Telehealth is playing a larger role in the delivery of cancer care, but there is more work that needs to be done to permanently increase access, according to a panel of experts during a plenary session at the National Comprehensive Cancer Network (NCCN) 2022 Annual Conference.
Oncologists Favor Continued Use of Telemedicine
Amye J. Tevaarwerk, MD, Associate Professor, Mayo Clinic Cancer Center, Rochester, MN, presented findings from a recent survey aimed at assessing oncologists’ perspectives on telemedicine’s present and future roles for patients with cancer. In 2020, the NCCN EHR Oncology Advisory Group created a 20-question survey for all 30 NCCN member institutions to be answered by all oncology providers. The surveys were returned by 1038 individuals from 26 institutions; respondents were largely oncologists (58%). Few respondents (19%) had participated in telemedicine visits prior to the COVID-19 pandemic, but at the time of the survey, most (84%) had conducted both telephone-based and video-based visits.
Results showed that respondents believed that 46% of postpandemic visits could be conducted virtually.
Most respondents thought that video visits were better than or equivalent to office visits for reviewing benign or reassuring data (eg, labs and imaging), performing follow-up visits for patients on maintenance therapy or in surveillance, and explaining important malignancy-related clinical data. Office visits were still preferred for making decisions on malignancy-related procedures and treatments, for assessing complications of treatment, and for establishing personal connections with patients and their families. A total of 93% of respondents reported “rarely” or “never” seeing an adverse event arising due to a telemedicine visit.
Respondents did acknowledge, however, that challenges to telemedicine needed to be addressed. These included lack of patient access to technology, inadequate clinical workflows to support telemedicine, and uncertainty about insurance coverage and reimbursement postpandemic.
“When I think about the future of telemedicine, I think about the profound need for more outcomes data and data on caregiver engagement,” Dr Tevaarwerk said. A key consideration, she added, is licensing, regulatory, and reimbursement support for telehealth.
Regulating Telehealth
Robin Zon, MD, FACP, Chair, South Bend Medical Foundation, Mishawaka, IN, and Co-Chair, American Society of Clinical Oncology (ASCO) Expert Panel, discussed the regulatory landscape for telehealth, noting that an executive order aimed at improving rural health and telehealth access was passed in August 2020. This order included the testing of innovative payment mechanisms and other public health emergency (PHE) measures. She said that the position of ASCO is that the Centers for Medicare & Medicaid Services should maintain these expanded telemedicine policies after the expiration of the PHE declaration.
The Interstate Medical Licensure Compact (IMLC) established a voluntary, expedited pathway to licensure of physicians who want to practice in multiple states, and legislation to issue licenses is moving forward in several states.
“The ASCO perspective is that all states should participate in IMLC and that in states that do not participate, lawmakers should enact legislation to join,” said Dr Zon. “ASCO will work with state medical associations and state affiliates to support these efforts. State and federal policies permitting telemedicine to cross state lines should include a provision requiring that the doctor-patient relationship be established prior to provision of any telemedicine services.”
Dr Zon said that ongoing concerns regarding telemedicine include avoiding a “digital divide,” which perpetuates health inequities by penalizing patients with lower education and incomes, especially those of color; establishing audio-only and video parity for telemedicine visits; and addressing out-of-state medical licensure restrictions. She urged physicians who use telemedicine to check their medical liability policies, which should provide comprehensive coverage for telemedicine in all states where they practice.
Telehealth Reimbursement
Dr Zon said that policymakers should ensure broad coverage and adequate reimbursement for all telemedicine services by all plans and payers through service parity and payment parity reforms. In addition, federal and state governments must work to promote health equity through encouraging the use of telemedicine in all care settings, including but not limited to rural and safety net providers.
“Expanding broadband access is a potential solution to close the gap in telehealth equity,” she said. Funds for this purpose have been appropriated via the American Rescue Plan but detailed plans are not yet available. In addition, payment parity for audio-only visits, which are now reimbursed at a lower rate than video visits, may promote better access to telehealth. One program, the Affordable Connectivity Program, is designed to help low-income households pay for broadband and Internet services.
Both legislative and regulatory work is needed to permanently increase access to telehealth. The PHE will be extended through July 2022, with continued coverage of audio-only services. In addition, originating and geographic site restrictions have been delayed.
“COVID-19 changed everything,” said Lucy R. Langer, MD, National Medical Director, Oncology and Genomics, UnitedHealth Group, Portland, OR. She acknowledged that telemedicine remains an important element of virtual cancer care, with the rates of telehealth visits appearing to stabilize at levels well above those seen before the pandemic. She asserted that many payers plan on continuing to invest in virtual care.
Dr Langer said that telehealth represents an opportunity to use current momentum to enhance patient care, including optimization of appropriate resource utilization; provision of care where, when, and how patients want to receive it; promotion of enhanced wraparound patient support services (ie, 24/7 virtual visits, app-based symptom reporting, telephonic case management, direct patient interaction with treating oncologists, educational materials); enhanced value by improving the quality of cancer care; and better care coordination across multiple specialties.
