Post COVID-19 clinics: Should your health system open one?

Dr. Tariq Cheema thinks back to last December, when COVID-19 patients packed his hospital, some of whom would be stabilized and discharged, but then eventually die.

There was one particular woman, Dr. Cheema said, who inspired him to help conceive and found a post-COVID-19 recovery clinic at the Allegheny Health Network near Pittsburgh. This patient was in her early 30s, a mother of four and had no chronic medical conditions. She seemed to be doing O.K., so they sent her home.

"But she'd rapidly had a decline in her lungs, and ended up back in the ICU on a ventilator and eventually passed away. That was the turning point for me," said Cheema, who is the clinic lead at the Allegheny Health Network Post COVID-19 Recovery Clinic. "We started seeing those types of cases where everybody thought that they were out of the woods, and then they would get discharged, and a couple of weeks later show up in the emergency room in complete cardiac arrest and pass away."

Cheema and his colleagues at the Allegheny Health Network Post COVID-19 Recovery Clinic wanted to create a specific program for patients who'd had COVID-19 that would facilitate check-ins after they recovered from their initial illnesses. So far, they've been slammed.

"The minute we opened this clinic, we got bombarded with cases," Cheema said.

Health systems across the country are opening post-COVID-19 clinics to care for people who have a wide range of symptoms and are desperate for reassurance that they're not going nuts. Many doctors don't know what to do with patients presenting with up to eight symptoms ranging from shortness of breath and fatigue to anxiety and tingling in their fingers.

Up to one-fifth of COVID-19 patients will develop long-haul symptoms. Because there is such a wide range of symptoms that don't have clear causes, caring for those people involves a long string of lab and diagnostic testing, detailed intake histories and referrals to all kinds of specialists.

All that work generates money, said Dr. William Lago, a family medicine physician at the Cleveland Clinic who was involved in the creation of its reCOVer Clinics for people who'd contracted the virus.

"From the business standpoint for each of these patients, there's lab, cardiology and pulmonary workups and, since we're utilizing a number of our existing specialists even within their own offices, when you look at the overall reCOVer Clinic, that in itself from the standpoint of the hospital practice brings revenue," Lago said.

At the two-hospital, not-for-profit system Edward-Elmhurst Health outside Chicago, administrators knew its patients would end up traveling to academic medical centers like Northwestern or Rush when symptoms recurred, and they saw an opportunity.

"We're really the first health system that's not an academic system to develop these clinics" in the area, said Samantha Rodriguez, system manager for neurosciences programs and acute care services at Edward-Elmhurst Health. "We didn't want to lose our patient population when we knew that we had these resources available within our system."

Edward-Elmhurst Health's post-COVID-19 program opened July 6, and the system estimates it will see around 650 patients during this fiscal year. Post-COVID-19 Patients are integrated into 12 neurologists' weekly calendars for 24 appointments that are held open until demand goes down. These neurologists were already seeing the bulk of post-COVID-19 cases, and they refer patients to other in-house specialists as needed.

Norton Children's Hospital in Louisville, Kentucky, integrated its post-COVID-19 clinic for kids and adolescents in conjunction with its infectious disease clinic. Initial visits last an hour and clinicians collect detailed histories from patients. Because post-COVID-19 care remains fairly undocumented due to its novelty, it made sense to triage initial referrals to infectious disease specialists, said Dr. Daniel Blatt, a pediatric infectious diseases physician.

"There are plenty of times where people come in with long COVID-19 symptoms from their primary care doctor, and then we diagnose them with something different," Blatt said. "That's where having an infectious disease specialist really, really helps out."

Norton Children's doesn't require patients to have had a positive COVID-19 test in the past to access the clinic. "If we had to rule it out ahead of time, it wouldn't be a very effective clinic because we would miss some people, and we would also bias our judgment ahead of time," Blatt said. "But obviously lab tests that we get ahead of time help our diagnosis. The more information we get, the better."

The Cleveland Clinic has limited patients to referrals from within its system and to people who previously tested positive for COVID-19, in large part because of the huge demand. What started off as a small clinic at an outpatient practice with one advanced practice provider and one physician assistant has grown into its own office with three additional doctors, a full-time nurse, a technician and one receptionist and scheduler.

"We're trying to limit down the scope a little bit so that we don't completely open the floodgates. We realize there's a huge demand for this," Lago said. "Eventually, we will open up to patients outside of the clinic and we'll be able to take people who have supposed COVID that we have no way of proving."

Another reason some systems are limiting post-COVID-19 recovery care to people with a documented history of the disease is insurance coverage. Insurance companies only assigned a diagnosis code for post-COVID-19 pulmonary rehab therapy at the Allegheny Health Network about six weeks ago, for instance.

The Allegheny Health Network has had to figure out ways to get treatment covered for patients who never tested positive for COVID-19 and were never hospitalized—who, for example, caught the virus at the beginning of 2020 when there was no testing. That might entail administering cardiopulmonary exercise tests to measure breathing and heart functioning, which can uncover problems that aren't detectable when patients are at rest. And insurers often resort to the oldie-but-goodie method of limiting access to treatments: step therapy.

"You have a patient who's coming in with shortness of breath or a cough, and you want to get a CAT scan because we know that both post- COVID can affect the lungs pretty rapidly, but there are a lot of insurance companies that will not actually allow you to get those CAT scans" because the diagnostic test isn't usual for someone with just that symptom, Cheema said. "We will have to get smaller tests like a chest x-ray that shows issues and leads to an insurance company approval. It's not clear cut as it would be in any other disease."

Cheema estimates that post-COVID-19 will join the ranks of COPD, heart failure and diabetes as one of the most common chronic diseases in the U.S., with billions of dollars spent on these patients. And depending on how the pandemic progresses in parts of the country where it's resurging, these clinics might stick around for quite a while.

At New Jersey specialty hospital Deborah Heart and Lung Center, patient volume expectations exceeded initial projections by almost 50%, said John Hill, vice president of pulmonary services. The hospital will run the numbers in November to determine if its integrated clinic will become an established part of the pulmonary clinic that's opening next February, he said.

Deborah Heart and Lung Center is seeing the need for this care diminish as the vaccination campaign continues, access to monoclonal antibodies improves and masking rules are in place in certain settings, Hill said.

Still, the hospital's post-COVID-19 program is seeing about three new patients a week, including those traveling from New York, Delaware and Pennsylvania. Deborah Heart and Lung Center physicians can treat heart and lung-related symptoms, and they refer patients to neurologists closer to home for those symptoms.

Health systems are likely to maintain their post-COVID-19 programs and clinics for at least another year, their representatives said. In addition to generating revenue, these clinics can bolster the chains' regional reputations.

"We're getting notoriety and clout as the premier place for children with long COVID to go get treatment," said Blatt from Norton Children's. "And we didn't have to invest a lot to do it. We just had to be thoughtful about it.