis in nearly 9.6 million emergency or outpatient department visits in 2006, according to the 2011 report, "The Burden of Musculoskeletal Diseases in the United States," a joint project of several medical societies. Plus, many rheumatology patients need inpatient care for the serious medical problems that sometimes accompany their rheumatologic conditions.

Regardless, the way to attract these patients to the hospital is by offering strong outpatient rheumatology care that, ideally, is well-coordinated with the other specialty services these patients often need.

Care models span the spectrum from employed rheumatologists providing care mainly at a hospital outpatient clinic to independent rheumatologists who use the community hospital primarily for ancillary services.

In recent years, the growing incidence of osteoarthritis, fueled by the aging of the population and the obesity epidemic, has helped to spur creation of outpatient musculoskeletal centers at some hospitals with sufficient volume. Osteoarthritis was, by far, the most common reason for hip and knee replacements, which represented 96 percent of the nearly 1 million inpatient arthroplasty procedures performed in 2006, the musculoskeletal diseases report found. By 2030, more than 570,000 primary total hip replacements and 3.5 million primary total knee replacements are expected to be done in this country.

One-stop shop

Patients with arthritis or other musculoskeletal conditions have medical needs that cross several specialties. For these patients, a musculoskeletal center offers a one-stop shop for a wide scope of care, which can include orthopedics, rheumatology, rehabilitation, pain management and imaging.

One example is the New York University Langone Medical Center's 110,000-square-foot Center for Musculoskeletal Care, which opened in March. The facility consolidated virtually all the outpatient musculoskeletal services across the medical center: reconstructive and joint replacement surgery, spine disorder treatments, arthritis and autoimmune disease care, sports medicine, physical and occupational therapy, imaging, and pain management. It includes a 7,200-square-foot gym and therapy space. In its first six months, the center had more than 70,000 visits, says Steven B. Abramson, M.D., director of the division of rheumatology and a senior vice president and vice dean at NYU Langone.

Patient care is coordinated via electronic health record. Physicians can access each other's notes and make referrals electronically. The shared location offers benefits. "I can just walk across the hall and have an orthopedist come in and look at a patient just as a brief hallway consultation," Abramson says.

The EHR and providers' physical proximity give patients more satisfying, coordinated care. "It reduces the time that patients have to spend between encounters with each of the specialists," Abramson says. "When you integrate and coordinate care like this, there is a time benefit that improves outcomes."

The University of Michigan is experimenting with clinics that combine rheumatology, orthopedics and rehabilitation medicine in one location. The focus is on patients with osteoarthritis and other orthopedic or rheumatologic problems that could be medical, surgical or a combination of both. "The idea is if the patient is referred to orthopedics but he or she really needs to see rheumatology, you could make that lateral shift right on the same day and get two encounters with the patient right there," Fox says.

The clinic is held two half-days a week, and a third half-day will be added soon. "We'd like to expand it to where essentially all of our nonsystemic autoimmunity practice would be in combination with orthopedics and rehab medicine," Fox says.

The multispecialty clinic approach is better for physicians because they can make a care plan together that day, he adds. Patients benefit from quicker and more efficient care.

The emergence of this model shows that hospital leaders understand that a hospital is not separate from the ambulatory provision of care, Abramson says. "If I'm a CEO of a hospital, I have to have a network of ambulatory care providers, and I have to have those providers connected electronically. In musculoskeletal care, that's the leading push of that trend because it is such a team sport."

Expanding the scope

The clinical scope of rheumatology is growing as other specialists turn to rheumatologists for treatment of certain conditions, Fox says. "There are lots of patients with diseases we didn't used to see, but they're referred to rheumatology now because it's realized that immunosuppressive treatments of various types — not just biologics, but some of our other usual medications — can be used for people with these diseases." He cites inflammatory eye disease, autoimmune hearing loss and skin conditions as examples.

Other specialists are comfortable diagnosing the conditions, but aren't comfortable treating patients with the medications in the rheumatology arsenal. "This has gotten bigger and bigger, and we're starting now to set up other models of care where, for instance, we will have a rheumatologist practice in the eye clinic and do that component of the care there," Fox says.

The coordination of ambulatory services across specialties doesn't just help the patient. "It's in the best interest of the hospital from an economic point of view," Abramson says. "By keeping that work internally, a hospital limits leakage. You don't just see patients in one site and send them off to see another doctor in another part of [town] or even outside your own care providers."

These patients can bring infusion center, lab, imaging and rehab business to hospitals, says Eric Ruderman, M.D., chief medical officer at Epiphany Healthcare Advisors in suburban Chicago and professor of medicine at Northwestern University Feinberg School of Medicine. Volume depends on the community's size, the physician practice's internal capabilities, the hospital's offerings and the hospital's relationship with the rheumatologists, he adds.

A handful of biologic medications used to treat autoimmune diseases are given via infusion, making this service essential to rheumatologists and their patients. Lab work is relied upon for diagnosing some rheumatologic conditions, for monitoring the course of disease and for determining if some drugs' dangerous side-effects have occurred. Imaging is used frequently to diagnose and track various arthritic conditions.

