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13 Articles in Volume 21, Issue #5
Analgesics of the Future: Interleukin-17 Inhibitors for Treating Psoriatic Arthritis
Ask the PharmD: What evidence exists for metformin in treating rheumatoid arthritis pain?
CDC Opioid Prescribing Guideline Updates Are in the Works: Will the Changes be Enough?
Chronic Pain Management in Marginalized Populations: How to Rebalance the Provider-Patient Relationship
Dantrolene: The Forgotten Molecule for Outpatient Spasticity
Forgotten Analgesics: The Drugs Pain Practitioners Need to Reconsider
Machine Learning Predicts Patient Response to Rheumatoid Arthritis Therapy
Perspective: Where Have All the Rheumatologists Gone?
Rheumatoid Arthritis and Bridge Therapy: Primary Care Considerations
Root Cause of Plantar Fasciitis: Three-Step Exercise Protocol
Shoulder Pain and Rotator Cuff Injuries: Emerging Treatments
Special Report: The Evolution of Rheumatoid Arthritis Treatment, from Gold to Gene Therapy
Transfer of Care: Barriers and Solutions in Chronic Pain Management

Perspective: Where Have All the Rheumatologists Gone?

More HCP training is not the only answer to filling the rheumatology gap – we need multifaceted solutions that improve reimbursement rates, increase access to care, and adequately manage chronic pain.

Editor’s Note:The author has evaluated and treated more than 25,000 patients with rheumatic disease and chronic pain syndromes, and spent 30 years in clinical practice and teaching medicine.

 

The US is facing a shortage of physicians in all specialties but particularly in primary care and in non-procedure-based medical specialties, including rheumatology. Although the number of US primary care providers (PCPs) has increased by about 10% in the past 10 years, this has not kept pace with the general population size increase and the geographic maldistribution of PCPs.1  Despite the increase in PCPs, the density of PCPs relative to population decreased from 47/100,000 to 41/100,000 during those 10 years, and this decrease has been most prominent in rural areas.2

Experts predict a further shortage of 50,000 primary care providers in the next 20 years.1

The current rheumatology workforce of 5,500 full time healthcare providers has not kept up with demand and the gap is expected to widen due to physician retirements and other factors. (Image: iStock)

Rheumatology Shortage: The Data Reveal Gaps in Access to Care

The current rheumatology workforce of 5,500 full time equivalent (FTE) healthcare providers (HCPs) has also not kept up with demand.3 This gap can be traced to a flat, fixed number of rheumatologists entering the field while there has been an increase in physician retirements – myself included. As the general population lives longer, there has been a significant increase in arthritis diagnoses, with an expected 30% to 50% increase in rheumatic disease diagnoses in the next 15 years.3  Estimates are that this increase will result in a 25% to 50% loss of US rheumatology FTE by the year 2030, with a potential shortage of 2,000 to 4,000 FTE providers.3

Combined, primary care and rheumatology clinician shortages reflect similar issues taking place in the industry (see “Industry Parallels” below). Both primary care and rheumatology shortages are most prominent in rural and underserved metropolitan populations.2,3 The COVID-19 pandemic has reinforced inequities in healthcare and vaccine access in underserved and rural areas across the country. In uncovering the data:2

  • 90% of rheumatologists practice in urban metropolitan areas
  • In 2015, 21% of rheumatologists were in the Northeast, 17% in the mid-Atlantic compared with only 11% in the Southeast and 3.9% in the Southwest
  • The ratio of rheumatologists per 100,000 patients ranged from 3.07 in the northeast to 1.28 in the southwest.
  • By 2025, the vast majority of US regions will only have 0.5 to 1.0 rheumatologists per 100,000 adults, significantly lower than the recommended ratio of 1 per 10,000.

 

Industry Parallels to the Clinician Shortages in Primary Care and Rheumatology

  • Most problematic in rural and underserved areas
  • The aging of the US population will increase these provider shortages
  • Fiscal disparity compared to procedure-based specialties

 

HCP Workforce Shortage: Reasons and Consequences

Procedure-based Specialists Earn More

The long-standing payment disparities between procedure-based specialties and primary care as well as specialties like rheumatology has been an important factor in healthcare workforce shortages. Of total annual healthcare expenditures in the US, 5% to 7% are for primary care, significantly less than every peer country. Fee-for-service reimbursement currently accounts for 75% of national payments; while there are high rates of reimbursement for technical or specialized procedures, rates are low for chronic disease management, vaccinations, and mental healthcare.4

Primary Care Leads to Lower Medical Costs, Longer Life

Greater use of primary care has been associated with lower medical costs, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. In fact, states with a greater ratio of PCPs have had lower general mortality and infant mortality rates.4 In one large study, every 10 additional PCPs per 100,000 in the population was associated with a 52-day increase in life expectancy, whereas an increase in 10 specialist physicians per 100,000 population corresponded to only a 19-day increase in life expectancy.4

Delayed Specialty Referrals

At the same time, there have been a number of studies demonstrating the importance of an adequate supply of rheumatologists in the US.6 Increased or delayed time to rheumatology care has correlated with more severe rheumatic disease, worse outcomes, and increased healthcare costs.6

Gaps in Chronic Pain Management

In addition, HCPshortages in primary care and rheumatology have adversely impacted chronic pain management. The vast majority of chronic pain management, such as for headaches and low back pain, takes place in primary care. However, most PCPs have neither the time nor training to adequately care for individuals with chronic pain conditions. PCPs know that a team approach to chronic pain is ideal but have limited access to physical therapists, mental health care professionals, or complementary healthcare practitioners.

The US medical system has largely been based on specialty silos rather than an integrated team approach. One obvious solution is referral to pain specialists. However, there are only about 5,000 pain specialists in the US today,7 which averages out to one pain specialist for every 29,000 Americans suffering from chronic pain.

