PRESIDENT'S MESSAGE
Colleagues:

These have certainly been trying times for our patients as well as ourselves and families. COVID is dominating everything we do, and it appears that will continue over the near future. I am hopeful that rheumatology practices will weather the storm and come out of it stronger than ever. Nevertheless, shortages of Hydroxychloroquine and Tociizumab have impacted many of our patients. The pandemic has particularly caused heightened anxiety among our patients who are in the high-risk group for viral poor outcome because of their disease and the medications they take to suppress the disease. We should all be keeping abreast of issues and the American College of Rheumatology has provided frequent updates. I am not happy about patients being forced to get their biologic infusion at home as level of oversight seems less. Patients are holding/stopping their medications without consulting with their rheumatologist in some instances, which may lead to more difficulties for them in the future. Reimbursement for telephonic visits is minimal which unfortunately is the preferred communication tool of many of my technologically challenged patients. Rheumatology practices have seen tremendous drop in revenue forcing application for the government’s small business loans. Bankruptcy may be outcome for some practices. See Dr Walker’s commentary of her experiences in this newsletter.

All that said, the PRS is fortunate our Annual Scientific Meeting is in the fall and we anticipate another fine meeting. See Dr Dunn’s update. Our advocacy day in person activities had to be cancelled due to COVID, but we now have a dedicated group to help us stay on top of the regulatory issues and organize advocacy activities for the organization. See Dr Killian’s update.

The PRS Board is beginning to work on the man/woman power shortage that is worsening in the state. We will be rolling out efforts to recruit advanced practitioners to rheumatology helping our members hire train and retain nurse practitioners and physician assistants. There will be formal presentation on the subject at our meeting and more on the specifics later this year. Helping fellows do scholarly activity is a high priority for PRS but would like to do more for the community rheumatologist. We had to cancel “meet and greet” events due to COVID but hope to reschedule those when the pandemic has subsided. Stay tuned. We are trying hard to engage our pediatric colleagues, see Dr Scalzi’s commentary.

If you would like to volunteer for the organization, let us know. Specifically, we would like a tech savvy rheumatologist to help us with redesigning our website. We have a team of IT folks who will handle the technical work, but they would like some help with ideas how to improve the rheumatologist’s experience on our website.

Please all be safe during this time and if there is anything PRS can do for you let us know. 
Al Denio, MD
COVID-19, A VIEW FROM PRIVATE PRACTICE
Nancy Walker, MD, MPH

Undoubtedly, life has changed for us all in many ways. The health threats of Covid-19 have far-reaching implications for Rheumatologists. Clinically, the pathophysiology of cytokine storm progression and potential management options in our field has been met with keen interest and optimism for us all regardless of practice site. In private practice, we face unique resource allocation and financial challenges.

Our practice of eight providers (five Rheumatologists, two Physician’s Assistants and one Nurse Practitioner) noticed a significant reduction in patient flow early in March. It became clear by the third week in March that we needed a plan that respected social distancing but also incorporated systems that protect our financial health as well.

We made a difficult decision to lay off our extenders and focus on telemedicine. Effective March 6, 2020, the Centers for Medicare & Medicaid Services (CMS) broadened access to telehealth under the “1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.” This legislation includes established and new patient access following the same in-person billing schedule. We are using the “doxy.me” platform that provides an easy link to patients who have an email address and linked camera. As time passed, more insurance carriers have expanded coverage that includes telemedicine. However, convincing some of our patients to embrace this type of medical care has been a bit challenging.

COVID-19 AND THE RHEUMATOLOGISTS - MY PERSONAL EXPERIENCE
Lawrence Brent, MD

During April, like everyone else, I was doing telemedicine seeing almost no patient patients in the office at all. A rare patient would venture to the office for an injection. During the first 2 weeks of April, I was on the Rheumatology Consult Service at Temple University Hospital. All consults were done virtually just by talking with the referring physician teams and looking through the data in the electronic medical records. We had very few consults that were of a rheumatologic nature.