The number of self-injectable and oral drugs for rheumatologic diseases has grown, but use of infusion medications isn't expected to slack off because there are more of these therapies, their indications for use have expanded, and they work for many patients for whom front-line rheumatology drugs have failed.

The University of Michigan can't keep up with demand. "We're finding [that] we open up a few infusion beds and within a few months they're full, and we need to open up more infusion beds," Fox says.

Infusion services are provided at the medical center and satellite facilities, he notes. The medical center owns the infusion units. So, while the rheumatologists order infusions, the hospital keeps the revenue.

Rheumatologist Crispin Abarientos, M.D., estimates that his patients represent about one-third of the patients at the infusion center at Middlesex Hospital in Middletown, Conn. His patients' labs and imaging also are done at the hospital.

The trend among larger, independent rheumatology practices and multispecialty practices is to provide imaging and infusion services in-office, Ruderman says. But independent, one- or two-physician rheumatology practices might not have the infrastructure or staff to handle these services and send their patients to a hospital or another center.

The high cost of infused biologics also could help to drive this trend. As payers strive to control cost, they will begin clamping down on more-costly hospital infusions in favor of infusion in physicians' offices, Ruderman says.

Payers chime in

Regardless of where infusions occur, providers can expect more utilization management efforts from payers on these and other expensive rheumatology drugs. Rheumatologists already are familiar with insurers' prior authorization rules, requirements that patients fail nonbiologic therapy before biologic medication is covered, and formulary restrictions.
Now, some insurers are shifting biologic medication coverage from a medical benefit to a pharmacy benefit and charging patients a percentage of the cost, according to a 2008 survey featured in the "Biologics Trend Report." Some biologics cost tens of thousands of dollars a year. "If a patient is on a fixed income, what is he going to do?" Abarientos says.

Other insurers continue to consider biologics coverage a medical benefit, which is an important consideration for hospitals moving toward an accountable care organization or other risk-sharing model, Ruderman says.

"If you've got X number of rheumatoid arthritis patients, as many as 50 percent of whom ultimately may be on medications that cost $25,000 to $35,000 a year and you don't factor it into your cost per member or lives that you cover, you're going to lose a ton of money," he says.

The prospect of ACO development is causing uncertainty among some rheumatologists. The worry is that an overemphasis on primary care and budget control could lead to delays in referrals to specialists. "If there is a delay in getting to see a specialist who makes the proper diagnosis and who puts you on the medicine you should have been on six months ago, that's not good for care," Abramson says.

Abarientos says he sees patients whose osteoarthritis or rheumatoid arthritis has gone undiagnosed for years. By the time they come to him, they already have severe joint damage and need aggressive disease management.

Fox, however, says ACOs shouldn't pose a threat. "Rheumatologists can practice in almost any kind of setting," he says, adding that primary care physicians are too intimidated by rheumatologic diseases for a lack of referrals to be a concern.

Midlevels step up

Another rheumatology trend is increased use of midlevel providers. It's being fueled by a growing shortage of rheumatologists, increased demand for services and cost pressures.

"Twenty years ago, I'd never heard of using a physician assistant or nurse practitioner in a rheumatology practice, and now we're doing that," says Eric Matteson, M.D., rheumatology chair at the Mayo Clinic, Rochester. "They can help us to manage patients for routine follow-up and make it cheaper for the health care system."

The change is occurring at community and medical center practices, Fox says. Although diagnosis and patient evaluation is done by rheumatologists, osteoarthritis and follow-up of stable rheumatoid arthritis, fibromyalgia and other more musculoskeletal rheumatologic conditions can be handled by skilled NPs and PAs for much of the treatment course, with intermittent physician involvement.

In addition, most osteoarthritis is managed by primary care physicians, Fox says, because it's extremely common given the aging of the population, and because not all osteoarthritis patients can see a rheumatologist or need to. "Eventually, if it gets really bad, it's time for them to go to the orthopedic surgeon. But there is an in-between group where we get involved in the management."

Inpatient care required

Although rheumatology by and large has become an outpatient field, inpatient care still is a factor. Arthritis or another rheumatic condition was the primary or secondary diagnosis in about 5.2 million hospitalizations in 2007, according to the 2011 burden of disease report. Community hospitals, especially those in competitive markets, continue to need good links with rheumatologists to attract their patients when they need hospitalization.

Several autoimmune diseases — including rheumatoid arthritis, gout and lupus — not only affect patients' joints, but can cause serious problems in other body systems. The various forms of vasculitis, an autoimmune disease that inflames blood vessels, can harm multiple organs. Patients with these diseases are more likely to suffer heart attacks, strokes or kidney disease than the general population.

"The patients we're seeing in the hospital for rheumatologic services are patients who have rheumatologic disease and some major comorbidity, like heart disease," Matteson says.

In addition, the immunosuppressive drugs taken by patients with autoimmune disease can cause infections, some of which are serious enough for hospitalization.

The complex and chronic nature of the diseases they treat means rheumatologists generate business for other service lines, including cardiology, gastroenterology and radiology.

