May 2020 Edition Vol.11, Issue 5

Cancer Versus COVID-19: Telemedicine, Financial Fallout, and the Future of Community Oncology Care 

By Chase Doyle

The novel coronavirus may have sidelined the global economy, but cancer doesn’t take a day off, which is why community practices have been working tirelessly since the outbreak hit home to ensure quality care for their patients.  At the Community Oncology Alliance (COA) 2020 Annual Conference, virtual presenters across the country discussed the role of telehealth in bridging the crisis, the financial impact of the pandemic, and the lessons they hope translate to the post-COVID world.

Telemedicine: Bringing the Practice Together

In early March, monumental changes to telemedicine policy enabled the technology to flourish while reducing risk and volume in the clinic. As Debra Patt, MD, MPH, MBA, Vice President, Medical Oncologist, Hematologist, Texas Oncology, reported, patients can now receive telemedicine services at any point of care, and clinicians can administer telemedicine from any point of service. Furthermore, a wide range of clinical services are covered, and the broad approval of service modalities has been partnered with state policy changes that will allow the compliance and legal aspects of telemedicine to continue. 

Multiple telemedicine platforms have become acceptable during the pandemic and have been critical for the rapid adoption of this resource. “We’ve been able to support existing patients and evaluate new patients, including subspecialty evaluation, social work support, and advanced care planning,” said Dr. Patt. 

Sibel Blau, MD, Medical Director at Northwest Specialties called telemedicine a godsend, saying, “We’ve had this technology at our fingertips but never fully tapped into its potential. Now, it’s actually improved patient care in ways that we couldn’t have imagined.”

The ability to invite patients’ family members from different parts of the country into a consultation has the potential to transform care, whether it’s a survivorship visit, supportive care, chemotherapy teaching or even acute care. Other advantages iterated by Dr. Blau include treating very sick patients who don’t want to visit in-person and making decisions whether a patient needs to go to the emergency room, the hospital or the clinic for care.

“I can’t imagine not having telemedicine going forward,” she added. “I’m really hoping that reimbursement remains.”

Emerging Trends in Telehealth

Nick Recker, Chief Executive Officer of Path Forward, noted that telemedicine has always shown great promise in helping fulfill the triple aim of healthcare, but challenges, such as unequal adoption, reimbursement difficulties, varying state laws, and lack of clear HIPAA guidelines, stood in the way. According to Mr. Recker, the pandemic has broken down these roadblocks.

“In the last six to eight weeks, we’ve seen that red tape get stripped away,” he said. 

Unprecedented adoption, however, has also highlighted new risks and challenges. In the initial rush to implement telehealth services there were serious reliability issues. Mr. Recker noted that even the best cloud-based platforms labored under the stress of adding thousands of new users. 

“Thankfully, we’ve seen those platforms stabilize over the past few weeks,” said Mr. Recker. 

As practices figure out the optimal role for this technology, modifications to defaulted platforms need to be made. While most oncology practices have opted for off-the-shelf cloud-based solutions with low startup costs others have chosen more universal collaboration tools. Regardless of the initial product, Mr. Recker emphasized that practices need to pivot to strong telehealth governance to ensure long-term success. 

Creating a standard will reduce inefficiencies associated with rapid implementation. What’s more, said Mr. Recker, IT groups within community oncology practices must now consider physicians’ homes as part of the network and incorporate that into strategic planning. Due to security concerns, physicians and providers should also be encouraged to use practice-provided laptops and equipment when working from home.

The assumption is that these devices are going to have a higher level of security controls and monitoring software in place to protect the telehealth encounter experience. “While telehealth platforms themselves have built-in encryption, home networks or home devices are often less secure and have less monitoring for malware,” he noted.

View an OBR interview with Nick Recker:

 

The Financial Impact of COVID-19

Despite significant adoption of telemedicine, an increase in canceled visits has been unavoidable. Even more worrisome, said Jeffrey Patton, MD, Chief Executive Officer, OneOncology and Executive Chairman of the Board, Tennessee Oncology, is the significant drop in new patient volumes. 

“We worry that some practices are being impacted financially more than others, which could accelerate consolidation in the marketplace,” said Dr. Patton.

