publication date: Jul. 17, 2020

Conversation with The Cancer Letter

Lucio Gordan: Patients must have the option of telehealth to avoid COVID-19 exposure

Lucio N. Gordan

Lucio N. Gordan, MD

Managing physician/president,

Florida Cancer Specialists and Research Institute

 

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. Our full coverage of SARS-CoV2 is available here.

As cases of COVID-19 surge in Florida, Lucio Gordan, managing physician and president of Florida Cancer Specialists and Research Institute, is working to increase the role of telehealth.

The volume of telehealth went up dramatically as the massive practice adjusted to the first wave of COVID-19. After the first surge passed, telehealth dropped off slightly.

Now, as Florida sets grim daily world records in the numbers of COVID-19 cases and deaths, the practice is ramping up telehealth. And, like everyone else in oncology, Gordan is concerned about the possibility that reimbursement for telehealth will return to lower, pre-COVID, levels. (See a related story on telehealth reimbursement here.)

“The highest we were before the second wave, [was] 26%,” Gordan said to The Cancer Letter. “We went down to 22%. Now, I want to push it up to 30-40% or so for the next four weeks, when clinically appropriate, so we can diminish the risk of exposure to the patients and staff.”

When the pandemic first struck in the U.S., CMS and private insurers made emergency changes in reimbursement to make telehealth economically viable. 

Florida Cancer Specialists is “extraordinarily happy and grateful to Medicare, CMS, and the commercial payers, which reacted very quickly to the crisis back in March. We have a concern coming up here towards the end of July that the rules may change, and the reimbursement may drop by 70%,” Gordan said.

“So, hopefully commercial payers will be on board with continuation of reimbursement rates at usual standard E&M codes, because it’s extraordinarily important. For instance, a large company like ours, and just for magnitude purposes—we see about 75,000 new patients a year, and about 400,000 returns—it’s important that these patients are given the option of telehealth.

“There’s so many patients who could avoid exposure.”

Florida is second only to New York in the number of COVID-19 cases and the number of deaths. On July 17, the  state  reported over 100 deaths for four days in a row. Cumulatively, Florida has had 327,241 cases and 4,805 deaths, Miami Herald reported.

 

Gordan spoke with Paul Goldberg, editor and publisher of The Cancer Letter.

 

Paul Goldberg:

First of all, how has COVID affected your practice?

Lucio N. Gordan:

In the beginning of the crisis, back in March 2020, we saw a sudden drop in new patient volume of about 28%, and return visits about 15%, and chemotherapy volume was down by 11%.

And then we have recovered, I think, as far as new patient volume of we’re still down year over year about 12-13%. The return patients were still down 4-5%, and chemotherapy or infusions was still down 2-3%. So, from a volume standpoint, it has been pretty significant.

And now we’re going to see the Wave B in the first phase, who knows what this is, we haven’t even gotten to the second phase yet. We are already instituting some changes in flow here.

We implemented telehealth very quickly, on the first wave, in a matter of about five business days, we were on board with telehealth.

So, that helped. We’ll be significantly more prepared. We are still about 22-25% telehealth, now. We need to leverage that up.

 

PG:

How is the second wave different? How is it different from the first? Or whatever it. Wave 1B? How is Wave 1B different from Wave 1A?

LG:

We are better prepared, of course. We have reasonable stocks of PPE and N95s. We’re running short on gowns for the infusion rooms, just because there is a national shortage of those.

But we are better prepared. We have all the procedures in place as far as checking temperature of everyone in the clinic twice daily. We have the questionnaire of everybody who comes in ready, and everybody’s already implementing upon entry of the clinic.

We are limiting inflow of visitors, no vendors in the clinic, unless critical. So, I think we are better prepared for this second phase here of the first wave.

But on the other hand, the magnitude of the second wave in Florida can be much higher; right? Because we’re seeing 12,000, 15,000 new cases a day these days. And back in March, we were seeing 3,000-4,000 cases.

I think it’s a matter of time for the virus to permeate through the folks who are older or higher-risk to start stressing the hospital systems.

 

PG:

I see. So, mostly you’re not really seeing your cancer patients affected by it, or are you?

LG:

No, not yet. We do have patients that have been admitted with COVID, and most of them have done well.

We are seeing this second wave of the first, more employees getting affected. For instance, back in March, we had, I want to say, less than 10 employees that got COVID. Now we have more—we have about 70.

 

PG:

How many employees do you have?  You have a huge practice.

LG:

We have nearly 4,000 employees. So, we are very much under control, but we also run a tight ship.

If we start seeing increased absences, it can get complicated for us to maintain full operations. We have moved everyone from revenue cycle information technology—and everything that can be moved to home, we have.

But there are all of us physicians, PAs, nurse practitioners, all the supporting clinic, we just simply can’t not be there.

 

PG:

It’s interesting that it’s the younger crowd that’s getting COVID now in Florida—and fewer cancer patients.

