By Andrew Hertler, M.D.
Like a hurricane-force wind, the COVID-19 pandemic has blown through the health care system and ripped at the weak spots, further exposing racial disparities, underfunding of public health and the perverse incentives of fee-for-service health care that have long lain under a veneer of stability.
But when it blew down the door, COVID-19 also swept in several changes that have been knocking for years prior. And many of those changes appear here to stay, for the better.
That’s certainly the case in oncology. As the pandemic struck, oncologists and cancer practices quickly adapted to balance treatment against the threats posed by the virus. Such pivots, though made under pandemic duress, happen to simultaneously address longstanding challenges facing the field: a convoluted patient experience, expensive drug innovations that bring marginal clinical benefit, and preventable utilization of EDs and hospitals.
For practices seeking to improve outcomes while retaining clinical autonomy and financial stability, these five COVID-19 pivots have strong potential for improving care delivery, patient experience and outcomes, and the financial health of both patients and oncology practices—even after the urgency of the pandemic eventually fades.
1Refining the value calculation to include competing priorities
Broadly,COVID-19 has forced us to weigh the value of cancer therapy against other serious concerns in a way that has long eluded oncology care. On behalf of our patients, our field has typically fought to claim every inch of ground we can in the battle against their cancer. But that has sometimes led us to embrace expensive drug innovations that bring marginal improvements in survival, often at the expense of quality of life. For pancreatic cancer, for example, one drug increases survival a median of about 10 days while increasing costs by $7,000 a month.
Now that we face another serious threat in COVID-19, the field has had to reprioritize its success metrics. For some drugs or treatment regimens, the incremental improvement in efficacy may not justify the increased risk of compromising immunity or requiring additional patient visits and potential virus exposure.
This is a new and important shift in the conversation about value in oncology, and one that is long overdue. Although it was spurred by the competing concerns of another deadly disease, we can hope that it leads to more transparent and open discussion about expensive drugs that don’t meaningfully improve patients’ lives.
2Permanently embracing telehealth
Telehealth has enabled practices to balance the need to reduce potential exposure to the virus while continuing to treat patients with cancer. Roughly 85% to 95% of active oncology treatment cycles have continued during the pandemic, according to internal NCH data across the 8,000 practices with which we collaborate. Telehealth has helped enable that continuity of care, accounting for up to two-thirds of visits to some of these oncology practices.
As patients come back to in-person clinics, telehealth may be relegated to certain visit types—for example, for surveillance of signs of recurrence, chemotherapy toxicity checks, confirming prescription adherence and virtual assessments via wearable devices that can limit patient time physically in the office. But it will still have an important role.
Continuing some level of telehealth for patients actively undergoing treatment or surveillance may also help practices manage potential surges in new patients in coming months. NCH has seen a 70% drop in claims volume for breast and colon cancer screenings, and even higher screening drops have been reported by other surveys and media outlets. If predictions hold true, after screenings rebound we will see a bolus of new cancer diagnoses, and many of those cases will be caught at later stages, requiring more aggressive and costly therapies. Telehealth may give cancer practices the flexibility to manage fluctuations in the number and severity of cases.
3Deploying nurse-led triage tools to prevent unnecessary ED and hospital utilization
Patients undergoing cancer therapies may experience complications that scare them enough to risk a masked visit to an emergency department. That was a costly trip—and often preventable— even before the added risk of virus exposure: About half of Medicare patients undergoing chemotherapy visit the emergency department with complications, and about 60% of those visits result in a hospital admission—at an average cost of about $22,000. But often those symptoms—such as nausea, pain and extreme fatigue—can be more appropriately treated in the cancer practice, or even without leaving home. Sometimes, a new prescription for anti-nausea meds is all that’s required.
COVID-19 has heightened the importance for cancer practices to implement standardized triage protocols to direct patients to the most appropriate site of care. When patients call with complications, nurses follow evidence-based screening tools or algorithms to determine severity and assess their need to visit to the ED versus being seen at the cancer practice or even managing the patient at home. This will continue to be a high-value service after the virus is under control.
4Adapting treatment protocols to incorporate alternative regimens and care delivery locations
Keeping patients out of the emergency department is just one example of directing patients to the most appropriate level and location of care. By adjusting treatment protocols, we can reduce patient visits to clinical settings and tackle spending.
Cancer therapy pivots worth keeping top of mind as post-COVID-19 treatment options include the recent tilt toward a higher use of oral therapies that can be administered in a home setting, stopping chemo for patients in deep remission, moving medications for bone metastases from monthly to every three months, and evolving National Comprehensive Cancer Network guidelines suggesting decreasing the intensity of some of these and other therapies. Antibodies, for example, are often continued for a year in breast cancer patients, but the risk of clinic visits can outweigh the health benefits, and some antibody therapies are now being discontinued after six months, with an impact on outcomes that may not be clinically significant to the patient. Similarly, radiation therapists are adopting treatment plans that deliver therapy in fewer doses—or fewer fractions—an approach long shown to have equivalent outcomes to standard treatment plans and one which minimizes patient visits for treatment.
5Reflowing patients in clinical settings
During COVID-19, some extreme examples of modifying patient flow have included patients being checked in while in their cars, or screening checks being taken remotely a day in advance of an in-person appointment. While these drastic pivots may not need to stay in place, practices have made other physical modifications that would be welcome in a post-COVID world—for example, increasing privacy during chemotherapy treatment by spacing patients farther apart, and minimizing the number of family members and immunocompromised patients in a waiting room. Expanding office hours to accommodate patient panels would give patients additional options for balancing appointments with their own schedules. And home collection of routine labs can streamline visits and potentially reduce costs.
COVID-19 may have forced our hands as oncology practices, but in many ways, the pivots made from urgent necessity are highly appropriate amid the ongoing shift to value-based care and value-based reimbursement.
Dr. Andrew Hertler is chief medical officer for specialty care management company New Century Health.