Assessing the Need for Improved Access to Rheumatology Care
Assessing the Need for Improved Access to Rheumatology Care
Of the 77 physician medical directors surveyed, 36 (47%) responded. Of these, 24 (67%) described their CHC as federally qualified, and 3 (8%) as federally qualified look-alike centers, both of which are reimbursement designations from the US Department of Health and Human Services (Table 1). Look-alike centers meet all of the requirements of federally qualified health centers, notably location in an underserved area, provision of primary care services, and a sliding fee scale; however, they do not receive funding from a specific federal grant. Among respondents, 7 (19%) were owned by academic medical centers; however, 24 (67%) were affiliated with an academic institution, and 10 (28%) admitted patients to teaching hospitals. Twenty-six centers (72%) were located in federally designated medically underserved areas. On average, 91% (SD 25%) of the housing in the CHC ZIP codes was classified as urban.
Overall, 30 (80%) of the CHCs participated in a referral network. The mean percentage of visits for patients with private insurance that resulted in outside referrals was 21% (SD 16%), similar to 27% (SD 20%) with Medicaid, and 20% (SD, 13%) without insurance. The majority of CHCs (52%) referred patients to rheumatologists at academic medical centers. Of the 33 directors who responded to the question, 18 (55%) indicated that there was a need for better access to rheumatologists at their CHC. However, 20 (61%) felt that their patients would prefer to see a rheumatologist on site at their CHC. Two CHCs (5.6%) had an on-site rheumatologist: one for a half day per week and one for a full day per week.
The CHCs served a wide range of RA and SLE patients. Eight of the respondent CHCs estimated that their physicians had fewer than 10 RA patients, and 14 had fewer than 10 SLE patients. Twelve CHCs served more than 30 RA patients, whereas only 4 CHCs had more than 30 SLE patients. Of the 2 CHCs with on-site rheumatologists, one reported having greater than 30 SLE and RA patients, 81% to 100% of whom see a rheumatologist. The majority of respondents felt that their CHC physicians would start neither an RA patient on a DMARD (86%) nor an SLE patient on an immunosuppressant (94%). However, 58% of directors stated that their physicians would refill a DMARD, and 50% would continue an immunosuppressant.
After stratifying by the medical directors' response to whether better rheumatology access was needed, we observed no statistically significant differences by CHC location in medically underserved areas or affiliation with academic medical centers (Table 2). There were also no differences in DMARD- or immunosuppressant-prescribing practices. Among directors who indicated a need for better access, 44% felt that the majority of their SLE patients saw a rheumatologist, compared with 80% in the group with sufficient access (P = 0.08). A similar trend was noted among RA patients (P = 0.11). Medical directors at CHCs that needed better rheumatology access were more likely to report that patients with Medicaid (P = 0.01) and private insurance (P = 0.04) required outside referrals, compared with directors at CHCs that did not need better access.
Of the 36 respondents, 28 (78%) ranked the proposed intervention options from 1 (preferred) to 4 (Figure). The highest ranked option was a patient navigator; 16 (57%) respondents ranked it first. Dominant themes based on written responses included the role of the navigator to coordinate care (5/18, 28%), to reduce cultural and language barriers (9/18, 50%), and to assist with management of other chronic illnesses (3/18, 6%). Feedback regarding a CHC-based nurse practitioner/physician assistant with a remote rheumatologist included on-site access to rheumatology care and DMARD therapy (5/17, 29%) and the need for a well-trained, independent practitioner (5/17, 29%). In terms of rheumatic disease–specific health passports, nearly half (44%) of the medical directors felt that low literacy, English language skills, level of education, poor compliance, and cultural differences would limit its use. Three respondents (17%) felt that an Internet-based version would be inaccessible for the majority of their patients. The least preferable intervention was telemedicine; 13 (46%) respondents ranked it last. Limitations included inadequate technology and technical support (8/20, 40%), the impersonal nature of telecommunication (4/20, 20%), and language and literacy issues (3/20, 15%).
A few medical directors highlighted additional obstacles to rheumatology care. One respondent stated that the main problem is not a lack of rheumatologists but rather inadequate "access due to insurance and language barriers." Similarly, 2 other directors noted the challenge of finding nearby rheumatologists, even at major medical centers, willing to accept patients with no insurance or with MassHealth (the state Medicaid program).
