Rheumatologist Shortage Threatens Arthritis Care

Kanika Monga, MD


January 05, 2021

The Centers for Disease Control and Prevention (CDC) estimates that more than 54 million Americans live with doctor-diagnosed rheumatic disease in the United States. Add those people with joint pain that hasn't been formally diagnosed, and that number is closer to 91 million, or nearly 1 in 3 Americans.

Over 100 autoimmune, inflammatory, and degenerative conditions fall under the umbrella of rheumatic disease. These chronic and sometimes debilitating conditions can have a variety of systemic manifestations that affect a person's quality of life. Arthritis is one of the leading causes of disability in the United States.

Rheumatic conditions are also associated with high costs. Federal estimates put the cost of arthritis at $304 billion overall, of which $164 billion was attributable to lost wages and $140 billion to medical expenses.

There is convincing evidence that early and aggressive treatment of rheumatic conditions leads to less radiographic damage, slower progression rates, and lower disability rates. Slower progression also means fewer activity limitations, which gives patients a chance at a better quality of life. Most believe this window of opportunity is within the first 12 weeks of symptom onset; others say it is any period before damage can be seen on radiographs (especially in rheumatoid arthritis). Although the window has mostly been studied in rheumatoid arthritis, it probably also exists in spondyloarthritis, systemic juvenile idiopathic arthritis, and other conditions.

Unfortunately, many factors contribute to a delay in diagnosis and treatment of rhematic diseases. One study found that the median delay between a patient expressing their symptoms to their general practitioner (GP) and them being referred to a rheumatologist was around 6.9 weeks, and four GP visits. A new national patient survey by the American College of Rheumatology (ACR) and its Simple Tasks public awareness campaign shows that even after referral, more than 60% of patients experience a wait time of more than 30 days to get an initial appointment in rheumatology; over 27% had to wait more than 61 days.

Shortfall in Rheumatologist Workforce

The delays could be attributed to a workforce shortage in the subspecialty of rheumatology. As mentioned, 91 million Americans may be living with a rheumatic condition, but only 5595 full time adult rheumatologists are currently practicing in the United States. By 2030, the demand for rheumatologists is projected to exceed supply by 4729 adult rheumatologists.

Supporting the medical workforce to preserve and expand access to care is crucial. The shortfalls will probably have the most significant impact on patients in underserved and rural areas, because there is a geographic maldistribution of rheumatologists in the United States. Furthermore, this geographic maldistribution is expected to increase over the next 15 years.

Despite the workforce shortage, an estimated 100 applicants did not match into rheumatology fellowships because there were not enough positions. The number of residency and fellowship positions needs to be increased in rheumatology and other specialties experiencing a shortage, and in programs that have training facilities in underserved areas.

The shortage of pediatric rheumatologists is even more stark. There are only 400 board-certified pediatric rheumatologists in the United States, and nine states have none. According to the Arthritis Foundation, only 1 in 4 children with arthritis are able to see a pediatric rheumatologist.

Treatment Delays

Even after establishing care with a rheumatologist, patients often experience delays in treatment due to payer utilization management techniques, such as prior authorizations and step therapy. These not only lead to delays in care but also have a negative impact on patient health and outcomes. In the ACR patient survey, almost half of the patients reported being subjected to step therapy or prior authorizations in the past year. 

In an American Medical Association physician survey, 91% of physicians reported that prior authorizations caused delays in patient care, and 74% of them indicated that it sometimes led to treatment abandonment. Prior authorizations not only affect patients but also healthcare providers. Over 86% of physicians report the burden of prior authorizations to be high in their practices, and a majority notes that the burden has increased in the past 5 years.

I have personally experienced the impact of prior authorizations in my own clinic. The process is cumbersome and inefficient, and it lacks transparency and automation, which leads to a lot of frustration and can extend over weeks at a time. 

Step therapy (or "fail first") is a payer utilization management technique that requires options on formulary to fail in the patient before he or she can access the physician prescribed, nonformulary option. The process has been found to put other unnecessary burdens, such as medication side effects, on patients as well. The Arthritis Foundation found that step therapy was stopped in 39% of cases because the insurer-preferred drugs were ineffective and in 20% because of worsening conditions.

Access to care is of utmost importance for Americans with rheumatic disease, especially when the potentially positive impact of treatment within the window of opportunity is considered. This requires a focus on reversing the workforce shortage and improving access to medications that are recommended by rheumatologists.

Kanika Monga, MD, is a practicing rheumatologist at the Houston Methodist Rheumatology Texas Medical Center in Houston, Texas. Monga is also a member of the American College of Rheumatology's Communication and Marketing Committee. Her interests include medical journalism and patient advocacy.

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