"[Rheumatology patients] all will wind up in the hospital at one point or another, either because of a complication or a comorbidity," Matteson says. "They get cancer, they have heart disease, they have strokes, they have GI bleeding, they have infections, so having a good relationship with rheumatologists is a good thing."


A leader in measuring and improving quality of care

The field of rheumatology has been a leader in developing quality measures, beginning with rheumatoid arthritis and branching out from there, says Eric Matteson, M.D., rheumatology chair at the Mayo Clinic, Rochester, Minn. "We routinely use a battery of measures in the assessment of our patients and use these with great effect to help us guide treatment of our patients toward better outcomes," he says.

The American College of Rheumatology has published quality measure sets and practice guidelines for conditions including rheumatoid arthritis, gout, osteoarthritis and rheumatologic drug safety. This year, the college published new practice guidelines for gout and updated its recommendations for use of disease-modifying antirheumatic drugs and biologic agents for rheumatoid arthritis. In the works are an update of the guidelines for the most common form of juvenile arthritis and new guidelines for axial spondyloarthritis, an arthritis of the back.

The Mayo Clinic tracks a variety of rheumatology quality measures, Matteson says. The data are captured through the electronic health record, and performance results are shared with physicians every six months.

At the Center for Musculoskeletal Care at the New York University Langone Medical Center, new patients are asked to fill out questionnaires on their iPads or home computers before they see their doctors. "The information … enters the electronic health record and becomes patient-reported outcomes that we follow for individual patients," says Steven B. Abramson, M.D., director of the NYU division of rheumatology. "Then, as part of research efforts, we can call up this data and begin to ask questions about all the patients in our group with certain conditions, how they're doing and aggregate the data." — Geri Aston


FRAMING THE ISSUE:

  • To a large degree, rheumatology services have moved to outpatient settings.
  • Hospitals can maintain their service lines by developing a network of ambulatory care providers and
    connecting them electronically.
  • Other specialists are sending patients to rheumatologists for certain treatments. Hospitals will benefit by coordinating ambulatory services across specialties.
  • Hospitals need good links with rheumatologists for referral of patients; 5.2 million hospitalizations were for a primary or secondary diagnosis of some rheumatic condition.

EXECUTIVE CORNER

Creating a one-stop shop

Some large institutions are creating outpatient musculoskeletal centers that are a one-stop shop for orthopedic, rheumatologic, rehabilitative, pain management and imaging care. Patients with arthritis or other musculoskeletal conditions have medical needs that cross specialties. Placing these services in one location means that patients can, for example, see their doctors and receive imaging or rehab without leaving the building. Providers' physical proximity, along with a shared electronic health record, foster integrated and coordinated care. Offering comprehensive services in one place means patients are less likely to seek outside providers.

Downstream revenue

Rheumatologists can generate downstream revenue for hospital infusion centers, labs, and imaging and rehab departments because their patients typically need one or more of these services. Volume depends on the community's size, the physician practice's internal capabilities, the hospital's offerings, and the hospital's relationship with the rheumatologists. However, payers' cost concerns and rheumatologists' interest in keeping revenue in their practices might mean infusion and imaging increasingly are done in physician offices.

Remember the inpatients

Although rheumatology has become an outpatient field, by and large, inpatient care still is a factor. Many rheumatologic diseases not only affect patients' joints, but can cause serious problems in other body systems. Patients with these diseases are more likely to suffer heart attacks, strokes or kidney disease than the general population. Having good relationships with rheumatologists can bring referrals to the hospital when patients require admission.— Geri Aston


Fibromyalgia

  • Prevalence: 5 million adults in 2005
  • Inpatient: 262,200 hospitalizations
  • ED visits: 412,700
  • Outpatient department visits: 369,100
  • Physician office visits: 3.2 million

Gout/other crystal arthropathies

  • Prevalence: 8.3 million adults
  • Inpatient: 552,100 hospitalizations
  • ED visits: 277,800
  • Outpatient department visits: 265,000
  • Physician office visits: 2.3 million

Osteoarthritis

  • Prevalence: 26.9 million adults in 2005
  • Inpatient: 2.5 million hospitalizations
  • ED visits: 186,200
  • Outpatient department visits: 1.3 million
  • Physician office visits: 18.4 million

Rheumatoid arthritis

  • Prevalence: 1.5 million adults
  • Inpatient: 399,200 hospitalizations
  • ED visits: 40,000
  • Outpatient department visits: 344,600
  • Physician office visits: 3.2 million

Systemic lupus erythematosus

  • Prevalence: 322,000 to 1.5 million people, depending on source
  • Inpatient: 166,500 hospitalizations
  • ED visits: 44,000
  • Outpatient department visits: 85,600
  • Physician office visits: 1.1 million

Note: All prevalence figures combine primary and secondary diagnoses. Inpatient data is for 2007; outpatient and ED data are for 2006.

Sources: American College of Rheumatology, Centers for Disease Control and Prevention, "The Burden of Musculoskeletal Diseases in the United States," 2011