March 2021 Edition Vol.13, Issue 3

With Telehealth, the Oncology Community Faces a “Goldilocks” Dilemma

By Aaron Tallent

The COVID-19 pandemic allowed physicians to embrace telehealth by using electronic technologies such as video conferencing to conduct care. At the Association of Community Cancer Centers (ACCC) Annual Meeting and Cancer Center Business Summit held virtually in early March, Kavita Patel, MD, MS, FACP, described how a prominent Midwestern practice went from using telehealth for less than one percent of its visits to 95 percent in a matter of 30 days.

Dr. Patel, the Fellow and Managing Director for the Center for Health Policy at the Brookings Institution, and other speakers at the ACCC meeting discussed how they are looking forward to a return to normalcy in their lives and health care, but want telehealth to be utilized at a greater level than it was before the pandemic. The question is how frequently should this form of care, which allows patients and providers to safely meet for certain visits and cuts down on commute time, be used.

“That’s going to be an ongoing debate,” said Dr. Patel in the opening policy keynote address. “There are especially some payers who would argue that we should return to the way it was. Less than one percent is too little, but certainly ninety-five percent is too much, and it becomes a Goldilocks problem. What’s the right amount of telehealth?”

An Overnight Transformation

Many oncology practices were incorporating limited telehealth infrastructure within their practice before the pandemic. For example, Central Care Cancer Center, which has 10 locations across a 150 mile radius of Kansas and Missouri and sees a high number of patients in rural areas, utilized telehealth for five percent of its visits in approximately half of its facilities. The visits were mainly for patients to receive second opinions from oncologists at larger cancer centers, such as the University of Kansas Cancer Center, and the platform that was used depended on the patient and location.

In March 2020, Central Care Cancer Center streamlined the number of platforms it used to primarily Zoom and doxy.me to give its staff and patients less tools to learn and thus, less confusion.

“Because [technology’s] so flexible and you have too many options, not everyone uses the same and not everyone is familiar with that technology,” said Johanna Garzon, MHA, HBAT, Cancer Center Director of Central Care Cancer Center and Heartland Cancer Center.

The Centers for Medicare and Medicaid Services (CMS) also made changes to telehealth policies that helped practices make telehealth more widely available to patients during the pandemic. First and foremost, Medicare began reimbursing practices at the same rate for telehealth services as for in-person visits during the pandemic, along with not requiring patients to have an existing relationship with the physician providing care via telehealth. CMS also made another significant change in allowing physicians who are licensed in one state to see a patient in a different state through telehealth.

With these changes, CMS reported that the number of patients meeting through telehealth went from 11,000 a week to 1.3 million by the end of April. Between March and August of last year, Garzon said between 50 and 60 percent of her center’s visits were conducted via telehealth.

“We were very lucky because we already had the infrastructure here,” she said.

Telehealth Post-COVID

The frequency of telehealth’s use once the country fully reopens post-pandemic hinges significantly on the decisions of CMS regarding the flexibility it provided during the public health emergency once patients can safely begin in-person visits. The first question will be how to reimburse physicians for telehealth visits. Dr. Patel said the parity with in-person visits likely won’t continue given what may be perceived as distorted incentives.

“You don’t want to pay the exact same amount for an in-person visit as you would a virtual visit, but it’s clear that allowing for people to do more virtual visits is actually going to expand adherence and access,” she said.

Dr. Patel and the other panelists also noted that more data on the positives and negatives of telehealth is key to making more informed, long-term decisions. The benefits in improved quality of life for patients have been touted, but so have the potential long-term costs. The Congressional Budget Office (CBO) has historically estimated that expanding telehealth will increase Medicare spending. However, Frank Micciche, Vice President of Public Policy and Communications for the National Committee for Quality Assurance, says CBO’s estimate is based on what he thinks “is the mistaken belief that people will come out of the woodwork because they can all of a sudden access telehealth. Unfortunately, with the pandemic, this is not a great proving ground in terms of rebutting that belief.”

Micciche also said that coming out of COVID-19, it is key that oncology professionals document their experiences with telehealth and share that information with their colleagues and policymakers. They also should be impartial in how they collect and report this information.

“The data will tell – I think primarily positive stories about the use of telehealth and how it’s helped and how it will help going forward. It may tell some negative stories,” he said.

One unflattering aspect of telehealth is the fact that it has been widely used for about a year and already has added to health disparities. Unequal access to technology, lack of digital literacy, and poor internet access have prevented this type of care from reaching many patients in remote, underserved areas. Feyi Olopade Ayodele, MBA, Chief Executive Officer of Cancer IQ, Inc., a Chicago-based startup company specializing in innovations in cancer care, said that taking the technology burden off the patient is crucial to making telehealth more equitable.

“I think that’s really the only way to truly make it so that you’re not reliant on having a great internet connection or having a computer already,” she said.

These challenges will need to be overcome and more analysis needs to be conducted before telehealth in oncology is, as Goldilocks would say, “Just right.” However, the panelists agree that finding the best fit is worthwhile.

“I do think we need to maintain the momentum here after COVID-19,” said Garzon.

SIDEBAR: Electronic Patient Reported Outcomes Can Help Monitor Symptoms Outside the Practice

People living with cancer can also keep their care team apprised of their symptoms on a regular basis through electronic patient reported outcomes (ePROs). Ethan Basch, MD, MSc, Chief of the Division of Oncology and Physician-in-Chief at The N.C. Cancer Hospital, discussed how ePROs can improve monitoring of toxicities and symptoms in cancer patients.

“Early in my career, I began to observe that, unfortunately, we often missed symptoms that patients may be experiencing that emerged later on and we realized that they were presenting themselves much earlier, but they evaded our notice,” he said.

Dr. Basch has conducted extensive research in ePROs. Under his team’s model, patients report through an ePRO system or their portal. The oncologist or nurse is then able to monitor it through pulled reports or alerts in cases of severe symptoms and then circles back with direction or next steps on managing the symptoms, such as counseling, supportive medications, or referrals. The reporting can be done over the Internet, smartphone, or a good old-fashioned telephone. In the latter, an automated voice asks questions and the patients pushbutton their answers.

“In fact, many patients in the United States, particularly in community practices and rural areas, prefer the telephone approach to the web approach,” said Dr. Basch.

Numerous clinicals have shown the benefit of ePROs. Dr. Basch presented findings from a randomized clinical trial published in the Journal of the American Medical Association in 2017 where seven percent fewer patients in the ePRO self-reporting arm had to visit the emergency room when compared with standard care. The study also showed that the median survival was 5.2 months longer for patients who self-reported their symptoms.

Part of the reason for the better success is that the proactive monitoring of symptoms prompts earlier clinical interventions and allows patients to stay more functional. In addition, the symptom monitoring better controls chemotherapy side effects, allowing for potentially more effective treatment.

“In this study and in other studies, patients have been able to stay on chemotherapy longer when using this kind of a PRO intervention,” said Dr. Basch, who is now leading the PRO-TECT Cancer Symptom Study, where patients report on 12 symptoms on a weekly basis. The research project is underway at 52 sites in the United States and results are expected next year.

For practices looking to set up an ePROs system, Dr. Basch warns that there is greater work for the nursing staff on the front end to adjust workflow, train patients, and manage alerts and it should be implemented by an experienced quality improvement team. For patients, he recommends multiple ways to interface, surveys that do not require passwords, and reminders for patients who miss the surveys.

“You don’t just turn the on button on. You have to make sure that your clinic is ready for this, as with any care enhancement,” said Dr. Basch.

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