The need to adapt effectively and provide consistent care to patients with cancer during the public health threat caused by coronavirus disease 2019 has prompted the expanded use of telehealth.
The need to adapt effectively and provide consistent care to patients with cancer during the public health threat caused by coronavirus disease 2019 (COVID-19) has prompted the expanded use of telehealth. Regulations on telehealth have been relaxed, and this affords oncology practices the opportunity to better serve this high-risk patient population during the COVID-19 crisis while mitigating the spread of the pandemic.
“Circumstances on the ground have radically changed in a short period of time where we recognize that telehealth technologies can be used in a public health emergency,” Ryan Howe, deputy director of the Hospital and Ambulatory Policy Group at the Centers for Medicare & Medicaid Services (CMS), said during a webinar on April 3, 2020, hosted by the Community Oncology Alliance (COA).
“We’ve really had to think strategically about how to manage [patients with cancer],” said Debra Patt, MD, MPH, MBA, a breast cancer specialist and executive vice president of Texas Oncology in Austin. “We cannot really stop operations…and if patients do not receive therapy for the months that we expect coronavirus to persist in our community, then their cancer will progress, and they will have an adverse outcome.”
Telehealth has enabled practices such as Texas Oncology to dramatically reduced clinic volumes, creating a safer environment for patients who still require treatment administered at health care facilities. “We have a desire to decrease the volume in our clinic by a large margin. By taking out all the follow-up patients, we were able to reduce our volume by 80%, making it a safer environment for our most vulnerable patients,” Patt said.
Telemedicine also gives clinics the opportunity for family consultations and important conversations about patients’ prognoses and whether they need advanced-care planning.
“With a patient with advanced cancer, this conversation is urgent, but you can’t have other people in the clinic now,” Patt said. “We have had to think strategically about how to manage patients. By reducing volume, we’ve created a safer environment that allows patients to get the care they need.”
Policy Changes Enable Expansion
Before the pandemic, statutory provisions limited the use of telehealth services that Medicare would cover. Patients had to live in a designated rural area and could access telehealth only in a health care setting (as opposed to their homes), and physicians had to be licensed in the state in which the patient resided.1,2 Because of such limitations, telehealth had little uptake prior to the pandemic, particularly among oncology practices.
Although more than 50 US health systems already had in place telehealth technology to allow clinicians to see patients at their home, few oncologists had embraced the technology.3,4
On March 17, 2020, CMS waived the setting of care and geographic restrictions that had been place. By expanding this benefit on a temporary and emergency basis under the Coronavirus Preparedness and Response Supplemental Appropriations Act,2 CMS has authorized Medicare to pay for office, hospital, and other visits furnished via telehealth across the country, including in the patient’s home. The action, however, does not mean that state or local licensure is automatically waived; the American Medical Association (AMA) advises practices to check state requirements.5
CMS is allowing licensed providers to render services outside their state of enrollment as well. The agency has indicated these are temporary waivers for the COVID-19 crisis, although several speakers at the COA webinar have indicated they would like to see these changes persist.
“CMS has been incredibly responsive. They have listened to what we have said and what we have asked for in terms changes for telehealth. Telehealth has been a virtual lifeline,” said Ted Okon, executive director at COA, said during the webinar.
Additionally, the Office for Civil Rights at the US Department of Health & Human Services said it would not impose penalties for noncompliance with requirements related to the Health Insurance Portability and Accountability Act (HIPAA) during the COVID-19 public health emergency.6 Some of the technologies being used for telehealth may not fully comply with the requirements of the HIPAA rules.
Private payers have followed CMS’ lead and made changes to their policies as well. The American Society of Clinical Oncology (ASCO) has put together a guide with information and updates about payers’ changes.7 Payers listed in ASCO’s guideline have issued temporary changes to their coverage for telehealth services. For example, they may waive member cost sharing for a covered telemedicine service or allow providers to bill for a standard face-to-face visit for all virtual care services, including those not related to COVID-19.
On April 30, CMS released an updated rule increasing payments for some visits via telehealth.8 In response to requests from ASCO, CMS is increasing payments for telephone evaluation and management visits to match payments for similar office and outpatient visits, which will increase payments from a range of about $14 to $41 to about $46 to $110. The payments are retroactive to March 1, 2020.