Results
Of the 77 physician medical directors surveyed, 36 (47%) responded. Of these, 24 (67%) described their CHC as federally qualified, and 3 (8%) as federally qualified look-alike centers, both of which are reimbursement designations from the US Department of Health and Human Services (Table 1). Look-alike centers meet all of the requirements of federally qualified health centers, notably location in an underserved area, provision of primary care services, and a sliding fee scale; however, they do not receive funding from a specific federal grant. Among respondents, 7 (19%) were owned by academic medical centers; however, 24 (67%) were affiliated with an academic institution, and 10 (28%) admitted patients to teaching hospitals. Twenty-six centers (72%) were located in federally designated medically underserved areas. On average, 91% (SD 25%) of the housing in the CHC ZIP codes was classified as urban.
Overall, 30 (80%) of the CHCs participated in a referral network. The mean percentage of visits for patients with private insurance that resulted in outside referrals was 21% (SD 16%), similar to 27% (SD 20%) with Medicaid, and 20% (SD, 13%) without insurance. The majority of CHCs (52%) referred patients to rheumatologists at academic medical centers. Of the 33 directors who responded to the question, 18 (55%) indicated that there was a need for better access to rheumatologists at their CHC. However, 20 (61%) felt that their patients would prefer to see a rheumatologist on site at their CHC. Two CHCs (5.6%) had an on-site rheumatologist: one for a half day per week and one for a full day per week.
The CHCs served a wide range of RA and SLE patients. Eight of the respondent CHCs estimated that their physicians had fewer than 10 RA patients, and 14 had fewer than 10 SLE patients. Twelve CHCs served more than 30 RA patients, whereas only 4 CHCs had more than 30 SLE patients. Of the 2 CHCs with on-site rheumatologists, one reported having greater than 30 SLE and RA patients, 81% to 100% of whom see a rheumatologist. The majority of respondents felt that their CHC physicians would start neither an RA patient on a DMARD (86%) nor an SLE patient on an immunosuppressant (94%). However, 58% of directors stated that their physicians would refill a DMARD, and 50% would continue an immunosuppressant.
After stratifying by the medical directors' response to whether better rheumatology access was needed, we observed no statistically significant differences by CHC location in medically underserved areas or affiliation with academic medical centers (Table 2). There were also no differences in DMARD- or immunosuppressant-prescribing practices. Among directors who indicated a need for better access, 44% felt that the majority of their SLE patients saw a rheumatologist, compared with 80% in the group with sufficient access (P = 0.08). A similar trend was noted among RA patients (P = 0.11). Medical directors at CHCs that needed better rheumatology access were more likely to report that patients with Medicaid (P = 0.01) and private insurance (P = 0.04) required outside referrals, compared with directors at CHCs that did not need better access.
Of the 36 respondents, 28 (78%) ranked the proposed intervention options from 1 (preferred) to 4 (Figure). The highest ranked option was a patient navigator; 16 (57%) respondents ranked it first. Dominant themes based on written responses included the role of the navigator to coordinate care (5/18, 28%), to reduce cultural and language barriers (9/18, 50%), and to assist with management of other chronic illnesses (3/18, 6%). Feedback regarding a CHC-based nurse practitioner/physician assistant with a remote rheumatologist included on-site access to rheumatology care and DMARD therapy (5/17, 29%) and the need for a well-trained, independent practitioner (5/17, 29%). In terms of rheumatic disease–specific health passports, nearly half (44%) of the medical directors felt that low literacy, English language skills, level of education, poor compliance, and cultural differences would limit its use. Three respondents (17%) felt that an Internet-based version would be inaccessible for the majority of their patients. The least preferable intervention was telemedicine; 13 (46%) respondents ranked it last. Limitations included inadequate technology and technical support (8/20, 40%), the impersonal nature of telecommunication (4/20, 20%), and language and literacy issues (3/20, 15%).
A few medical directors highlighted additional obstacles to rheumatology care. One respondent stated that the main problem is not a lack of rheumatologists but rather inadequate "access due to insurance and language barriers." Similarly, 2 other directors noted the challenge of finding nearby rheumatologists, even at major medical centers, willing to accept patients with no insurance or with MassHealth (the state Medicaid program).
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