When COVID-19 began spreading rapidly across the globe, cancer providers and patients had to rapidly acclimate to the idea and practice of telehealth. Waivers were issued and rules were changed to allow patients to continue receiving care without fear of exposure to the virus, and Zoom became a household name.
With the recent approval of the COVID-19 vaccines, the beginning of the end seems near. Although the regulatory landscape may begin to change and licensure requirements will likely tighten again after the emergency declaration is lifted, it seems that telehealth is here to stay in oncology. According to Jennie R. Crews, MD, MMM, and Janelle Wagner, RN, OCN, both from Seattle Cancer Care Alliance, telehealth in oncology is also poised to expand to aspects of cancer care beyond the patient/provider visit, potentially into supportive care, genetic counseling, survivorship, and navigation.
“When COVID came along this winter, we had to rapidly change our response and think about telehealth in new ways,” said Dr Crews at the Academy of Oncology Nurse & Patient Navigators 11th Annual Navigation & Survivorship Conference. “We had to quickly mobilize this as an option for patients because of safety concerns and travel restrictions. So across the country, telehealth in the world of oncology suddenly became a reality and was rapidly scaled at many institutions.”
Dr Crews began by pointing out a few important definitions to know when discussing telehealth:
- Telehealth: Uses both video and audio (distinguishing it from a regular telephone call)
- Originating site: Where the patient is located at the time the service is rendered
- Distant site: Where the provider is located at the time service is rendered
- New and established patients: Same definitions as for in-person visits
“Historically, there has not been widespread adoption of telehealth, particularly in the field of oncology,” she said. A multitude of barriers have stood in the way of telehealth in oncology, many of them around reimbursement and the inability to demonstrate a return on investment, state and federal regulations, logistical considerations (ie, scheduling), institutional issues with credentialing and oversight, and provider and patient buy-in to this modality of care.
However, the use of telehealth in oncology has rapidly expanded in response to the COVID-19 pandemic, and now, legislative and regulatory efforts are underway to secure that expansion in the field of oncology post–COVID-19.
Breaking Barriers to Teleoncology
The events around COVID-19 translated into regulatory changes that lifted many of the previous barriers to the practice of telehealth. For example, in March 2020, the World Health Organization declared COVID-19 a pandemic, and at the same time, President Trump declared a national emergency. This set into motion some important allowances for the Centers for Medicare & Medicaid Services (CMS), like the 1135 Waiver, and additional waivers shortly thereafter.
The 1135 Waiver allowed for the lifting of geographic restrictions on originating sites, allowing patients to receive telehealth services in their homes, and clarifying that providers could conduct telehealth visits from home. Also, new or established patients could be seen in telehealth visits, whereas previously only established patients could be seen.
“It also created Medicare payment parity between telehealth and in-person visits, which was huge for providers, as it allowed them to be reimbursed at equal rates,” she noted.
The second round of regulatory waivers, issued on April 30, 2020, expanded the definition of “eligible provider,” which opened up telehealth as a care modality for additional providers, including physical therapists and occupational therapists.
“But it didn’t expand the definition of ‘eligible provider’ to the degree that we’d hoped, because it excluded other providers such as pharmacists and nurses,” she added.
Additionally, the second round of waivers recategorized CPT codes for telephone calls, recognizing them as telehealth (since telephone calls were previously reimbursed at a very low rate). It allowed hospitals to bill for facility fees when the patient is at home (if they followed certain steps to make their home an extension of their outpatient environment), and allowed for providers to bill for total time (including preparation, visit, care coordination, and documentation) for telehealth.
Individual states also enacted regulatory changes in regard to telehealth. In response to COVID-19, Medicaid was allowed to cover telehealth services on a state-by-state basis without seeking federal approval. Many private payers expanded their telehealth benefits (ie, waiver of cost sharing and copays for telehealth visits), although many of the major payers are now walking back these benefits, she noted. Many states also waived licensure requirements or offered expedited licensure so that telehealth could be practiced across state lines. However, Dr Crews pointed out that this is a fluid situation, and providers should check state-to-state regulations/legislation, as well as payer websites for details.
For resources that explain how these rules and regulations have been changing over time in response to COVID-19, check the Center for Connected Health Policy (www.cch pca.org/resources/covid-19-telehealth-coverage-policies) and the Federation of State Medical Boards (fsmb.org/advo cacy/COVID-19), she advised.
What Will Happen Post-Pandemic?
Going forward, some of the waivers issued by CMS will require legislative action to become permanent, particularly the originating site waiver. “That waiver stems from the Social Security Act,” she noted. “While CMS has the jurisdiction to waive it under a public health emergency, in the long term it will require legislative action to reverse.”
A number of legislative bills have been introduced at the federal level to help make telehealth more usable in a post-pandemic world. For example, 9 telehealth bills have been rolled into 1 “Super Bill”: H.R. 7992 Telehealth Act, sponsored by Rep. Ann Wagner (R-MO). A few of the elements of this proposed legislation include expanding the authority of the Department of Health and Human Services to waive requirements, removing the geographic requirement on where telehealth can be conducted (a key element of the legislation), and also looking at studies to expand access under Medicare/Medicaid.
In its most recent proposed physician fee schedule, CMS has also commented on various elements of telehealth (eg, beginning in 2021, CMS will not continue to reimburse for audio only at the same rate as audio/video, but it is seeking comments on whether reimbursement for this should be changed).
“And certainly, additional groups (American Medical Association, American College of Physicians, American Heart Association, Association of Community Cancer Centers, etc) have been very active in advocating for changes in legislative agendas around telehealth, both at the state and national levels,” she added. “They’re pushing for the expansion of telehealth not only for reimbursement and location of patient, but also urging expansion of access by providing better broadband.”
Delivering oncology care from a distance requires significant care coordination, making a strong case for telenavigation.
Telenavigation is defined as care coordination by the oncology nurse navigator in tandem with the interpersonal care team, the patient and their family, using technology such as interactive video, audioconferencing, and telephone for communication. In addition to some of the more obvious benefits like convenience, flexibility, and safety, it has been shown to improve care coordination with patients in remote areas, improve care team communication, address patients’ barriers to care and logistical challenges, and provide patients and families with education, survivorship care, and a high level of social- emotional support.
According to Ms Wagner, institutions should now be incorporating telenavigation into the services they provide and tracking its benefits and utilization to optimize this care modality for patients.
“With all the new laws that support telehealth, now is the time to bring this to your institutions,” she said. “Patients who have experienced telehealth are now asking for it. They want this instead of phone visits; they want to be able to see their navigator, but they don’t want to travel anymore.”
Of course, there are inherent challenges to the delivery of telenavigation, most notably the issue of licensure across states, but that is not the only barrier. According to Ms Wagner, other significant challenges include the issue of payment/recognition of nurses as telehealth providers; patients feeling vulnerable on camera in their own space (especially in the first conversations postdiagnosis, when many are trying to hide their emotions); the issue of some patients feeling it is not hands-on care; and of course, technology difficulties. “But as virtual medicine grows and we continue to provide more and more telenavigation, that will become less of an issue,” she said.
According to Dr Crews and Ms Wagner, telenavigation represents the future of navigation, and these appointments should become the standard of care if an in-person visit is not possible.