This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.
Community oncology practices in the United States are reeling from a sharp decrease in business—whether you look at new patients, chemotherapy visits, or non-chemo visits—the result of reduced activity and stay-at-home orders across the country to mitigate the spread of SARS-CoV-2.
Early data compiled by Flatiron Health and made available exclusively to The Cancer Letter make it possible to visualize the severe impact of the COVID-19 pandemic on community oncologists. The data, which are derived from 270 oncology practices that use Flatiron’s OncoEMR platform, show that:
Visits from new patients, per week, decreased by about 3,000 from over 8,000 in early February to less than 5,000 toward the end of April, a nearly 40% drop,
Total patient visits decreased dramatically after March 9—in the five-figure range,
Patient visits involving chemotherapy were reduced by up to 17% in the Northeast, while non-chemo visits plunged across the country, up to 37%, and
Cancellations and no-shows nearly doubled, up to 80%.
“I think it’s clear there has been a shock to the system,” Bobby Green, chief medical officer and senior vice president of clinical oncology at Flatiron, said to The Cancer Letter. “We’ve seen a drop-off in new patient visits. We’ve seen a drop-off in chemotherapy visits. We’ve seen a drop-off in follow-up appointments. We’ve seen an increase in cancellations.
“This puts many practices at risk,” said Green, who is also a practicing medical oncologist at Florida Cancer Specialists and Research Institute. “There’s a lot of financial concern that’s out there right now about being able to stay open and keep the lights on.”
The uptick in adoption and use of telehealth in place of in-person visits is encouraging, although it pales in comparison to the overall decrease in patient volume.
“Telehealth isn’t completely making up the difference in our drop in volume, but I do think it’s definitely helping,” Green said. “We’ve seen community oncology practices go from zero to 60 in getting telehealth up and running very quickly. I think you may have seen some of the early experimentation in academic centers, but community practices have really, from an operational standpoint, I think, really spun this up pretty quickly.”
A recent report by the Community Oncology Alliance suggests a 20.8% increase in practices merging with or being acquired by other practices and larger corporations over the past two years. If operations continue to be depressed in the ongoing pandemic or by a resurgence in COVID-19 cases in the coming months, this trend may gain strength, Green said.
“I worry a lot that COVID-19 is going to accelerate things,” Green said. “But COVID-19 is having a real impact on hospital systems as well; everyone is hurting right now. So, while this does have the potential to accelerate consolidation, the answer is that we don’t know yet, but, yes, I’m worried.”
As patients delay diagnoses and visits, longitudinal studies may be needed to understand how the pandemic may be changing trends in cancer mortality, and how contingency therapeutic regimens, i.e. more neoadjuvant chemotherapy ahead of delayed surgeries, are affecting patient outcomes.
“Now the questions are: How long can this last?” Green said. “What’s going to happen over the next several months as COVID-19 cases start to decrease? But then, what will happen if we get another COVID-19 wave in the fall? How can practices be prepared?”
Green spoke with Matthew Ong, associate editor of The Cancer Letter.
Matthew Ong: Thank you for sharing these early data with us. I have to say, they don’t look incredibly encouraging for the community practices represented in your dataset. What are your observations?
Bobby Green: As the EHR provider for our practices, Flatiron is able to see the changes in activity pretty much in real time, and to assess the impact of this extraordinary event both on our services and operations, and on our providers. We feel it is important to share what we have observed.
With that said, from my perspective, there’s clearly been a shock to the system.
It’s pretty amazing what community oncology practices—independent clinics that vary in size—have continued to do through all of this disruption. They have really stepped up and responded, everything from screening patients, setting up tents outside the clinic, and even helping patients in their cars. Really just continuing to make sure that cancer patients get taken care of.
From our perspective, as a partner and EHR provider to community oncology practices, we’ve seen a drop-off in new patient visits. We’ve seen a drop-off in chemotherapy visits. We’ve seen a drop-off in follow-up appointments. We’ve seen an increase in cancellations.
Now the questions are: How long can this last? What’s going to happen over the next several months as COVID-19 cases start to decrease? But then, what will happen if we get another COVID-19 wave in the fall? How can practices be prepared?
Everyone, I think, expects that there will be a rebound in patient visits. There are patients who aren’t getting their mammogram and colonoscopies, and so they’re not getting diagnosed yet. These people will be getting diagnosed at some point in the future, so many of our practices are expecting to see a wave of new patients as these more elective procedures start to take place.
