COVID-19 Pandemic Accelerates Growth of Community Oncology, Shift Toward Telehealth

In an interview with Pharmacy Times, Stephen Divers, MD, an oncologist and hematologist at the Genesis Cancer and Blood Institute, discussed the outlook and trends in community pharmacy. Divers is a co-chair of the Community Oncology Alliance 2023 meeting happening March 23 and 24, and a co-presenter of a session titled “Looking into the Crystal Ball: Tomorrow and the Next 20 Years of Community Oncology.”

Q: The COVID-19 pandemic accelerated the growth of community oncology practice. Can you discuss the rate of growth in community oncology at this point?

Stephen Divers, MD: So, I think that community oncology has sort of a double-edged sword with 2 answers to that question. I think the oncology space as a whole has grown and community oncology probably had a significant lift, as people didn't want to travel to metropolitan areas and academic centers and wanted to stay closer to home. I think that was a tailwind for community oncology practices, for sure. But I think there was also a negative related to that, in that patients didn't even want to come into the community practice for a while, just because of the COVID-19 concerns. So, they didn't want to be anywhere. You know, I had patients that stayed home for everything. The problem with what we saw with that was decreased screenings throughout the country, and we saw subsequent increases in advanced stage diagnoses. For example, I saw a lady yesterday who's had a breast mass since before the pandemic and did not choose to pursue it until last week. So, she has a locally advanced breast cancer now, and so we're going to have to deal with that. What would have been fairly manageable breast cancer 2 years ago is now going to be a much more difficult story. And so, I think that vignette played out throughout the country. And so, from that standpoint, that has resulted in an increased pressure, say in quarter 1 and 2 and 3 of this year, with a larger volume of patients showing up. And we see that, we look at the numbers, and then the staffing requirements needed to meet that. That's tough, you know.

Just a brief example, for CT-guided needle biopsies within the area, and I'm talking about a 60-mile radius, I mean, they're 20 days out to get a biopsy on somebody, you know, whether it's in our shop, or in the nearby hospital or neighboring hospitals, and so, you know, it's over 2 weeks. So, you know, what would have taken 3 to 4 days before is now 2 weeks out. So, there is some pressure in the community oncology space to manage that volume of patients that is coming in, which really, you know, is a delayed patient population that was out of touch for 2 years from the pandemic. So, I think that that there is some growth, but that's probably also in the metropolitan areas as well, not just limited to community oncology. And it's something we're going to have to manage at a time when the cost of doing business has gone up quite a bit, right? So, you have significant inflation, you have wage increases for staffing, and staff shortages. And, you know, there's even a Senate hearing on trying to help deal with staff shortages, and what's the driver for that? So, COA has sent out a comment letter to address that to some degree and to meet these rising needs post pandemic. You know, with margin compression related to rising cost of inflation and employee comp benefits, it's a tough spot for all of oncology really.

The other, I guess, negative driver, I think, is in the community oncology space, you have a lot of competition from 340B hospitals who tend to have a much wider margin in which they operate. And so, the community oncology space probably hasn't grown as much due to acquisition by larger health systems. And so, they do tend to prey on community oncology practices and integrate those into larger health systems, which limits patients’ access to care, so that probably offset some of that growth that you might see. But for the practices that are sustainable, it is a difficult spot to be in. And so, if you think in the community oncology space, right, we administer all these IV medicines and so every tubing, every bag, none of that's reimbursed, right? And all of our reimbursement rates are fixed. And so, the costs of all those supplies has gone up and there are no codes for any of that, you know, that cost doesn't get passed down to the consumer. So that has to get absorbed by these practices. And that's what results in significant margin compression there.

Q: The pandemic also accelerated the shift toward telehealth. How is this utilized in community oncology and how do you see this changing or growing?

Stephen Divers, MD: Yeah, this is a bit of the crystal ball question. I think telehealth was a value add for sure. For patients during the pandemic, I mean, it allowed them to remain in touch with their providers. I know we just commented on the margin compression and difficulties with inflation and, you know, maximizing efficiencies within a practice. I think telehealth does add some value, but I think in no way shape or form is it an efficient means of administering care. Essentially, all of our patients are going to need IV treatments or injections or whatever that has to be managed, and lab draws, too, effectively. And so, the idea of sending a nurse to one location, you know, versus centralizing those services, the efficiency is really not there. And so, I think telehealth is a good value add for the patients, but I think from cost of the whole system, I don't think there's a meaningful cost savings. Because, yes, we can have a conversation over telehealth, and it saves some travel time, but, you know, to mediate any effect there, if I send a home infusion company or whatever, you lose all those efficiencies. You know, a one-off one-on-one, going to a patient's house, drawing a lab, administering a treatment, I mean, those are not built-in efficiencies within the system. But I think from the patient's perspective, the telehealth adds some value.

