Telehealth and Reimbursement Issues Top of Mind at AMCCBS

Telehealth and revenue optimization and their intersection with COVID-19 were hot topics at the ACCC 47th Annual Meeting & Cancer Center Business Summit (AMCCBS) this week. Panelists discussed the appropriate use of telehealth in cancer care, debated the continuation of such care as the pandemic recedes, and addressed persistent gaps in oncology services in diverse populations.

In the wake of many cancer programs across the U.S. being compelled to develop some version of telehealth due to COVID-19, session panelists shared their insight into the adequacy of the different platforms through which patient care is delivered remotely. “There is no one-size-fits-all solution,” said Kelley Simpson, MBA, director and practice leader at The Chartis Group. She explained that virtual care should be defined differently depending on where along the cancer care continuum it occurs. For example, the design and goals of telehealth differ depending on whether providers are conducting cancer screenings, discussing treatment options, or providing survivorship and follow-up care.

“The definition of telehealth itself is in dispute,” said Feyi Olopade Ayodele, MBA, CEO of Cancer IQ, Inc. She emphasized that by understanding telehealth as simply providing the same in-office services virtually, providers do not take into account the unique capabilities of telehealth, and thus sell it short. “Telehealth is not just a new way of conducting typical office visits,” said Ayodele. “It can be transformative in the way it provides patient care.”

Unequal Access

One recurring topic running throughout the AMCCBS sessions was the uneven distribution of telehealth services in relation to geography, age, race, and socio-economic status. “We need to understand what the gaps in telehealth are, rather than assume we know them,” said Frank Micciche, vice president of public policy and communications at the National Committee for Quality Assurance. “For example, there is an assumption that older people do not like telehealth, but some providers find that older adults accept it more than others, since they’ve recently needed to learn new technologies to stay in touch with their grandchildren.”

“Since the ultimate goal of telehealth is to increase access to care,” said Johanna Garzon, MHA, HBAT, cancer center director at Central Care Cancer Center, “it is a big topic of conversation in rural regions.” Through Garzon’s experience designing and implementing a telehealth program across the ten rural sites her cancer center services in Kansas and Missouri, she has found significant disparities in access to the technology that fuels remote care.

Twenty percent of the patients Central Care Cancer Center serves have a landline phone or non-smart cell phone, precluding them from participating in video-based telehealth visits. Even more surprising to Garzon was her discovery that some patients—and some providers—are unaware of the existence of telehealth. “Eliminating these barriers are key to implementing and effectively using telehealth in rural settings,” said Garzon, adding that relatives and care teams can play important roles in providing access to geographically isolated patients.

Garzon has identified poor access to technology as the biggest barrier to the long-term provision of telehealth. “We don’t have the same technology that our patients have, and vice versa,” she explained. “This poses reimbursement challenges with coverage rules that preclude telephone-only visits.”

But whether audio-only communication is appropriate for patient visits is up for debate. Michael Kolodziej, MD, vice president and chief innovation officer at ADVI Health, said that he believes audio-only visits are inferior to video interactions. “If you just do a telephone call, you are unable to visually evaluate the patient,” said Dr. Kolodziej. “When you see patients in the office, watching them walk into the room can tell you so much about how they are doing and what treatment may be most appropriate. You don’t want to lose that entirely.”

Shelley Fuld Nasso, MPP, CEO of the National Coalition for Cancer Survivorship, agreed that while audio-only is inferior to video for patient visits, it’s better than nothing. Even if patients have the necessary technology, Nasso said, that doesn’t mean they know how to use it: “If you spend half of the visit struggling to talk to a patient who is having problems using the technology, it’s better to just have a quality phone call.”

The Patient Perspective

While the rapid adoption of telehealth that has enabled cancer programs to continue to care for patients during the pandemic has been widely praised, that acclaim is largely testimonial and anecdotal—and generally confined to providers. In an effort to better understand what patients think about the remote care they’ve received, several patient advocacy groups asked them to identify the pros and cons of their experiences with telehealth.

Nasso shared the results of a survey in which patients with cancer identified the positives and negatives of remote care. While patients appreciated not having the transportation and logistical challenges associated with in-person visits, they also said that they missed the personal connections they previously had with the members of their cancer care team, who were often not present at their virtual visits with their oncologists. And while some patients struggled with a learning curve in relation to using new technologies, they also said that virtual visits better enabled them to share details about their care with family members, and some expressed being more at ease in their home setting when interacting with their doctors.