How Practices Implement Telehealth
The AMA has developed a step-bystep guide to implementing telehealth based on insights from across the medical community,5 although the guide stresses that the process is not always straightforward. Licensure and reimbursement are 2 of the most common challenges to scaling telehealth in practice, and the AMA suggests that investing time in understanding the complexities will save time and resources later.
Speakers at COA’s webinar offered insight into their telehealth initiatives. For example, Texas Oncology, with 221 sites throughout the state and about 60,000 new patients a year, has been using telemedicine for 5 years, but because of statutory limitations, this was primarily a clinic-to-clinic operation, Patt said.
“We’ve previously used telemedicine to bridge the gaps in medical subspecialties and that is meaningful, but its use case was limited,” she said.
Texas Oncology began expanding its telemedicine services in February 2020. The first phase was to onboard about 15% of the clinicians to complement triage for acute care evaluations.
The second phase started in March, with onboarding for about 80% of clinicians for acute care, established visits, and new patient consultations. By early April, Texas Oncology had 500 doctors, 150 advanced practice providers, and 900 support staff who had access to the telemedicine program.
Patt said she would like to see CMS expand coverage of telehealth for preventive services and would like the expanded services to be available throughout 2020.
“There is a discordant narrative regarding expected duration of illness for the pandemic. Some practices have been reluctant to adopt changes because this may last only a month. That is a limitation. If CMS had a policy allowing this to last for the year, it would facilitate adoption.”
Bud Pierce, MD, PhD, a physician with Oregon Oncology Specialists, noted that the loosening of CMS regulations has also enabled practices to innovate. “As a long-time practitioner, I love doing this now, and it’s so powerful to take into the future to take better care of our patients. Let’s use technology to be innovative. One of the main impediments to innovation in medicines is rules and laws. We need to be paid for the work we do,” he said.
Oregon Oncology Specialists, which has 4 sites (soon to be 7) and sees 3000 new patients a year, has used Zoom over the past few weeks to conduct follow-up visits with several older patients who were concerned about coming to the office. “We’re using Zoom because we weren’t doing any telemedicine before this. This was so much better than a phone visit. It’s important to see patients. You get so much more from that,” he said.
But Patt cautioned clinicians about using some technologies. “It’s great that CMS has allowed for the noncompliant platforms such as FaceTime, Skype, and Zoom during the health crisis, but these are not long-term solutions,” she noted. Texas Oncology is using the VSee telemedicine platform, which is encrypted and HIPAA compliant.
Dennis Zoet, chief business development officer at Cancer & Hematology Centers of Western Michigan, said his group is using Doxy.me because it is easy for patients and is HIPAA compliant.
“This is the right vendor for my practice right now; I don’t know if this is the right vendor for my practice 6 months post- COVID-19 emergency implementation,” he said during the webinar.
Cancer & Hematology Centers of Western Michigan, which has 5 locations and saw 8000 new patients in 2019, was able to make telehealth available quickly. The practice signed up on March 18 and had the first virtual visit 2 days later. At the time of the webinar, 53 staff had been trained on the platform and the practice had 22 stations available for virtual visits, with 400 scheduled virtual visits.
Zoet offered a few lessons learned from his practice’s implementation, as well as points to consider. After 1 patient came to the office instead of doing a virtual visit and other patients said they did not have a usable or charged device, he implemented a training program for appointment schedulers and included a script for them to follow when speaking with patients.
“The patients are so appreciative, they are enjoying it, although they are experiencing some hiccups,” he said. “We also are doing quick surveys of 5 minutes to get feedback from the doctors and we have support for them as well.”
Mission Cancer & Blood in Des Moines, Iowa, is having nurses set up the telehealth appointments.
“The appointment scheduler is not a clinical person, and to now explain to the patient why we are switching them to a telehealth visit is a clinical discussion,” said Phil Stover, JD, MBA, the practice’s CEO. “We wanted this to be a clinical team assuring the patient we are taking care of them. That has helped us with streamlining the implementation.”
Mission Cancer & Blood, which has 3 main locations, also created a handbook for its providers with policies and procedures; information about One Touch Telehealth, the platform they are using; troubleshooting information; and how-to’s for engaging patients.