A Multidisciplinary Approach to Care Coordination Challenges in Psoriatic Arthritis

Announcer:
This is ReachMD, and you’re listening to Beyond Skin Deep: Impacts of Psoriatic Arthritis, sponsored by Lilly.

Dr. Greenberg:
Psoriatic Arthritis, or PSA, is a chronic inflammatory disease that impacts both the skin and joints, requiring a multidisciplinary approach that involves two groups of specialists, a rheumatologist and dermatologist. How closely these two specialists align directly impacts a patient’s outcome. And while this multidisciplinary approach isn’t without its challenges, there are ways rheumatologists and dermatologists can work together to create a personalized long-term care regimen.

I’m Dr. Michael Greenberg, a dermatologist from the Illinois Dermatology Institute, and joining me is Dr. Madelaine Feldman, Clinical Associate Professor of Medicine at Tulane University School of Medicine and a practicing rheumatologist. We’ll be sharing our perspectives on the care coordination challenges rheumatologists and dermatologists often face when managing psoriatic arthritis patients and how we overcome them.

Madelaine, welcome to the program.

Dr. Feldman:
Well, thank you, Michael, for having me here to talk about this topic.

Dr. Greenberg:
How long have you been a rheumatologist?

Dr. Feldman:
I’ve been in practice nearly 30 years.

Dr. Greenberg:
Oh, me too. I’ve been in practice, actually, almost 40 years, so this is good. So we’ve got some old-timers here with some wisdom.

Dr. Feldman:
Yes, I’m definitely an old-timer.

Dr. Greenberg:
So, to start out, how are you currently collaborating with dermatologists with regard to psoriatic arthritis?

Dr. Feldman:
Well, collaborating with a dermatologist has been sort of a work in progress over the past 30 years. I’d say initially my contact with the dermatologist initially was probably just a phone call requesting a skin biopsy or maybe even asking them to explain the biopsy, but over the years, particularly as we’ve had newer medications to treat a lot of the diseases that we jointly take care of, the relationship has gotten closer. And I’ve found a couple of dermatologists who are very interested in systemic autoimmune diseases, and so we talk on the phone. We are in the process of trying to get our EHRs to talk to each other and have a HIPAA-compliant way to share pictures. But we’ve become very close over the years, and it’s important to find a dermatologist that has this interest and is willing to take the time to talk about the patients.

Dr. Greenberg:
That’s interesting, because today, being a dermatologist myself, I know we are usually so overloaded with patients that it’s really difficult to get through to us and talk to us at times. Do you ever find that, where you’re stuck in the office and it’s like, “How do I get through to this guy?” How do you work that out, or do you make a prior arrangement?

Dr. Feldman:
Well, sometimes we’re at the same Journal Club, and I’ll pigeonhole the dermatologists there. But I think the key is, if you can find someone with that interest, they’ll make the time. I think probably one of the most difficult hurdles to get over is exactly what you were talking about. Dermatologists have very, very tight schedules, and getting in touch with them can be difficult, so we do a lot of after-hours talking and sharing, of course, HIPAA-compliant pictures, and you just have to make it work.

Dr. Greenberg:
Do you ever sometimes communicate through mid-level providers like physician assistants to get messages through to the dermatologists?

Dr. Feldman:
I do when they have them. I have one in particular that works in a university setting, and she has some very good mid-levels that convey my messages and ask for help at times; and others that don’t have mid-levels, this is where I think dermatologists can actually help rheumatologists. Sometimes it’s as simple as learning how to use topicals. And in that case, if the relationship has been one where both sides are sort of teaching the other sides what to do in case of an emergency that you can’t get in touch with them, I think that’s probably one of the tenants of having a good collaboration, is be willing to learn what you can.

Dr. Greenberg:
I agree with you completely, because a lot of what goes on beneath the skin is a total mystery to me and most other dermatologists. We’re learning more about psoriatic arthritis only because we have to because it’s here.

Now, do you find that you make a lot of primary diagnoses of psoriatic arthritis and refer to dermatologists, or are dermatologists referring to you, or is it equal?

Dr. Feldman:
Most of the time it’s the dermatologists referring to me. I will get a call or a referral put in, patient with psoriasis and joint pain. And we are very busy, and sometimes it can take several months for a new patient to get into our office, and that’s, I think, another good reason, particularly in psoriatic arthritis, to have a good relationship with the dermatologists, because almost 30% of patients who come into a psoriasis clinic potentially could have psoriatic arthritis, and getting them early visits with the rheumatologist actually can prevent joint destruction down the line, so I think early referrals are important. So, when it looks like an inflammatory arthritis, and particularly if I have a relationship with that dermatologist, I will go ahead and add them on and make room for them quickly—again, speaking to the importance of collaborating with the dermatologist, because both understand that if the patient has psoriasis, you can get permanent joint damage if it’s psoriatic arthritis and not treated in a timely manner.

Dr. Greenberg:
What you said here I think is brilliant. It’s about developing communicative relationships between dermatologists and rheumatologists, because when my rheumatologist friend upstairs picks up the phone and calls me and says, “I’ve got to get somebody in today, they are really bad,” they get in today, and it’s because of that relationship that we’ve culled between the 2 of us—because I know I can do that too.

Dr. Feldman:
Absolutely. There’s a trust that forms between the 2 practices, and you know that they’re not sending you something, someone that has had damage to their knee for many, many years and they have been hurting for 5 years and can they get in today. I know the dermatologist isn’t going to call me about something like that. So, absolutely, the trust and relationship is probably the key to making this work.