LG:

Right. So, 50-70% of the new cases are between 20 and 40 years of age, as you said. However, it’s a matter of time for us to see an uptick in the mortality rate and ICU utilization.

I think, now, we know much better how to manage folks at high risk. Like nursing homes, I think we’re going to tighten up the access much better and more quickly than before, but I think the hospitals will fill up.

For instance, last night I was checking the ICU utilization in Florida, we were at 82% of capacity, which is still pretty good to have 18% open, but like Miami-Dade, I think they were at 95% full.

In my city, Gainesville, I think we were about 80% ICU capacity, but shrinking quickly.

We still have some capability of expanding. As you know, a lot of hospitals in Florida are already canceling elective procedures, surgery, so that we can use more hospital beds and ICUs and OR space, ER space, for COVID vents.

 

PG:

And this will, of course, trickle down to oncology.

LG:

Absolutely. It’s hard to quantify what is the potential mortality from the delays in diagnosis of individuals who forgo colonoscopies a year, forgo mammogram, or delay symptom management because of COVID access or COVID concerns.

There’s a paper in the British Medical Journal stating that there may be a 20% increment in the mortality of oncology patients in the UK, at least. I think it’s going to be probably a 10% uptick here in the U.S.  as well. Just a gut feeling, from what I’m seeing.

 

PG:

What about cancer patients that you are seeing who are getting COVID? Is there anything you’re getting, any sort of data, anything helpful? Anything useful?

LG:

We are participating in the ASCO registry as to how these patients are doing and how we’re treating them.

So, in collaboration with ASCO, to try to find out how these patients fared.

I think there’s significant variation of care, Paul, as you know, when these patients get to a hospital these days.

In our centers here, at least where I work, a lot of these patients are treated with remdesivir, if they’re hypoxic, and dexamethasone, and sometimes a convalescent plasma in a clinical study; that’s what I’ve seen the most.

So far, I have not personally lost any patients to COVID-19, but I’m sure it’s happening across the state.

We haven’t measured yet. As you know, we have about 90 offices, 250 doctors. So we don’t have the whole data in our hands to give you a precise answer at this point.

 

PG:

But everybody has dexamethasone. Do you have enough remdesivir?

LG:

We do not stock remdesivir in clinic, because we don’t want to take remdesivir away from the hospital systems, right? So we have zero remdesivir.

So, if our patients need to be hospitalized, we would hope that the hospitals will have enough stock. But I hear that in the Southeast Florida market, it’s already a tight on location, very tight.

I understand the governor’s office and distributors trying to facilitate transfer of remdesivir from other locations, to the Southeast of the country, to allow us to treat the patients, but it’s getting tight.

 

PG:

What about reimbursement for telemedicine? How are you doing on that?

LG:

So far so good. Extraordinarily happy and grateful to Medicare, CMS, and the commercial payers which reacted very quickly to the crisis back in March.

We have a concern coming up here towards the end of July that the rules may change, and the reimbursement may drop by 70%.

So, hopefully commercial payers will be on board with continuation of reimbursement rates at usual standard E&M codes, because it’s extraordinarily important.

For instance, a large company like ours, and just for magnitude purposes—we see about 75,000 new patients a year, and about 400,000 returns—it’s important that these patients are given the option of telehealth. There’s so many patients who could avoid exposure.

 

PG:

How much telehealth do you do now?

LG:

Right now, the highest we were before the second wave, we were at 26%. We went down to 22%. Now. I want to push it up to 30-40% or so for the next four weeks, when clinically appropriate, so we can diminish the risk of exposure to the patients and staff.

 

PG:

Do you make money on each telehealth, versus in-person visits?

LG:

Yes, so far we do, because the reimbursement has been relatively equal to a standard E&M code.

But if there’s a significant drop, then there’s going to be a wash or a negative even. So that becomes very complicated.

 

PG:

Can a doc make as many telehealth visits as regular visits; what’s your thinking on that?

LG:

Yeah, we can. Telemedicine is critically important. There are some limitations, of course. We usually end up having telehealth for patients who are actually not getting an infusion in the clinic on the same day, because if they’re coming in, we will see them in person.

But for somebody who has less complex medical problems, telehealth has been very beneficial. We can troubleshoot an acute medical problem, if it’s not too complex, answer questions, provide explanations about treatments.

One can probably see the same number of patients via telemedicine, or more. But it’s not one solution for everybody.

 

PG:

Are you delaying some of the visits? And when you do, do you keep track of it? Do you call them again after?

LG:

Absolutely. We are.

Let’s say if we have a patient with a history of breast cancer, adjuvant setting, this patient is getting hormonal therapy, and she’s on an every-six-months schedule, we are pushing this patient out a month or six weeks, if the patient consents.

We have the nurse triage system call the patient, make sure there’s no problem, offer a telehealth and then push out six, eight weeks. If the patient does not desire telehealth, then they stay in the books, so they will get automatically called by us so we don’t lose track of the patient.