But I don’t think any of us really know what that looks like. What’s the timeline? And then, ultimately, what’s the lasting impact on practices going to be? Oncology is certainly different than a lot of other medical specialties in that cancer patients need to be treated now.
At the same time, you’ve read that people aren’t showing up at hospitals for strokes, people aren’t even showing up for appendicitis, which is just mind-boggling to me. The incidence of appendectomies at hospitals has gone down. What’s happening to all those people suffering from appendicitis?
When are we going to start seeing the people who developed a cough that might’ve been a sign of lung cancer? Or who had a mass that was a lymphoma, who normally would’ve gone to see their doctor but have delayed it?
What does this mean for the viability of these practices? Specifically, have you seen closures or hospital acquisitions during this time?
BG: I absolutely think this puts many practices at risk. I don’t know that we’ve seen any practices that have closed or been acquired during the pandemic yet, but we do know that this is putting a financial strain on practices, and we certainly hope that this isn’t a scenario where large hospital systems use this to further gobble up community practices.
And telehealth doesn’t seem to quite be making up the difference, although it is being used. CMS has issued Medicare waivers, but are practices having issues with prior authorizations with private insurers, not to mention building infrastructure and capability for telehealth? What are the challenges that are unique to your cohort here?
BG: Telehealth isn’t completely making up the difference in our drop in volume, but I do think it’s definitely helping in a couple ways. One is, I think it’s giving access to patients who otherwise might not have come into the clinic.
Secondly, it’s enabling us to continue to take care of patients who otherwise would have had to come into the office, but you are able to instead do it remotely to ensure their safety. There are obviously certain things that you can’t do via telehealth, but I am very bullish on it.
This pandemic felt like an impetus, a technological pressure test on the system that, I hope, is going to result in telehealth being a lot more prevalent after we’re out of this.
CMS has been amazing for all of this by relaxing regulations and making telehealth at this scale available so quickly. I honestly can’t say enough about that.
There are many logistical and technological challenges in getting practices and patients set up for telehealth.
Do I have enough WiFi bandwidth in my practice now that we have 15 doctors all live video streaming on and off throughout the day? Does my patient have high-speed internet at home? Does my patient have a smartphone? Does my patient know how to click on a link and log into a virtual server?
There are definitely those challenges that we need to overcome, but there is a world in which telehealth can ultimately help improve health care disparities.
There are many patients who have to take two buses to get to my clinic, and if there are ways that I can take care of them without them having to do that, that’s great. But if they don’t have high-speed internet, it’s really hard to do a remote visit.
I had a previous conversation with Dr. Ben Neel at NYU about telehealth and he said, “Necessity is the mother of innovation.” Large academic centers have been scrambling to scale up their telehealth programs, but how are community practices managing?
BG: This is with my bias as a community oncologist. So, with that asterisk there, I would argue that, actually, community oncology practices are better prepared to deal with things like this.
I think one of the lessons of the whole value-based care experience is that, more often than not, independent practices were able to adapt quickly. We’ve seen community oncology practices go from zero to 60 in getting telehealth up and running very quickly. I think you may have seen some of the early experimentation in academic centers, but community practices have really, from an operational standpoint, I think, really spun this up pretty quickly.
I see, they may be able to be more nimble and to move faster.
BG: Yes. Four years ago, Bob Kocher, a venture capitalist who worked on the Affordable Care Act in the Obama administration, wrote an editorial in the Wall Street Journal, titled “How I Was Wrong About Obamacare.” In the editorial, he wrote how he thought that it was going to be the big academic systems and health centers that were going to be the value-based care innovators, but it turned out that the smaller independent practices have become the innovators.
I think, in some ways, we may be seeing that again here, though this is not to say that academic centers don’t also provide an enormous amount of value and of course play a critical role in cancer care.
Definitely. The Northeast appears to stand out in your data, in average decrease in chemo and non-chemo treatments and visits, as well as increase in patient cancellations and no-shows. Is that the New York effect as well as greater compliance with public health guidelines? What is your sense about what’s going on here?
BG: The Northeast is just such a hotspot. Many of our Northeastern practices are in the New York City area, in the boroughs right outside of Manhattan, in the middle of the hot zones. And I think it’s a combination of the social distancing and the lockdown. People are scared to go out.