But I mean, my crystal ball would be, I think, for touches in between therapeutic treatments, telehealth may maintain some value, and I think at academic centers where maybe patients are continuing to receive the actual care in the community but want to maintain continuity with an academic center. So, I think telehealth adds some value there. So, my guess is it will probably be more uptake, or continued uptake of telehealth in academic centers more so than in the community because ultimately, these patients have to get touched at some point physically for treatments and lab draws and those sorts of things. And the efficiency is going to be in the community clinics and not so much within the patient's home. You know, once we get to the day and place where AI and wearables get you what you need without having to come into the clinic, then that may change. Telehealth will probably, you know, ramp up, flower up quite a bit. And my guess is that probably, you'll see a decrement in that over time to a point, and then it will level out to be the value add that it is. But again, it's limited because it's hard to create any therapeutic intervention through digital media. So, I think there's certainly a trend toward improved chronic care management. And I think chronic care management is best done in the outpatient setting. You know, hospitals are built for acute care, inpatient, and so not really well designed for chronic outpatient care management and models like [the Oncology Care Model] and the new [Enhancing Oncology Model] are much better at addressing the continuity of care in the chronic disease state in the outpatient setting. EOM theoretically would launch in July.

Q: The Oncology Care Model (OCM) ended in 2022, so what do you predict regarding the next oncology payment model from CMS?

Stephen Divers, MD: So, I think there are some pluses to EOM and we're grateful to have a new model out there. I think EOM is built to win from the payer side, because there's a 2% success already built into the model. The other models that are out there for chronic disease management are CCM, TCM, and PCM models, but I think we as community oncology need to embrace the idea that these patients are part of our community. They're part of it, you know, we're going to see them at the grocery store. And so we have to commit to the resources and technology to help them manage a chronic disease state in the outpatient setting, whether that's part of a government funded model or whether that's part of a bit of restructuring internally to include, you know, EHRs and patient navigators and patient care teams, to help manage that disease state day to day in the outpatient setting. I think that's something that you'll see community oncology practice continue to pivot toward. I think OCM was obviously the kickstarter for that and helped us to understand the value there.

We'll see. I think a lot of people signed up [for the EOM], we'll see how many people execute the contract. There's a real issue with EOM in that the volume that you're going to see, because of the 7 disease states that it has, is not going to get anybody to an advanced alternative payment model. And so, everybody is going to remain in MIPS pretty much. And so, you're really going to be doing 11 Plus MIPS plus. So that puts some administrative burden on the practices. Because unfortunately, the way it's geared, you're not going to get a large enough percentage of your practice that's going to be able to participate EOM to qualify for an advanced payment model. So, I think that's an inherent flaw within the project. And the EOM has been slow to really get your baseline or your benchmark so you can accurately predict how well you would perform in that model. So, we'll see. I think we'll learn a lot in the next, you know, 8 weeks on where everybody chooses to participate in the EOM.

But I think you'll see continued uptake in these sorts of chronic disease management models, whether it's EOM, patient navigation, patient care teams. And I would love to see more resources put towards that, so that some of those can be funded projects, you know, so there are codes that can be built, like you have with CCM and TCM and PCM. And hopefully, we can evolve as an outpatient community oncology provider to manage that chronic disease state in the outpatient setting out of the acute care setting in a more efficient manner. So, I think, you know, as long as we continue to evolve and improve on that. But I think, like I said, we have to have resources dedicated to that, because there was a window between OCM and the EOM where practices paid for all these resources, they use the dollars from OCM to fund that. In EOM, those per payment, per month, or per patient per month payments were cut in half in EOM versus the OCM. And then you had 6 months with nothing. So, you're trying to figure out how to maintain those resources for patients in the interim. So, there is a gap there that has to be filled. So, we'll see. But you know, I think for the most part, community oncology practices are very patient centric organizations. Certainly, here at [the American Oncology Network] we are. I mean, it's always patient first, and so we're going to do what we can to make sure we're providing the full continuum of care for them.