We are pushing out some treatments, like osteoporosis infusions or injections, other less critical infusions that a month or six-weeks delay is not detrimental to patient’s outcome. We are prescriptive in involving patients in this decision.

 

PG:

Have your procedures for patients getting into the clinics changed from the first time around? Is there anything that you’ve learned that you’re doing that you weren’t doing before?

LG:

Right. I think we are much stricter as far as an entry into the clinic on this second go-around.

Visitors, only essential visitors or individuals who are companions to patients, somebody who needs a wheelchair, a patient with a cognitive or significant physical dysfunction or a major medical problem that the son or daughter, or other family member needs to be with.

So, we have a list of criteria that allows such individuals to come with the patient. We are making sure that, as I said, everybody’s getting their temperature checked twice daily, it’s recorded and reported to each office manager.

We are sending more prescriptive information to the patients and their families via email or other forms of broadcast, to be compliant with utilization of masks.

So, we’re trying to take a very proactive leadership to inform the community of importance of heeding scientific advice.

 

PG:

How long was your break from between Wave 1A and Wave 1B?

LG:

So, between March 15 and May 15 was intense. Then we got between May 15 and July 1 that was a little bit of a break, and now it’s back to the intense mode again.

 

PG:

I don’t want to put you on the spot, but who’s to blame?

LG:

Well, again, excellent question. I think the severe problems with honestly, lack of leadership, in a state and  national levels.

I think the utilization of masks is such a no-brainer. This is a health matter, and not politics. This is a respiratory disorder, and it’s transmitted by either droplets, aerosolized particles or both.

We opened business too quickly, and we really didn’t emphasize the importance of a social distancing and masks and appropriate care and respect to each other.

It has been a massive failure of healthcare policy, absence of buy-in of general public, lack of cooperation, personal responsibility and respect toward the fellow neighbor if you will.

 

PG:

Oh yeah. The United States has no system.

LG:

Finally the number of tests have increased, but, still, if you look, there’s an hour and a half or two hour waiting lines to be tested, so we’re not up to scale.

And we let it spread too much, Paul, and there’s no way we can trace back any contact, effectively, any longer.

Because 10% of us probably are testing positive these days in the state of Florida, how can you trace back 10% of people? It’s impossible.

 

PG:

Yeah. It’s kind of run away, the runaway train, which actually hasn’t occurred in Europe, for example.

LG:

Exactly.

 

PG:

Or Asia.

LG:

Yes. Again, lack of good policies. Lack of good systems in place. And at the local level of delivery of services, like clinics and hospitals, people have done an exceptional job. But, again, you need to transmit calm and education to the people to heed to scientific data.

 

PG:

If this is the new normal, do you think you would be able to adapt?

LG:

Yes. Again, I think going back to normalcy, whatever normalcy is, will happen only if and when 75% of us gets a vaccine that’s at least 50% sustainably efficacious

We still are struggling to have access to PPE, especially N95s. So, that is a concern. But what we’re doing, we are keeping people away from the office that we can, as far as non-clinical staff. We’re trying to expand hours of operations in our clinics. We are also trying to diminish the gatherings in the waiting and break rooms.

We are calling people, instead of coming to the waiting room, they can check in via phone and then they can wait in their car. We would call them to come in when it’s time. We have frequent terminal cleaning procedures, as we said, in the office is much more frequent.

We are installing plexiglass or physical barriers everywhere, the anti-sneeze devices and anti-droplet devices between infusion chairs, in the front staff area. So we are adapting.

It’s survival 101, and humankind has been good at that. And so we’re going to push it through, I just hope that all of us, as people would, again, be more compliant.

 

PG:

Yeah. So we’ll adapt. We’ll all be here a year from now, I hope.

LG:

We definitely will. And we will come out stronger. I am very bullish for the future, Paul.

I think a lot of new technologies will evolve from this tragic historical event, new procedures, hopefully telemedicine will be here to stay. I think we’ll have many more electronic gadgets to monitor the patients at home.

I think we’ll be using care management more often. And the other technologies that will allow us to do so, like 5G and its use as the platform of internet-of-things.

I hope there’ll be a bold silver lining in 2022—2021 is going to be very tricky still. I am not terribly confident that vaccines will be that efficacious in a sustainable manner, initially.

 

PG:

No, the RNA vaccines aren’t very easy to do.

LG:

Yeah. Because if you go back to SARS-1 and MERS, there hasn’t been a vaccine in 13 years. It’s not that they haven’t tried.

 

PG:

Right. Well, dengue fever has one.

LG:

Right.

 

PG:

But it’s not an easy one.

LG:

No, no.

 

PG:

Is there anything we’ve missed?

LG:

Let me think here… We continue to meet very frequently with our COVID-19 crisis team in our company.

I think what’s important to say is to maintain very open communication with the staff members physicians, patients, set up some expectations, and, again, be based on facts and in science.

That’s what I always try to do, because it’s usually reproducible. But I think we’ve touched upon most points.

 

PG:

Well, thank you very much.

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