Questions Remain Around the Use and Affordability of Telehealth in Oncology

Michael Kolodziej, MD

For cancer centers throughout the country, telehealth has presented unique opportunities, including greater flexibility for patients. For physician with patients who live far from the center, telehealth allows for an in-office experience from home. However, physicians with patients who need advanced care cannot care for these patients via telehealth.

Additional challenges provider face include payment options, delivering bad news, and the inability to do a physical exam over telehealth. As in person visits become an option again, questions remain around where telehealth should be utilized moving forward.

In an interview with Targeted Oncology™, Michael Kolodziej, MD, the senior advisor for ADVI Health as well as an American College of Physicians Fellow, discussed the impact the COVID-19 pandemic has had on oncology practice. 

What impact has the COVID-19 pandemic had on your practice?

I do primary care at a volunteer clinic. And it basically shut us down, which I think largely happened to many oncology clinics. We went completely remote. We serve an indigent population, the opportunity to do telehealth was not really there, but we were able to do phone calls. We were scared, and they were scared. And so, we didn't see a lot of patients. And that is, that's what happened in oncology. The one difference in oncology, of course, was where there are patients receiving systemic therapy, lifesaving treatments, that didn't really have much choice. And I think practices have to develop an environment that was safe, to allow them to continue to care for those patients. And that was quite challenging. Initially, the challenges were around things like people and processes of care, which included masks and social distancing, limiting family members in exam rooms, what have you. It also led to the development of different ways of engaging patients. And I think that's what a lot of the HFC meeting has been about how that has worked out, what's good about it, to some extent, what's bad about it, and whether that's going to be a lasting legacy of how we take care of our cancer patients.

What are some of the pros and cons how cancer clinics have handled the COVID-19 pandemic?

We've heard a ton about how practices have viewed telehealth. I personally felt it was important to ask patients about what they thought about telehealth and I had known that both Cancer Support Community and National Coalition for Cancer Survivorship, had done some work, engaging their membership to try to define exactly what worked in telehealth for their members. And that's what we talked about today.

To summarize, I think we can say that they both felt that telehealth was a really good solution for some patients, and perhaps was the only solution for a while. And that's because people were scared. They were really frightened to go out and providers were scared too. I think we've learned a couple things about telehealth in terms of what's good about it. I think convenience is good about it. Convenience is really good about it. I think if you have lived in an urban area, you have to struggle with traffic and parking and childcare and all that other stuff, telehealth is just a godsend. I think the ability to have a focused conversation in a fairly efficient way, rather than sitting in a waiting room having your doctor run an hour by, that's really good. There's no doubt about that. It allowed patients to engage with their physicians or providers in a really timely fashion. If you talk to patients, they hate waiting for test results. They just hate it. It's one of the worst things. And this sort of truncated, the waiting time substantially. I think that was all good.

I think there are clearly shortcomings. One thing is that telehealth is not good for all kinds of visits. We've heard actually in other sessions here, that telehealth is probably not good for the first visit, because there's a certain amount of bonding that needs to occur in that first visit. On the other hand, telehealth is pretty good for second opinions. telehealth seems to be really good for things like palliative care management or behavioral health. And that I think is an excellent solution. We heard also that survivorship might be something that telehealth could do. I think that's a great idea. But you can't do a physical exam by telehealth. I do believe that there is a therapeutic benefit of the laying on of hands, or the holding of hands, or giving a hug. And all that stuff you can't do via telehealth. We talked in our session a little bit about whether telehealth was a way to get bad news. I personally, as a physician, would not be particularly comfortable about that.

I think finally the last thing that we really have a lot of uncertainty about is whether or not reimbursement is going to support continued use of telehealth. If patients got the same copay for a telehealth visit, would they feel cheated? And the answer is some actually might not feel that it was a good value. So, I think we need to sort out a little bit about how telehealth fits into the care delivery model and into the payment model. Because I think the way telehealth was paid for during the pandemic is not likely to continue in the same format going forward. It's not to say that it won't be paid for. I'm not I'm not sure whether or not there'll be certain criteria for telehealth visits, all that stuff has yet to be sorted out.

Do you have any advice for your peers working during this time? I'm going to reflect on my experience in my volunteer clinic. I think the oncology care ecosystem deserves a heck of a lot of credit for being able to continue to care for very complicated patients. A very high-risk population. It's amazing to me that we have heard very little about super spreader events in oncology clinics. And you know, what, all those oncology clinics that spent so much time working on, triage systems and personal protection, they deserve a ton of credit. One thing I would say is I know everybody's tired of it. But we're in the homestretch. Don't give up yet. We're getting there. We're in our volunteer clinic, we're starting to expand the patients we're going to see. I can tell you that taking care of diabetes and hypertension remotely in a homeless population is almost impossible. We are bringing those patients back in. I applaud and wish the practices success in vaccinating their patients. It is mind boggling to me that cancer patients we're not near that the top of the list, but alas, every state is doing their own thing. And I think maintaining a focus on how things like telehealth have made things better for everybody, a thinking about how that can be woven into the fabric of our care delivery model, irrespective of whether or not it's paid at parity with a face to face visit. In other words, I'm saying if you have to take a little bit of a haircut, on a telehealth visit going forward, I think that's okay. I think you'll find that there are certain kinds of visits that are just more efficiently delivered by telehealth and I would encourage practices to think about that whole wide universe of patient engagement on a remote basis, electronic reporting of symptoms, and use of physiological monitoring, which frankly, before COVID I would have told you I thought was a bunch of hooey. But I don't think that anymore, I really think that we are entering an era where the triage nurse will not be the sole way that the practice communicates with the patient, when they're not in the office. We're going to get so much better at engaging our patients and dealing with their symptoms real time. I really believe that.