Dr. Greenberg:
For those just joining us, this is Beyond Skin Deep on ReachMD. I’m your host, Dr. Michael Greenberg, and I have the pleasure of speaking with Dr. Madelaine Feldman on how rheumatologists and dermatologists can overcome the care coordination challenges that we typically face when we manage patients with psoriatic arthritis, and there seems to be many, many more patients out there with psoriatic arthritis these days.

Dr. Greenberg:
So let’s dig a little deeper in some of the challenges we faced over the years and even those that we still face. So, what have you felt have been the biggest challenges when it comes to coordinating care for your patients specifically?

Dr. Feldman:
Well, I think the biggest challenge is when the patient doesn’t respond to the treatment plan that we’ve put together, whether the skin is not cooperating or they’re getting multiple infections, whether the use of steroids is having to go up, Sometimes the biggest challenge is getting them back into the dermatologist, particularly if they have a dermatologist that I don’t have a relationship with. And if you don’t have a relationship with the dermatologist, sometimes you have competing medications, and if there’s any question of starting a medication first, that telephone call needs to be made, because I think that’s one of the biggest challenges is that someone gets put on a medication that, for example, is contraindicated in one of the medications that I have the patient on and the dermatologist is unaware.

Dr. Greenberg:
Now, some of the challenges in my experience, also, have to do with cost of medications and issues like this. I don’t know how you deal with this, but so often getting medications approved or when patients come to me and they complain they can’t afford medications, how has that been a challenge for you, and how do you solve that? That’s a tough one, I know.

Dr. Feldman:
That is a tough one. I think if we could solve that problem, we’d solve the drug pricing crisis in the United States. But having said that, we have a fairly tight prior authorization setup at our office, and we can get those prior authorizations in pretty quickly, and if patients are turned down completely, we go to foundations, but I think probably the biggest hurdle is step therapy. The preferred list, the preferred drugs on the formulary, if I don’t think that that is the proper medication or the patient had tried it when they were on a previous insurance plan, there is a lengthy approval process and appeals process that you have to go through. But we have full-time help that all they do all day is prior authorizations and do appeals. It’s unfortunate that it has come to that, but that’s the world we live in, and we’re trying to make the best of it.

Dr. Greenberg:
So, an idea that I had, just came up as we were talking, I’ll just run it by you. Wouldn’t it be an ideal thing to have almost a clinic or a practice with a rheumatologist and dermatologist side by side in the same office or in the same clinic working together? That would seem to be an ideal fantasy for this problem. Would it not?

Dr. Feldman:
That’s a good idea. I know orthopedists have added rheumatologists to their practice and they have collaborated in many cases, so our next opening in the office I may look for a dermatologist. That’s a great idea, Michael.

Dr. Greenberg:
It seems that rheumatology and dermatology have always been first cousins, so close with the diseases that we treat together.

So, what advice would you give to someone who’s just starting their career, either a dermatologist or rheumatologist and who’s likely going to face these challenges?

Dr. Feldman:
I think one of the first things would be—if they are coming in, they are just learning the doctors who are referrals, and is to actually first find a dermatologist that has an interest in rheumatic diseases. That is probably the most important. If it’s a dermatologist who mostly has a cosmetic practice, it’s probably not going to be the best fit in terms of collaborating on rheumatic diseases. So get to know the dermatologists in your area and find one that has an interest in rheumatic diseases, number one.

Number 2—and we have started to try to do this in my area—is have joint Journal Clubs to discuss whether it’s the latest research, and even going to product theaters where a new drug is being talked about that can be used both in dermatology and rheumatology. Use it even if you already know about the drug to meet some of the dermatologists in our area because they may... If they have an interest in that drug, then they may have an interest in collaborating with you.

I think, also, it might be helpful to try to, if you’re setting up your EHRs, to make sure that you’ve got a HIPAA-compliant way to exchange information through the EHR, particularly pictures. I think that’s very helpful.

And probably the last suggestion—I’m sure there are others—is pick up the phone. Whether it’s the dermatologists calling you or whether you want to call them, pick up the phone and talk on the phone to whatever specialist you’re working with—but I think particularly with psoriatic arthritis, getting to know the dermatologist and catching them when you can. And when they see that you have this strong interest in collaborating with them… I have never had a dermatologist shortchange me in terms of the advice that they give. Particularly, if you’re new out in practice, be willing to accept education from the dermatologist, because they are able to teach a lot more than you think they can. They know a lot more about the skin than you do and working together and taking advice from them is a good thing.

Dr. Greenberg:
Right. And I think another key suggestion, too, is when you add someone to your practice, let it be known. When a new rheumatologist gets added to a practice, I love to know about it because I can send patients to that practice and say, “Hey, I know they have got a new person. I know they have openings.” I think just that kind of communication is key.

Dr. Feldman:
You’re absolutely right. As soon as we took on a new rheumatologist, the dermatologists that I work with were so happy because they knew they could get patients in quicker, so that really is another important aspect of when a new person comes into the practice.

Dr. Greenberg:
Thank you so much, Dr. Madelaine Feldman. It’s just been a joy talking to you. Really, I think we’ve come up with some great solutions to help improve our patients’ outcomes. It’s so easy to lose ourselves these days in all of the regulations and the paperwork and getting the prescriptions approved that we forget that that suffering patient is why we’re here, so thank you so much.

Dr. Feldman:
Thank you for having me, Dr. Greenberg. This topic is very important, and I think what we’ve discussed in terms of the trust and communication is sorely lacking as we move on with electronic health records, so pick up the phone and talk. Thank you.

Announcer:
The preceding program was sponsored by Lilly. Content for this series is produced and controlled by ReachMD. This series is intended for healthcare professionals only. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com/beyondskindeep. Thank you for listening to ReachMD. Be Part of the Knowledge.