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.
While the news these days is rightly focused on hospitals and the government fighting public enemy number one, aka COVID-19 (the novel coronavirus), independent community oncology practices continue to treat and comfort patients who are at war with that insidious disease we call cancer.
Cancer doesn’t stop for even a global pandemic, and neither does the need of cancer patients to get treated. Community oncology practices have had to quickly shift gears and adapt to a new, challenging COVID-19 world, replete with the same issues the rest of the health care community is facing, including safety, staffing, and supply shortages.
Oncology practices quickly embraced telehealth to keep the normalcy of patient care on schedule while protecting all involved from the COVID-19 virus. At the same time, practices remain frustrated and angry that cruel indignities like prior authorization are still around—but now worse. And cancer professionals are baffled that the dangerous idea of home infusion of chemotherapy by a third party, such as a home health agency, is being put forth during this crisis.
A huge ray of hope came from Washington a few weeks ago when Administrator Seema Verma and her team at the Centers for Medicare & Medicaid Services (CMS) quickly unveiled new telehealth rules that gave oncologists the flexibility to seamlessly continue treatment with cancer patients on a computer or telephone without exposing them to COVID-19. The new CMS rules furnish 80 more services via telehealth and allow practices to bill for telehealth visits at the same rate as in-person visits. These are a godsend to struggling practices and scared patients.
One oncologist told us she did 31 Zoom check-ins just a week ago with patients who didn’t need to be seen in person. A seriously overworked oncologist, Sibel Blau at Northwest Medical Specialties in Washington state—an early epicenter of the pandemic in this country—said telehealth saved her 90 minutes of commuting time and enabled her to get something in short supply for providers during the pandemic: sleep.
And while telehealth is indeed a godsend, it doesn’t enable an oncologist to reach through the screen if a patient reacts badly to an infused drug.
Even without COVID-19, Salem, OR, cancer patient Tom Bailey, a retired urologist, is extremely happy with his new telehealth appointments. “I would prefer to do it this way. It saves a trip over there. It’s convenient. I don’t have to drive and park. It would be different if I didn’t have an established relationship.”
While telehealth is a huge benefit for patients with cancer who need to be seen by their physicians, the pandemic has not stopped bad and even inhumane practices. In fact, it has made them worse.
Take prior authorizations (PAs), the bane of oncologists whose well-considered treatment prescriptions are subjected to second-guessing by penny-pinching insurance and pharmacy benefit manager (PBM) bureaucrats with less education, real-world experience, or even knowledge of the individual patient’s needs.
Troy Ebberson, the insurance authorization specialist for Salish Cancer Center in Fife, WA, reports a significant uptick in the amount of time needed to obtain PAs due to staffing shortages at insurance companies, which creates procedural challenges.
“The most significant impact felt has been the additional time needed when contacting insurance companies to verify authorizations due to the delays,” Ebberson lamented. “Any delay in obtaining an authorization can cause a delay in patient care which can have a significant impact on their health.”
Since a PA is required for services ranging from radiology reports to biopsy results, COA took the unusual step of writing to President Trump urging him to, “request that all health insurance companies immediately waive prior authorization requirements for cancer treatments during this COVID-19 crisis.”
“If PA is lifted at this point, and we had the flexibility to choose a less toxic regimen or to bring a patient to clinic less often, it would be so much better and safer for our patients,” Blau said.
We know that as the COVID-19 pandemic slowly recedes, the curve f lattens, and the new “normal” eventually comes into focus for most Americans, community oncology clinics will still be there, treating patients with cancer who need them.
While extending the oncology office to the patient’s home with telehealth is a good idea, and prior authorizations wrapping a doctor’s informed medical decision in red tape makes a bad idea worse, the mere notion of even considering home infusions of chemotherapy drugs is just plain baffling, and remarkably dangerous.
An interim final rule released by CMS on March 30 would allow for infused or injected Medicare Part B drugs to be administered at home by a home health agency so long as a provider is present, via telehealth. As COA noted in an official position statement on the issue, this might be reasonable for certain diseases and drugs. However, for cancer, this is not appropriate and can be extremely dangerous.
While it’s true that traveling to one’s oncologist during the pandemic is at times impractical and potentially risky for an immunocompromised cancer patient, home health agency administration of cancer treatment is problematic, even when considering the possibility that patients could miss a chemotherapy treatment cycle due to the COVID-19 outbreak.
Cancer drugs can produce serious side effects or adverse reactions that the average home health nurse, spouse, or family caregiver is ill-equipped to manage. These can be sudden, severe, even deadly. And while telehealth is indeed a godsend, it doesn’t enable an oncologist to reach through the screen if a patient reacts badly to an infused drug.
Avoiding side effects and adverse reactions from chemotherapy, or reacting to them, is the job of a trained oncology nurse under the oncologist’s on-site supervision. Once home infusion treatment begins, the individual administering the treatments does not have access to the team of providers, additional drugs, tools, or equipment to deal with a potential adverse reaction. These can be potentially life-threatening.
Oregon Oncology Specialists’ Bud Pierce, a 43-year veteran oncologist, puts it more succinctly.
“We don’t need to compound this crisis with the unsafe administration of complex cancer drugs. If we don’t do it right, it will hurt or kill somebody. Let’s not go off the deep end with unsafe practices,” Pierce said.
The expansion of telehealth services has allowed practices to focus on making in-office infusions as safe as they can be for patients. With less patients visiting in-person and stringent sanitation protocols in place, the likelihood of disease transmission is significantly lowered.
As hospitals have stepped up and committed their resources to stopping the deadly spread of COVID-19, community oncology clinics are doing their part to continue to provide quality care for those who carry the burden of cancer. Each member of the health care field plays a vital role in this emergency, and community oncology providers are standing fast for their patients.
We know that as the COVID-19 pandemic slowly recedes, the curve flattens, and the new “normal” eventually comes into focus for most Americans, community oncology clinics will still be there, treating patients with cancer who need them.
But it will not be the same as before the crisis.
Community oncology clinics will continue embracing telehealth into treatment plans. Community oncology clinics will continue to fight with insurers over prior authorizations. Community oncology clinics will never allow ill-conceived ideas like home health agency infusion to become a reality. And, perhaps most importantly, community oncology clinics will continue being the local, affordable, and accessible site of care for patients.
And we will never forget the men and women who fight in the trenches every day against pandemics like COVID-19 or devastating diseases like cancer, and, most importantly, who they are fighting for.
As Winston Churchill said so memorably when the chips were down in the midst of World War II: “Never was so much owed by so many to so few.”
Ted Okon is the executive director of the Community Oncology Alliance (COA), a national association of independent, community cancer providers.