However, my Section Chief, Dr. Roberto Caricchio, is a basic scientist and immunologist. He was working with the Temple Lung Center, which has an international reputation, to treat COVID-19 patients who were doing poorly because of cytokine storm. Temple had a large number of COVID-19 patients. The patients were potentially enrolled in the Remdesivir trial about which I sure you have heard. If there was concern for cytokine storm, Rheumatology was consulted. Now I was involved in reviewing the records of these patients which represented a minority of the COVID-19 patients. This was the large majority of our consults often more than 10 new consults per day. There was a clinical trial which included Sarilumab but if the patient’s condition worsened, then there was a treatment algorithm which involved Tocilizumab, Anakinra, and IVIG. This really makes you think about the mechanism of action of these medications and the role of the respective cytokines in disease processes not necessarily related to the field of Rheumatology. I was evaluation very ill patients and having to make decisions about therapy. Because of the limited supply of some of the biologic agents, I actually had to ration treatments, which is not something I ever thought I would have to do as a physician. I also reviewed more Chest CT scan in 2 weeks than in my previous 35 plus year as a physician.

The fellows were indispensable in this process. However, their learning experience was drastically different. No hands-on clinic, inpatient consults, or procedures. All conferences were done using Zoom. There were not residents or medical students on rotation. This was all very different, and it is hard to determine the impact that this has had on their learning experience.

I also realized that, while I enjoy talking to patients, I much prefer seeing them. I also miss the clinical teaching that comes with seeing patients in person. I do not enjoy the long hours at the computer; my ass really hurts.
PEDIATRIC RHEUMATOLOGY IN THE PRS
Lisa Scalzi MD, MS

Well, these are unprecedented times. We have all seen new relationships forged across specialties, countries, social media, and virtual communications. I would like to take this opportunity to reach out to all of my pediatric rheumatology colleagues within Pennsylvania. We are so fortunate to have multiple medical sites with well-established pediatric rheumatology centers as well as pediatric rheumatology fellowship training programs in the state. Pediatric rheumatologists are well connected to one another not just across the country but also across the globe using our pediatric rheumatology list serve. It is likely that the limited numbers of pediatric rheumatologists encourages such close communication with one another. Unfortunately, a limited number of these pediatric physicians are registered with the Pennsylvania Rheumatology Society (PRS). I would like this opportunity to share with you the advantages of becoming a PRS member with a “pediatric spin”.

With more of our patients being denied medications by their insurances, and services, including infusions of these medications, it is vital that we represent our patients at a state level. Pediatric rheumatologists can join the advocacy committee, or just voice your opinions, and address our state leaders directly and/or identify patient representatives who have been victims of unfair insurance provider decisions. Our interests can also be supported by PRS through participation in the Specialty Leadership Cabinet of the PA Medical Society.

I imagine a future whereby PA pediatric rheumatologists can meet to facilitate potential collaborations that promote scholarly activity and the sharing of information. Years ago, there was a small group of pediatric rheumatologists from PA and Delaware, who would meet quarterly in a small church in a mall in the northwest Philadelphia area, to review topics and cases of interest which was presented as a mini-thieves’ market. There was a great deal of comradery that was forged over the years. Research projects, manuscripts, and educational opportunities resulted from this group. In a similar way, having a significant number of pediatric rheumatologists and fellows from within PRS can also result in successful and fruitful relationships.

If you are a pediatric rheumatology fellow, or a program director, the PRS offers many opportunities and perks, including complimentary membership without any dues. Due to the reduction in scholarship from the American College of Rheumatology, the PRS provides a one-time scholarship for each rheumatology fellow enrolled in an ACGME accredited fellowship program in PA to be used at any ACR sponsored meeting. Meeting, at the Annual PRS meeting, or now virtually since we all have new-found expertise in this arena, would also permit our fellows to forge new working relationships and potential projects and learning opportunities. The topics at the annual PRS meeting are of interest to adult and pediatric rheumatologists. There is presently, a rheumatology OSCE session at the Annual meeting and if the pediatric fellows and program directors would like to expand this to a Pediatric rheumatology OSCE we can consider this as well.
 