I also think we are seeing these decreases in visits and increases in cancellations because in areas where public transportation is the main mode of transportation, like New York, it becomes harder to go to the clinic when there is a higher risk of contracting the virus.
I’m also concerned about what looks like a big drop in new patient visits, by, what, about 3,000 visits from February to April?
BG: Yes. This is really interesting, and that number is obviously dramatic. And, Matt, while teasing this out will require deeper analysis, I will provide my anecdotal observations.
As you probably know, oncology practices see cancer patients, obviously, but also will see a fair amount of benign hematology. And I am hopeful that a big chunk of those new patients are benign hematology, where they are waiting a month or two months to get to the doctor, which is not as big of a deal as a patient with a new cancer diagnosis.
But, invariably, there will be some patients with new cancer diagnoses, and those might be, “I have a symptom and I just never got to my internist, so I never got diagnosed,” and some of those may be because of the drop in “elective procedures,” like colonoscopies, mammograms, those types of procedures that would’ve led to a cancer diagnosis.
And again, I can’t tell you what percentage of those make up that drop, but those are the patients who really worry me. I think what we’re looking at here is the short-term immediate impact from an operational standpoint on practices.
There are obviously going to be a lot of medium to long-term questions about how this impacted outcomes, delay in diagnosis and those things that will be critical to answer.
Right, it might be important to understand whether these delays would result in a significant uptick in overall cancer mortality, as a result of the pandemic.
BG: Yes, it’s going to be really important. And, again, speaking of health care disparities, what are the demographics of those new patients with cancer who aren’t coming in? That worries me as well.
Have you looked at the data on disparities, so far, or what is your sense of it anecdotally?
BG: We haven’t really dug into it in detail yet, and it’s one of those questions that is hard for me to even suggest anecdotally before doing so. You’re trying to guess what you’re missing, and we just don’t do that.
And, Matt, just as an aside, the dataset that we’re looking at here is a cut of our network, it’s different from Flatiron’s research datasets. Our research datasets are typically much larger—it’s a much deeper data set with a lot more clinical information that has been further processed and vetted. So not only is the dataset different, but our objectives in scanning this data are different because here we’re doing so as part of our internal operational management and support of our providers.
We’ve sort of taken a snapshot look here, but we haven’t really dug in and cleaned and validated the data in the ways that we would do for an outcomes study. Questions like this, including ones about disparities, are ones that Flatiron is going to be interested in doing down the road once we have developed robust datasets.
Got it. Also, have you seen broad changes in the kinds of treatment regimens that are being used or scheduled? You probably haven’t had the time to look at the data on this matter, but for instance, there are considerations for using neoadjuvant treatments because of delays in surgical interventions.
BG: We haven’t looked into the data yet, but I’ve heard the exact same things. Anecdotally, I think that we’re seeing increased use of neoadjuvant therapy to try to avoid surgeries and delay of treatments that you might consider “non-essential,” though that’s not the right word.
At a high level, when you’re making a treatment decision for a patient with cancer, you have to look at a bunch of different factors. You have to look at the risk from the cancer. So, for example, a fast-growing lymphoma to a slow-growing prostate cancer; and you also have to look at what are the other illnesses that the patient may have that could put them at increased risk.
And then, what are the potential risks of therapy versus waiting, or maybe even not treating? In taking care of cancer patients, in general you make decisions based on data, but also based on some uncertainty. That’s the art and science of medicine. But COVID-19 has thrown us a whole big curve ball of new uncertainty.
Also, what is Flatiron doing to support its community oncology partners at this time?
BG: We have a whole team spun-up to help support the practices. First of all, the head of our team who supports our practices’ revenue cycle management (RCM), Gail Airasian, is the one who kicked off all of this practice analysis that we’ve shared with you.
Gail and her teams are helping practices with their collections, A/R and appropriate financial analyses. This is of course critically important to help ensure they weather this storm.
We’re also providing data to practices to serve as a benchmark, so that they’ll be able to compare their data to try to get an understanding of how they are doing vis-a-vis the rest of the country.
We’ve helped our practices with thinking about how to integrate telehealth into our electronic health record, offering best practices on documentation of telehealth, and other questions that relate to our EHR.