 

The Rheumatologist’s Role in Pain Management

In my experience, rheumatologists have generally not considered themselves to be pain doctors. Although pain is the most important symptom of rheumatic disease patients, rheumatologists have focused on pain in the context of inflammatory/immune mechanisms. We have largely abdicated responsibility for chronic pain conditions that are not associated with a defined rheumatic disease. This has played out in rheumatologists’ role in patients with fibromyalgia and related chronic pain conditions. Back in 1997, an editorial in a leading rheumatology journal was titled, “Fibromyalgia: Scourge of humankind or bane of a rheumatologist’s existence.”8 With the forecasted rheumatology healthcare shortages, it is likely that rheumatologists will beever more resistant to taking primary responsibility for managing pain.

Mednet, a web-based interactive rheumatology program, recently posed this question to clinicians, “Do you treat fibromyalgia in your practice or refer back to PCP after ruling out autoimmune inflammatory pathology?” I responded, “During my practice, I had a special clinical and research interest in fibromyalgia, so I did see fibromyalgia patients regularly. I set aside two half-days weekly for fibromyalgia referrals and incorporated a group educational session after seeing new referrals. Any rheumatologist with an interest in chronic pain and fibromyalgia should use such a structure and utilize ancillary healthcare professionals. Otherwise, for most rheumatologists, our role should be to confirm the diagnosis and provide advice to the patient, family, and referring PCP, including options in long-term chronic pain management. I do not believe that rheumatologists should make the too-often blanket statement, ‘We don’t see patients referred to us for fibromyalgia.’”9

A practicing rheumatologist responded to this thread, stating that time is the core problem when evaluating these patients. The clinician noted that the assessment of patients with chronic pain conditions can take a disproportionate amount of time compared to evaluating others, even very ill patients with life-threatening conditions. Ultimately, it was noted, that focusing on centralized pain syndromes may not be the best use of rheumatologists' time.10 This opinion reflects that of many of my colleagues and reinforces my point that chronic pain management has not been considered a fundamental element of rheumatology practice.

 

Strategies to Address Rheumatology Workforce Challenges

Re-Examine Training & Reimbursement Rates

Looking forward, the most direct approach to labor shortages would seem to be increase the number of trainees entering the field. However, as noted, the 10% increase in PCP supply in the US in the past decade has not kept up with increased demand.1 From 2015 to 2019, the number of rheumatology fellowship applicants increased by 49%, from 256 to 366 with no major impact on predicted shortages.6 Retention rates of younger PCPs and rheumatologists have added to HCP workforce shortages, especially among international medical graduates (IMGs). Currently, 40% to 50% of rheumatology trainees in the US are IMGs, and 20% of those IMGs leave the US after their training.6

Until there is less fiscal disparity between procedure-based specialties and PCPs/non-procedure-based HCPs, these physician shortages will persist. In comparison to other high-income countries, the US has fewer PCPs than specialists, provides fewer PCP services, and has the greatest income disparities between these two groups.2 There has been a recent gradual shift from fee-for-service to value-based payment but dramatic fiscal changes in the near future seem unlikely.

The Centers for Medicare & Medicaid Services  (CMS) has established a comprehensive primary care initiative, and states such as Rhode Island and Oregon have increased spending on primary care with good patient outcome data.2 Optimal care in both primary care and rheumatology includes an integrated, multidisciplinary team with reimbursement based on value rather than volume.

Consider Distribution & Volunteer Services

More novel approaches to lessening the geographic maldistribution of PCPs and rheumatologists may include loan repayment initiatives, part-time locum tenens, and volunteer services by retired physicians to underserved areas. Financial incentive programs have been shown to increase the number of HCPs in underserved areas.6

Widen Telemedicine Utility

Telemedicine, expanded by the COVID-19 pandemic, has the potential to increase efficiency among PCPs and rheumatologists and provide more care to rural and underserved areas of the country. Electronic consultations (e-consults) have been increasingly utilized during the pandemic, with good acceptance by PCPs and specialists alike. For example, a common rheumatology consultation is for a positive antinuclear antibody test (ANA). This seldom requires an in-hospital or in-office visit and works well through telehealth. In the future, it will be important that reimbursement rates for telemedicine are competitive with in-office visits and that arbitrary state licensing restrictions for virtual visits be loosened. 

Extend Pool of Advanced Practice Providers

Increasing the pool of physician assistants (PAs) and nurse practitioners (NPs) HCPs has been an effective approach to physician shortages. PCP and rheumatology practices have widely utilized and endorsed PAs and NPs. A web-based rheumatology curriculum for NPs and PAs has been created to foster the transition of primary care NPs and PAs into a rheumatology practice.6 Currently, NPs are able to practice independently in only 20 states, and PAs must practice with a supervising physician.

 

How to Reverse HCP Workforce Shortages in Primary Care and Rheumatology

  • Increase the number of physician trainees
  • Improve career retention rates, including low retention in international medical graduates
  • Lessen geographic maldistribution with financial, lifestyle incentives
  • Increase use of telemedicine
  • Loosen interstate licensing requirements
  • Enhance use of non-physician healthcare providers, including advanced practice NPs, PAs
  • Improve reimbursement for cognitive vs procedure visits with focus on value, not volumebursement for cognitive vs procedure visits with focus on value, not volume

In conclusion, both primary care and rheumatology providers are facing significant workforce shortages. These HCP gaps will continue to cause added healthcare disparities in the US and will especially threaten the future of optimal chronic pain management. Multifaceted strategies are recommended to offset these shortages.

Last updated on: September 8, 2021
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Rheumatoid Arthritis and Bridge Therapy: Primary Care Considerations
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