By Sarah DiGiulio
The global COVID-19 pandemic has forced the medical community to move quickly to both help patients who are infected with the novel coronavirus and make other changes to protect vulnerable groups from getting the viral illness. With unprecedented speed, providers are shifting medical care to remote versus in-person delivery, including for oncology.
On April 3, the Community Oncology Alliance (COA) hosted a webinar with the Centers for Medicare & Medicaid Services (CMS) and doctors and administrators from several oncology practices across the country to discuss the changes that are quickly being made.
The speakers shared encouraging messages that the transition to a vastly increased amount of telehealth care in oncology is happening and is protecting some of the most vulnerable people across the country (those individuals who are immunocompromised because of a cancer diagnosis or treatment, often with several other comorbidities that would heighten their COVID-19 risk). COA and others on the call applauded CMS for quickly implementing the policy changes that are enabling oncology practices to make the swift telehealth transition possible.
But the speakers also recounted some pain points they've had to deal with through the transition, and caution about what long-term and lasting telehealth care models should look like.
Bo Gamble, Director of Strategic Practice Initiatives at COA, started the webinar deeming the speed at which change has been implemented with regards to telehealth delivery "phenomenal."
Ted Okon, COA's Executive Director, added: "CMS has been so incredibly responsive. They have listened to what we've said and what we've asked for in terms of changes in telehealth," Okon said. "Telehealth has really been a lifeline."
New CMS Rules
Previously telehealth had been limited in that physicians and providers could only bill for telehealth visits under certain conditions and for certain types of appointments. Last month, Congress passed a law to allow CMS to largely lift the restrictions after the public health emergency was declared.
"We recognized that telehealth technologies can be used in the context of the public health emergency," said Ryan Howe, Deputy Director of the Hospital and Ambulatory Policy Group at CMS.
Those regulatory changes have allowed oncology practices in turn to swiftly adapt the models of how they deliver care in terms of visits that can be done remotely versus ones that need to be done in a health care setting.
"We're working as hard as we can because we know the work that's being done on the front lines is so important," Howe said during the call. "Our goal is to be as supportive as we can."
The agency has issued several regulatory waivers and new rules for the duration of the state of emergency declaration. Some of those changes include following:[
- CMS has increased the number of services that can be billed as telehealth care, including more than 80 additional services (a full list of these services is available at www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes).
- Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists can now provide certain virtual services, such as eVisits, virtual check-ins, and audio-only phone visits.
- Clinicians can provide remote patient monitoring to new and established patients for both acute and chronic conditions.
- Limitations on how frequently various telehealth services could be administered have been lifted.
- For certain services requiring direct supervision by a physician or other practitioner, that supervision can now be provided virtually.
- Rules have been relaxed during the health emergency so that phones and other audio and visual apps are allowed to be used for telehealth under HIPPA laws.
- Reimbursements to clinicians for services furnished via telehealth will be paid at the rate they would have been paid if that service had been furnished in person (previously some telehealth services were reimbursed at a lower rate)
Time Is of the Essence
Several physicians invited to speak on the call commended the CMS response and explained that it had enabled them to quickly roll out changes in their own practices.
Debra Patt, MD, Executive Vice President of Texas Oncology, said the progressive changes from CMS have allowed them to dramatically reduce the volume of patients coming into their clinics, making those clinics safer spaces for the high-risk cancer patients that still need to physically go to health care settings to get active treatment and the health care providers administering that care. As of early April, Texas Oncology had 80 percent fewer people in their clinics overall and the cancer system is working to reduce that in-clinic volume even further, Patt said.
"We're working really hard to make this work," said Dennis Zoet, Chief Business Development Officer at Cancer & Hematology Centers of Western Michigan. "We do not have this all figured out, but we are learning really fast."
Cancer & Hematology Centers of Western Michigan has five locations and more than 400 employees and saw more than 8,000 new oncology patients in 2019. The cancer care system signed up with their telehealth vendor on March 18 and used it for the first virtual patient visit on March 20.
While the changes were made quickly and there is much in the process to smooth out and improve, Zoet added that the changes have critically allowed the providers there to continue to care for their patients through this health crisis. A message he would share with other providers and practices is to get started with the transition.
"We have no choice," said Phil Stover, Chief Executive Officer at Mission Cancer + Blood in Des Moines, Iowa. "We are facing an unprecedented health crisis and medical practices, including oncology, need to make these changes to mitigate risks to patients, to physicians and health care providers and staff, and fundamentally to keep these practices running." And the transition needs to happen in a matter of days. "The need for change arrived immediately," he stressed.
Communication is key when it comes to implementing these telehealth systems quickly, Stover said. His facility created an online telehealth handbook for providers and users that walked everyone through simple questions, like how to access the platform and login, to more complicated ones, like those about telehealth policy and procedures.
Zoet's team in Michigan created a script for the staff to follow for scheduling appointments and checking patients in, so that key details were communicated to patients. The team also created "how-to" documents for patients with information about things like how to access the telehealth platform, which devices were compatible, and reminders to double check that technology was charged before the appointment.
It was also important for the team to have a playbook on what to do when various components of the technology failed, Zoet said. "Lay out what to do when it fails. More than likely, it's going to fail—even if it's not on our end. Walk them through that process of what are the next steps."
Ways to Improve Telehealth
The system implemented right now at Zoet's practice is not perfect, he said. But it's working through this health emergency and that's really important, he said.
His advice for other providers on how to deal with the imperfections of whatever system they're implementing is to start a "to improve list" as soon as possible. Break it into categories: What can we address today? What can we do very soon? And what issues do we need to address over the next 3-12 months?
"The patients are experiencing a few hiccups here and there with the technology, but patients greatly appreciate seeing their docs and still having their visits," Zoet said.
Sarah DiGiulio is a contributing writer