We also have an information center to help our practices understand the changing regulations and what CMS is doing.We want to make sure they can benefit from what CMS is offering, the small business loans, and other changes being made by the federal government. When there’s information about the CARES Act, when HHS was sending out checks to practices, making sure practices were aware of all that information.
We also need to make sure that when, for example, CMS lifted the restrictions on being able to use FaceTime and Skype for telehealth, our practices are made aware.
Also, I think it’s really important for us to track the regulations that are changing outside of COVID-19, so for instance, some of the interoperability standards or various other pieces of the puzzle that are being put on temporary pause. Ensuring we’re helping our practices keep abreast of the whole picture, I think, is really important.
And by the way, a lot of this is complementary to what the Community Oncology Alliance (COA) has been doing. I think COA, as usual, has been doing a great job here.
I know this isn’t addressed in this dataset, but what can you tell us about how your academic partners compare in coping with the pandemic and changes in patient trends? What are the similarities and differences here?
BG: I think the academic centers, both from our experience at Flatiron and everything that I have read, conversations I’ve had, have in a lot of ways been very, very similar to what community practices are doing; initiating a lot of the same practices like doing standardized screening before coming into the office, not letting people suspected of being infected into the office, not letting guests accompany patients during visits unless absolutely necessary, making sure that there’s appropriate spacing between patients in the infusion room, initiating telehealth. I think all of those things have been similar.
The biggest difference that I can see is most of these academic centers also have an inpatient hospital to deal with as well, and that obviously adds a whole new dimension. So, I think that’s been the biggest difference. But in terms of how oncology clinics are operating, it seems to be pretty similar.
So, COA just released a report finding a 20.8% increase in practices merging with, being acquired by other practices or corporate entities, hospitals, etc., over the last two years. Do you expect this trend to be accelerated by COVID-19? And also, what does that statistic tell you about the changing landscape of cancer care?
BG: It worries me. I think we all know that when independent practices go into hospital systems, costs go up. Often, access is harder. And that’s not to say that academic medical centers, hospital systems don’t play a role in our health care system—of course they do, an important one.
But as we see more of these acquisitions by hospital systems, I don’t believe it’s good for patients. I worry a lot that the COVID-19 is going to accelerate acquisitions.
But COVID-19 is having a real impact on hospital systems as well; everyone is hurting right now. So, while this does have the potential to accelerate consolidation, the answer is that we don’t know yet, but, yes, I’m worried.
Did we miss anything?
BG: One of the things I would share is we hear all of these incredible stories of what’s going on in hospitals and in ICUs and what the frontline health care workers are doing. And I think we’re also seeing that across our community oncology practices.
Many of our practices have set up access for injections, blood draws and pre-screening in tents outside of their clinic, allowing patients to stay in their cars. I heard one story recently about a patient who needed to get an injection, but obviously did not want to go into the clinic. So nurses from that practice literally came outside in a torrential downpour with no umbrella, no raincoat, to administer this injection to the patient in their car, all to ensure their safety.
There are just so many stories about how people are stepping up and taking care of patients. It’s scary going out these days. It’s scary being around people. You go to the grocery store, and you get scared.
And I go into my clinic every week, and I see all of the staff in those offices who are there, who are checking in, sitting with patients, taking them back to the infusion room, treating them in the infusion room. These people are all putting themselves at some degree of risk, and that is just an incredible thing to see.
On another note, I’ve had some funny telehealth interactions. I had a patient come in last Friday when I was in the clinic, someone I was seeing for the first time. And they looked at me and said, “Wow, you look so young.” I was wearing a mask.
While that wasn’t a telehealth story, I use it because I think it’s funny, but also it tells you something about what the real life in-person visits now look like: you’re sitting in an exam room with more space between you and the patient than you normally would have. You’re wearing a mask. The patient’s wearing a mask.
In some ways, telehealth has started to almost feel more intimate than an in-person visit, because at least you’re not wearing a mask and you can see the person sitting across from you.
And of course, telehealth is clearly not for everyone. There are obviously people who need to come into the office or when a physical exam can be really helpful.
But overall I find it’s just been such a positive experience, with the asterisk that I mentioned before. There is a risk of increasing disparities for those who don’t have high-speed internet or the right technology.
I mean, just like how we once set up a system where pretty much everyone could have a landline phone, and we also set up a system where now pretty much everyone can have a cellphone, even if it’s not a smartphone, we need to set up a system where everyone can have high-speed internet and access to video technology to enable telehealth.