I hope that if you are not already a PRS member, you will consider becoming one. Membership fees are quite low. I welcome your voice and contributions to this group. Please do not hesitate to contact me at any time.

Best wishes to you all.
COVID-19 RECAP & RESOURCES
The American College of Rheumatology, in coordination with state societies, is acting swiftly to address the COVID-19 worldwide pandemic. We are focusing our efforts on areas that are most critical to you, your practice, and your patients. The ACR has developed several new practice resources and compiled pertinent information to help you navigate new and unexpected challenges as they arise. The information below highlights some of the information that is likely most important to you. Please continue to monitor the announcements and breaking news on the ACR website during this rapidly evolving situation as they provide additional information when it becomes available.

ACR Telehealth Guidance and Resources for Your Practice
CMS announced several new policies for coding and billing telehealth, including Medicare coverage for telephone-only services and significant additions to the list of covered services such as physical and occupational therapy e-visits. The ACR has updated the Telemedicine Provider Fact Sheet to reflect these updates and has created several new coding resources to assist with telehealth technology, as well as a quick reference guide on payer requirements for coding and billing. Since telehealth coding and billing policies are evolving rapidly, the ACR will continue to make updates as new information becomes available.

Advice for Talking to Patients About Shortages of Hydroxychloroquine
Patients who take hydroxychloroquine (HCQ) are facing a medication shortage, and providers who care for rheumatology patients are facing disparate policy recommendations for prescribing and allocation of antimalarials. Here are suggested points that rheumatology professionals may wish to consider when discussing this difficult issue with patients.

ACR Develops Infusion Guidance Best Practices
Patient access to office-based infusion services is a top priority for rheumatology practices and with the COVID-19 crisis, the ACR has created infusion guidance to keep rheumatology practices up to date with relevant information to navigate this complex landscape.

Health and Human Services Emergency Fund Disbursements to Practices
The Department of Health and Human Services (HHS) is disbursing the first $30 billion of the $100 billion Congress allocated to hospitals, physicians, and other healthcare providers in the Public Health and Social Services Emergency Fund in the Coronavirus Aid, Relief and Economic Security (CARES) Act. These distributions are reflective of the advocacy requests made by the ACR, the AMA, and other physician societies in response to challenges being faced during the COVID-19 emergency. HHS has confirmed these relief funds are emergency payments, not loans, to healthcare providers and they will not need to be repaid.

ACR State Letter for Recommendations for Hydroxychloroquine and Chloroquine Usage
The ACR led and coordinated an effort with 52 other partner organizations to send a letter outlining guidelines for the appropriate use of HCQ during the COVID-19 pandemic to every governor, lieutenant governor, insurance commissioner, and board of pharmacy in the United States. State societies were key partners in this effort to protect access to HCQ for rheumatology patients. Individual physicians use the letter as a guidepost and can modify the letter for their own advocacy purposes.

Relevant Emergency Orders and Information for Pennsylvania

Additionally, If you are experiencing COVID-19 related drug shortages, practice issues, or any other problems, the ACR has created an inbox solely devoted to those concerns. Share your comments and questions with them at COVID@rheumatology.org .

ACR Links
CORPORATE PARTNER NEWS
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MEET YOUR LEADERSHIP
Lawrence Brent, MD
Immediate Past President
10/1/19 – 9/30/21

Lawrence H. Brent, MD, is Professor of Medicine at the Lewis Katz School of Medicine, Temple University in Philadelphia, Pennsylvania. Dr. Brent is a member of the Division of Rheumatology and the Associate Rheumatology Fellowship Program Director. In addition, he is an attending physician in Rheumatology at St. Christopher’s Hospital for Children.