According to Dr. Patton, there are partners who can provide value and support, including OneOncology, AON, and US Oncology. Manufacturers, distributors, and life science companies are also stepping up along with COA.

“Every major manufacturer has now offered extended dating on drug purchases and most have offered protection on GPO [group purchasing organization] performance,” he said. “The companies we work with have worked with us to help us continue our mission.”

View an OBR interview with Dr. Patton:

Robert Braun, Corporate VP Operations & Integration, Regional Cancer Care Associates LLC, outlined the difficult challenges that lie ahead, especially for practices that operate within a financial risk model. 

In terms of the financial stability of practices, Mr. Braun asserted the need to examine potential remodeling of financials. “We’re going to need organizations like COA, local representatives, and people on the federal level to help us navigate this uncharted territory.”

While COVID-19 will impact payment reform, there will still be growth in value-based contracting according to Mr. Braun. Continued pressure on margins, however, will compel better business efficiencies to ensure viability and profitability.

Barry Russo, MBA, Chief Executive Officer, The Center for Cancer & Blood Disorders, underscored the unfeasibility of value-based care amidst the current crisis. Value-based payment models emphasize increased time and interaction with patients, but the pandemic has severely restricted in-person visits.    

Mr. Russo said it’s been incredibly challenging to interact and communicate with patients on a frequent basis in a way that also takes into account social distancing and protection. “Like everybody else in the past thirty days, we have been so focused on managing COVID-19 that we have lost a little traction on active triage and case-management processes for value-based patients,” he said.

Given two-sided risk with the Oncology Care Model (OCM), Mr. Russo expressed concern about the possible financial ramifications of patients being hospitalized because of COVID-19. On the other hand, the pandemic has reduced emergency room visits for a subset of patients living in rural areas that have historically used the emergency department as their primary care. 

“In the end, we’re going to have to talk with payers about the impact of force majeure events like this pandemic because there’s no way to model that,” said Mr. Russo.

Evolving Role in the Care Journey

The challenges posed by COVID-19 have caused community oncology practices to be even more reflective about appropriate allocation of resources and tools at their disposal. According to Mr. Braun, increased use of novel therapies like immunotherapy have made patient-reported outcomes more valuable than ever in the current environment. In addition, screening and assessment tools will become increasingly important given the infrequency of in-person visits.

Mr. Russo explained that regardless of the pandemic, cancer centers are a safe place for patients because they provide a deep understanding of the patient journey. While telemedicine has been “exciting”, he said it has also altered the expectations of patients seeking greater connectivity.

“Our communication with patients will need to focus on electronics in a broader sense, way beyond just telemedicine visits,” said Mr. Russo. 

Kathy Oubre, MS, Chief Operating Office, Pontchartrain Cancer Center, urged providers not to forget about patients in rural settings with more limited access. While there is a subset of patients who have embraced technology, said Ms. Oubre, there are also patients on flip phones or with computers that lack bandwidth and web cams.

Other trends, such as home infusions of biologics by non-oncology nurses, also gave her pause for concern.

“We’re already starting to see payer policies moving these infusions to the home setting after the first dose when many of us know that patients can have reactions well into the third and fourth dose and beyond,” said Ms. Oubre. “In my nonclinical opinion, this is bad medicine, and it puts the patient at risk.”

Finally, while extraordinary efforts have been made around the country to combat COVID-19 and deliver high quality care for patients with cancer, the crisis is far from over. Ms. Oubre said she anticipates a “huge surge of new patients” who have not yet been to a clinic in the coming months. 

“There’s a population of symptomatic patients who are waiting longer to seek initial care as a result of the pandemic, and by the time they see an oncologist, they’re going to have more advanced disease,” she said. 

View an OBR interview with Kathy Oubre:

Despite the chaos of the preceding weeks and the challenges to come, community oncology stakeholders remained optimistic about the future. 

“In the crucible of this crisis,” said Anthony Scalzo, MD, President, Hematology-Oncology Associates of Central New York, “We’ve seen the extra time and energy that people have placed into making our practice safe, how we’ve scrambled to maintain the level of care we’re accustomed to delivering, and we stand in awe of each other. We have greater respect and closer relationships than ever before.”

 

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