Elizabeth F. Franklin, PhD, MSW, the executive director of the Cancer Policy Institute at the Cancer Support Community, said that a recent survey she conducted of 500 patients with cancer revealed that patients are not uniform in their embrace of telehealth. “Telehealth is a very personal issue,” said Dr. Franklin. “I know some 70-year-olds who are very comfortable using it, and other older patients who prefer not to.” While the majority of survey respondents (61 percent) said telehealth was a good alternative to in-office visits, and 64 percent said it was more convenient, the preference for telehealth was not universal. “Some patients like telehealth and want to continue using it,” said Dr. Franklin, “while others like having it as an option.”

Reimbursing What Works

In the end, though, telehealth is only as workable as it is reimbursable. Before the dawn of COVID-19, obtaining adequate reimbursement for providing care remotely was a rare feat. Providers fear that, as the pandemic recedes, so too will coverage for telehealth. “We need an impartial assessment of when and where telehealth is comparable to in-person care,” said Micciche. “It’s not easy; it will require us to create processes that everyone can agree to.”

Ayodele added that, like telehealth itself, reimbursement for telehealth should not take a one-size-fits-all approach. Having a regulatory body or process to impartially identify when telehealth services are superior to or comparable with in-person care would go a long way toward developing appropriate reimbursement guidelines. “If advocacy for telehealth comes from both patients and providers attesting to its value, and showing data proving its value, that is huge,” Micciche said. “Show that your costs did not spiral out of control, show that deferred care is more costly. Document it, get patients to advocate for it, and show that to the decision-makers.”

Telegenetics

A session devoted to the delivery of telegenetics explored how these services have been impacted by the restrictions imposed by COVID-19. “Most providers saw a devastating hit to genetic counseling/referrals when COVID-19 hit,” said Rachel McConachie, RN, BSN, clinical operations director at Dignity Health Cancer Institute in Phoenix, Arizona. “But our numbers continue to rise.”

The pandemic notwithstanding, access to genetic testing and counseling in the cancer care community is gradually becoming more available, due in part to their easy accessibility via telehealth. Genetic screenings can be invaluable to patients, as they can help identify early-stage cancers, leading to faster treatment and better outcomes. Dignity Health developed its telehealth-based genetic screening program before the pandemic, and it has continued to grow. “We employ three genetic counselors, have a full-time assistant, and we are looking to add another due to increasing referral volume,” said McConachie.

McConachie added that oncology genetic counselors have been difficult to find as their program has expanded. “It is important to keep your staff happy and give them the right tools to serve your patients,” she said. One way Dignity Health has been able to retain these specialized counselors is by enabling them to work remotely. As Dignity Health’s program expanded during the pandemic, it introduced external software to improve its genetic counselors’ productivity, enhance follow-up care, and better gauge the program’s profitability.

Prevention on the Go

At her session, Renea Austin-Duffin, MPA, vice president of cancer support, outreach, and clinical research at Mary Bird Perkins Cancer Center in Baton Rouge, Louisiana, described the success of the “Prevention on the Go” program. The program aims to diagnose patients at early stages of disease and speed access to treatment, thus improving the likelihood of positive outcomes. In 2006, Mary Bird Perkins Cancer Center purchased its first mobile cancer screening clinic, which it named the “Early Bird.” The Early Bird traveled to local residents in their communities and offered them free cancer screenings. In 2013, a second mobile clinic, the “Early Bird II” was deployed. In 2016, the program was expanded to include the “Prevention on the Go” initiative, which offers workplace-based cancer education and screening.

“In discussions with employees in Louisiana, a number of them indicated that it was too difficult to take leave from work to get cancer screenings,” said Austin-Duffin. “Our Prevention on the Go mobile clinic drives up to the front door of worksites and provides screening services, which are not typically included in corporate wellness programs. This eliminates barriers to care and brings key prevention and early detection measures to employees where they work.”

The results have been remarkable. In the five years since the program’s inception, nearly 4,000 employees across 40 participating worksites have been screened. Fifty-seven percent of those people had never been screened before. Because of Prevention on the Go, 51 cancers have been detected, and 150 pre-cancerous lesions have been removed. “The program has been very effective,” said Austin-Duffin. “We have held screenings at local car washes and car sales lots. A lot of these people work outside and would never have gotten a cancer screening otherwise.”

Joint us this week as the ACCC 47th Annual Meeting & Cancer Center Business Summit tackles the topics of disparities in care, clinical pathways, and the future of value-based care. See what's coming up in our agenda.