By Christina Bennett, MS
Telehealth has largely remained untapped in cancer care, but that could be changing. At the 2018 ASCO Oncology Practice Conference, several experts shared their insights into the drivers of telehealth and the better, more efficient care that may result, that is, if roadblocks don’t trip up the digital technology.
“Consumer expectations are driving much of this,” said Christian Otto, MD, director of Teleoncology at Memorial Sloan Kettering Cancer Center. As seen in other industries, consumers are increasingly using digital convenience and, “People want health care online,” he said. And patients aren’t the only ones who stand to benefit.
Jennie Crews, MD, medical director at Seattle Cancer Care Alliance Network, listed several stakeholders eyeing telehealth. She indicated that employers are looking for workplace health solutions to decrease absenteeism; payers are looking for lower cost options at providing care and prevention; and small, rural hospitals are reliant upon telehealth to provide care to patients who may not have a specialist available in their community.
Telehealth encompasses an ever growing list of modalities, such as teleconferencing, store and forward, and remote patient monitoring. Furthermore, emails, text messages, wearables, and mobile apps fall under the domain.
Telehealth differs subtly from telemedicine, with the main difference being telehealth includes nonclinical activities, such as physician or patient education, in addition to clinical care, whereas telemedicine does not. Nonetheless, the American Telemedicine Association largely views telemedicine and telehealth as interchangeable terms and the cancer community is beginning to adopt this digital technology.
At Memorial Sloan Kettering, their home psychiatry pilot allows patients to have televisits at home, saving patients, on average, two hours and 10 minutes of travel time. Also, a supportive care program has been implemented where patients commute to a participating regional site for a televisit as opposed to an in-person visit in Manhattan, also saving on travel time.
“This benefits not just the patient but families as well,” Dr. Otto said. Usually a family member is present and that person may have to take time off to attend the visits with the patient.
Telehealth can also be used to provide care to patients outside of the United States. Linda Bosserman, MD, medical oncologist at City of Hope in California, shared the interworking of a remote second-opinion service that allows for distant care.
The second-opinion consults are conducted in either real-time video chat or via store and forward, in which the provider crafts a report and sends it to the patient. Patients in other countries, she explained, may have had a lumpectomy and don’t know they need radiation or were recommended the most expensive regimen when a simpler one has a better outcome and less toxicity.
“It’s incredibly rewarding,” said Dr. Bosserman about the remote consults. “The patients I’ve done [this with] then want to schedule follow-up along the way because you become their oncology advisor to bring world expertise wherever they are in the world.”
Unlike traditional medicine where episodic care is the norm, telehealth allows providers to consistently monitor patients and detect when a patient starts to trend out of a healthy threshold. This allows for earlier intervention to prevent an episodic event; and that, Dr. Otto said, is where the “tremendous” cost savings come in.
At Memorial Sloan Kettering, many of the patients coming into the urgent care center are admitted. “We see nearly 25,000 patients in our urgent care center and that creates an enormous amount of patient days of care annually for us. Imagine if we were able to monitor those patients on a more frequent basis and prevent exacerbations of cancer-related side effects and symptoms,” said Dr. Otto.
Memorial Sloan Kettering has already realized some of the cost savings through their Constant Care in-patient fall prevention program, in which patients are monitored in their hospital room via video. Before the program was implemented in the colorectal and gastric mixed tumor surgical unit, there were 1.6 falls per 1,000 patient days. That number fell to 0.9 falls per 1,000 patient days when the program was implemented at the start of 2017. The fall reduction translated to a 45% reduction in companion expenses of over $100,000 during 2017.
Timing Is Everything
Although real-time teleconferencing is a popular form of telehealth, that’s not expected to last. Experts predict telehealth will trend away from teleconferencing and toward asynchronous modalities, such as store and forward and remote monitoring. For instance, with store and forward, a routine follow-up visit can be completed via email. It can also be used to manage immune-related adverse events from immunotherapy agents. As for remote patient monitoring and mobile health, those modalities could capture patient-reported outcomes.
However, Dr. Otto cautioned that the use of asynchronous telehealth depends on the patient and what kind of relationship they have with their provider. Store and forward will not for work all medical problems. “Clearly if you have an acute medical problem, store and forward is not prudent,” he said.
Although telehealth may sound like an add-on to oncologists’ already burdened schedules, that’s not the intent. The idea is use digital technologies to remove inefficiencies from the practice. Follow-up patient visits can be handled digitally through asynchronous forms of communication, which frees up the provider’s time as well as office staff time because visits don’t need to be scheduled. It also reduces patients’ wait times to get an office visit.
“There may be some skepticism,” Dr. Otto said, “but those of us who work in telemedicine, our goal is to integrate digital care so closely with a provider’s daily practice that we don’t use the term telemedicine or digital care. You may see some patients virtually in your daily practice and see a number of them in your clinic as well, and that’s your clinic day.”
Despite the demand for telehealth, a ream of challenges currently stymy its success: high enough patient volumes, the right balance of provider enthusiasm, and cultivation of relationships with other institutions and providers. Beyond those is the formidable challenge of regulation and reimbursement.
Most states have some type of telehealth payment parity law, but only a handful have true payment parity. Dr. Crews explained that these states have “very strict payment parity that truly reimburse at a rate equivalent to an in-patient visit.” Other states have laws that require payment for telehealth, but they don’t dictate the amount. Commercial insurers therefore have the ability to set their own reimbursement rate, which often is less than an in-person visit.
“If we could have true payment parity, where a telehealth visit is seen as equivalent to an in-person visit, I think it would be very beneficial for a number of populations of patients,” said Dr. Crews.
Current telehealth rules and regulations from Medicare are also restrictive. Real-time virtual visits are the only modality that Medicare will reimburse, unless providers participate in a chronic care management program or a federal telehealth demonstration project. To qualify for reimbursement, the televisit must take place at a health care facility and the location of the facility is generally limited to health professional shortage areas in rural consensus tracks or counties.
CEO of The Center for Blood and Cancer Disorders in Texas, Barry Russo, told OBR that the tight telehealth regulations in Texas is a problem he’s seen firsthand. Due to regulations, his oncology practice hasn’t executed an official telehealth visit that was a chargeable event. The practice only uses telehealth visits for services they don’t charge for, such as telehealth psychotherapy.
Sign of Hope
The final rule for Medicare’s 2019 Physician Fee Schedule was released on November 1, 2018, and signals that the regulatory landscape could be loosening up to provide adequate reimbursement for telehealth services.
The 2019 final rule will require Medicare to reimburse for brief virtual check-ins by phone or video for established patients. “This type of virtual check-in could be used almost like a triage mechanism because there may be certain conditions or side effects that patients are having that could be addressed over the phone or through video conferencing that would not necessarily translate into an office visit,” Dr. Crews said.
The final rule also includes coverage of evaluation of recorded image and/or video submitted by patients (ie, store and forward) as well as coverage for inter-professional consultation service and chronic care remote physiologic monitoring (eg, blood pressure).
When Medicare decides to reimburse for a service, private payers typically follow. Medicare’s decision to reimburse for telehealth services may open doors on a state-to-state level to broaden telehealth coverage.