Pandemic Puts Telehealth to the Test

Telehealth, the use of electronic information and communications technologies to provide health care at a distance, has been touted as a way to counter health care disparities. Oncology had been slow to adopt telehealth, also called telemedicine, compared with some other specialities, but the COVID-19 pandemic pushed many cancer centers to treat patients remotely to limit the virus's spread.

“Prior to the pandemic, telehealth was already being utilized in some areas of medicine—psychiatry, for example—but wasn't really fully embraced by the oncology community, mostly because of CMS [Centers for Medicare & Medicaid Services] rules and regulations limiting geographic access,” says Robin Zon, MD, oncologist and former president at Michiana Hematology Oncology in Mishawaka, IN.

But on March 17, 2020, CMS granted an emergency waiver expanding telehealth access during the pandemic, allowing providers to accommodate more patients.

“Once CMS had announced lifting of the geographical restrictions, just days later we had a HIPAA [Health Insurance Portability and Accountability Act]-compliant platform in place … for audio and video consultations with patients,” says Zon, who co-chaired the American Society of Clinical Oncology Quality of Care Council expert panel on telemedicine, which recently published guidelines for telehealth in oncology (JCO Oncol Pract 2021;17:546–64). The guidelines cover several topics, including which patients can be treated via telehealth and the role of allied health professionals.

And to examine the question of disparities, a study published in November evaluated whether socioeconomic status (SES) correlated with telehealth use among patients newly diagnosed with cancer (JAMA Oncol 2021 Nov 18 [Epub ahead of print]).

“There's been a lot of positive discussion about telemedicine being able to mitigate cancer disparities as it can allow us to reach more patients, especially those who live further away from major centers,” says Ronald Chen, MD, MPH, of the University of Kansas Medical Center in Kansas City, and the paper's senior author. “We wanted to test this in a data-driven way, and the pandemic presented an opportunity,” he added.

Using single-payer administrative claims data, the researchers identified 16,006 adults diagnosed with breast, lung, prostate, or colorectal cancer between January and August 2020 who had at least one telemedicine visit within 30 days of diagnosis. Before the pandemic's start, the proportion of newly diagnosed patients who had a virtual visit was just 0.4%, rising to a peak of 54% overall in August 2020. An SES score was calculated for each patient based on area-level metrics, including median household income, employment status, and education level. By April 2020, 66.9% of patients in the highest SES quartile had had a virtual medical visit, while those in the lower SES quartiles were almost 20% less likely to have received an appointment.

“I see a huge [opportunity for] telemedicine to decrease urban and rural disparities in cancer care and healthcare generally,” says Chen. “But we have to make sure there's equitable rollout of such telemedicine so that it doesn't just benefit parts of our patient population.”

Notably, the study used deidentified data, calculating SES based on patients' ZIP codes. It did not factor in race or ethnicity.

“A ZIP code is an interesting surrogate to use to look at SES, but it doesn't really get at the real question of what influences a person's access to telemedicine,” says Huma Rana, MD, MPH, of Dana-Farber Cancer Institute in Boston, MA.

Rana notes that some patients may not have high-speed internet access, or if they do, may not have the level of computer literacy required to understand virtual meeting software. “Telemedicine has to be built for the patient population and their needs. There will be no telemedicine ‘magic bullet,’” she says.

For patients newly diagnosed with cancer, the extent to which telemedicine can help is often limited by their need for in-person tests, surgery, or chemotherapy, but some areas of oncology may see a more sustainable benefit for telemedicine.

“In our group for cancer genetics and prevention, there was very little to no use of telemedicine previously and that use skyrocketed for us during the pandemic. What we're doing is really amenable to remaining virtual,” says Rana, explaining that about 80% of clinical visits in her department are virtual.

Many physicians hope that patients will continue to have the option to use it as the pandemic eases. “Our patients really like having this option, even those who had to come in for in-person appointments with their oncologists or surgeons. They would often report that they were already exhausted and liked the flexibility of having this appointment virtually,” says Rana.

Despite this success, some amendments made to allow telemedicine provisions and reimbursement during the pandemic are set to expire at the end of 2021 unless the federal Department of Health and Human Services says that the public health emergency continues. Additionally, dozens of states have either extended or made permanent some telemedicine coverage obligations for private insurers.

“I'm hoping that CMS continues to allow for telemedicine, because my fear is that patients may be disadvantaged if they do not. Telehealth is not going to solve cancer disparities, but it I think it is a tool in the toolbox that, if properly utilized, can help alleviate some disparities,” says Zon. –Victoria Forster