Dr. Brent earned his medical degree from Jefferson Medical College, Thomas Jefferson University. Following an internship in internal medicine at West Virginia University Hospital, he returned to Thomas Jefferson University Hospital for an Internal Medicine residency and Rheumatology fellowship. He then completed a research/clinical fellowship in Laboratory Immunology, Clinical Immunology, and Pediatric Rheumatology at the University of Alabama at Birmingham. He was a faculty member in Rheumatology at Hahnemann University, then for many years a faculty member, Division Head, and Rheumatology Fellowship Program Director in the Division of Rheumatology at Einstein Medical Center in Philadelphia, PA before coming to Temple University in 2017.

Dr. Brent’s primary areas of interest are spondyloarthropathies, systemic lupus erythematosus, idiopathic inflammatory myopathies, and septic arthritis. He has authored numerous book chapters, manuscripts, and presentations on these subjects. He is a managing editor for the online journal Medscape (eMedicine), and manuscript referee for a number of peer-reviewed journals, including Journal of Clinical Rheumatology, Journal of Musculoskeletal Medicine, Clinical Rheumatology, Journal of Rheumatology, and Lupus. Additionally, he serves on the Medical Advisory Board of the Lupus Foundation Tri-State Philadelphia Chapter and the Medical Committee of the Arthritis Foundation, Eastern Pennsylvania Chapter. He was involved in basic research in lymphocyte and macrophage biology. He has been involved in numerous clinical trials including as a principal investigator involving the efficacy and safety of novel treatments for rheumatoid arthritis, systemic lupus erythematosus, and idiopathic inflammatory myopathies.

Dr. Brent is board-certified in Internal Medicine, with a subspecialty in Rheumatology. He is a Fellow of the American College of Physicians and the American College of Rheumatology, and is a member of Philadelphia Rheumatism Society, Pennsylvania Rheumatology Society, the American Association of Immunologists, and the American Association for the Advancement of Science. He has been recognized repeatedly as a “Top Doctor” in Rheumatology by Philadelphia Magazine. He is the past recipient of the Joseph Lee Hollander, MD Award recognizing excellence and achievement in the field of Rheumatology from the Arthritis Foundation Eastern Pennsylvania Chapter, and the Fleur-de-Lis Award for Outstanding Service from the Lupus Foundation of America.
Lisa Scalzi, MD, MS
Secretary/Treasurer
10/1/19 – 9/30/21

I am originally from upstate New York State and came to Hershey for my Med/Peds Residency in the 90’s, followed by a combined fellowship at U Penn/ CHOP. Our family was in Cleveland for 6 years, where I got my Masters in Clinical Research and was initially primarily research oriented. I have been back in Hershey at Penn State Children’s Hospital, practicing Pediatric Rheumatology since 2006 and am now the Division Chief. As I have grown older, I have developed a stronger sense of needing to make a difference; in the lives of my patients, in supporting the needs of those who need a voice, and for the community of rheumatology/ pediatric rheumatology. I hope that my involvement in PRS will help support my own mission to support the rheumatology community in PA and the patients we care for.
Brendan Leahy
Deputy Executive Director

I am a graduate of Middletown Area High School (2014) and Shippensburg University (2018) where I majored in Communications/Journalism and minored in Political Science. I joined PRS and Total Excellence in Association Management (TEAM) in the Fall of 2019. Prior to this, I spent over a year serving as a Promotions Director for a cluster of radio stations in the York/Lancaster market.

In my free time, you can find me watching Liverpool FC in the English Premier League and cheering on any Philadelphia sports team I can find on television.
If you are interested in posting a job, please contact us at (717) 558-7750, extension 1599 or  prs@parheumatology.org ​ . Postings are complimentary.
Ideas or suggestions for newsletter articles can be submitted to the PRS staff office,  prs@parheumatology.org  or by telephone, (717) 558-7750, ext. 1599.