Telehealth at Minnesota Oncology: Tackling COVID-19, Educating Patients, and Overcoming the Weather

The rise of telehealth during the COVID-19 pandemic has been an important topic at oncology conferences, with surveys showing various levels of satisfaction on the part of providers and patients, as well as concerns about disparities in the level of access to technology.^1,2

Reimbursement barriers to telehealth adoption came down during COVID-19, allowing oncology practices to see for the first time where its use made sense and where it did not. The American Society of Clinical Oncology (ASCO) responded with guidelines for telehealth use, suggesting that the technology likely will be part of the treatment landscape for good.³

A consensus is emerging. When it comes to diagnosing cancer, telehealth can never replace the in-person visit. But during a pandemic, it is highly useful—and perhaps better—for some elements of cancer care, because it can increase the number of touch points in areas such as survivorship care and nutrition, which would otherwise require a separate visit to the office.

For some practices, however, telehealth could prove a game changer when dealing with a problem that no quality measure or technology upgrade can fix: the weather.

Rajini Katipamula-Malisetti, MD, a medical oncologist and hematologist with Minnesota Oncology who practices in Coon Rapids, has seen telehealth’s usefulness up close. She spoke with Evidence-Based Oncology™ in December 2021, as the Omicron variant fueled another surge of COVID-19 cases and triggered another rise in hospitalizations.⁴ This happened as Minnesota reached the season when, in prior years, a wintry blast could wipe out an entire day’s schedule.

But now, schedulers at Minnesota Oncology know that if patients call to say they can’t come in because of a snowstorm, there’s a solution. “We’re just asking them to offer telehealth appointments,” Katipamula-Malisetti said. “We don’t want to cancel appointments.”

Better yet, the team can look at the forecast and proactively switch patients to telehealth appointments if a storm is coming. “It’s been really helpful,” she said.

Katipamula-Malisetti, a recipient of the ASCO Merit Award for her research on trends in mastectomy rates and MRI,⁵ is a believer in giving her patients a thorough education on what will happen during cancer treatment. She has found that with the pandemic, telehealth is a valuable tool that also offers some unexpected benefits.

Solving Multiple COVID-19 Challenges

Having patients see their physician, social worker, or nutritionist via telehealth obviously reduces the opportunity for infection, but that’s not the only problem it solves, Katipamula-Malisetti said. Staffing shortages have emerged across health care, and Minnesota Oncology may not have staff at each clinic for every type of service. Telehealth helps address that: “There are certain specialties where we’re still leveraging telehealth significantly,” she said.

Examples include the initial survivorship visit, at which patients and caregivers receive information about the effects of chemotherapy so that everyone knows what to expect. Due to COVID-19, right now telehealth can be a better option for this visit, she said.

“We still have a 1-visitor policy, whereas with telehealth, we’re able to have [a patient’s] daughter and her husband or whoever is going to be the point person. So, we’re still trying to have those survivorship visits be telehealth visits,” Katipamula-Malisetti said.

Another example: a genetics session at which family history is taken—having multiple family members participate is a plus, she said. Depending on the practice or the insurer, telehealth was used for these visits even before the pandemic due to the relative scarcity of certified genetic counselors.4 She cited visits about nutrition as a third example.

Due to COVID-19, Katipamula-Malisetti said, patients are more willing to try telehealth than they might have been in the past. With staffing shortages and hospital overcrowding, the challenge to simply gain access to care makes telehealth a viable option. For those who might not have tried it before, “it’s worth a shot,” she said.

Reimbursement

So far, Minnesota Oncology has had a good experience with telehealth reimbursement for the types of appointments it schedules, Katipamula-Malisetti said. But she has heard about CMS paying less for visits if they are telephone only—in contrast with the early days of the pandemic, when the priority was to reach patients in any way possible. In her view, flexibility is important to address disparities until solutions to disparities are found.

Asked if telehealth could help gather patient-reported outcomes if gene- and cell-based therapies were to reach more patients, especially those in rural areas, she said that this would be useful. “I think this is a tool that we can really leverage,” she said. If patients need check-in every day or 2, using telehealth to gather information could be better for the patient and keep costs down, she explained. The same would be true for gathering data from clinical trials.

The ASCO Telehealth Survey

The Minnesota Oncology experience with telehealth generally aligns with survey results reported at the most recent ASCO meeting, in May 2021. Only 3 types of visits were found appropriate for telehealth by more than 50% of the providers: discussions of imaging or laboratory results, chemotherapy education, and genetics counseling. More than 50% of survivors found visits on imaging or laboratory results or financial counseling to be appropriate; 90% of providers thought financial counseling was appropriate within the context of a broader visit on supportive care. Follow-up care found appropriate for telehealth by more than 50% of both providers and survivors included symptom management; for survivorship care, more than 50% of providers and survivors endorsed nutrition consultations and patient navigation via telehealth.¹

For all the positives that telehealth can offer, the question of whether all patients have the same access to technology has lingered since the start of the pandemic. The ASCO survey results showed that among survivors, 2.5% reported having no phone or no smartphone, 6.7% reported no or unreliable broadband or internet access, and 10.9% reported being uncomfortable using technology.

Katipamula-Malisetti said she would like to see payers get involved with helping ensure equal access to telehealth for oncology care, perhaps through pharmacies. A single primary care clinic may be “inundated,” she said. But partnering with the local health care infrastructure through pharmacies would be an appropriate role for payers, she said. A small area of the pharmacy could be set up with a laptop for telehealth visits to accommodate patients who don’t own a computer or who lack sufficient internet service.

“Is there a way to move the needle?” she asked.

References

1. Arem H, Moses J, Cisneros C, et al. Cancer provider and survivor experiences with telehealth during the COVID-19 pandemic. JCO Clin Pract. Published online October 29, 2021. doi:10.1200/OP.21.00401
2. Jewett PI, Vogel RI, Ghebre R, et al. Telehealth in cancer care during COVID-19: disparities by age, race/ethnicity, and residential status. J Cancer Surviv. Published online November 20, 2021. doi:10.1007/s11764-021-01133-4
3. Lawrence L. COVID-19 pandemic spurs quick uptick in telehealth adoption; ASCO provides guidance for oncologists. ASCO Post. September 10, 2021. Accessed January 17, 2022. https://ascopost.com/issues/september-10-2021/covid-19-pandemic-spurs-quick-uptick-in-telehealth-adoption-asco-provides-guidance-for-oncologists/
4. Minnesota’s COVID response capacity. MN.gov. Accessed January 17, 2022. https://mn.gov/covid19/data/response-prep/response-capacity.jsp
5. Katipamula R, Degnim AC, Hoskin T, et al. Trends in mastectomy rates at the Mayo Clinic Rochester: effect of surgical year and preoperative magnetic resonance imaging. J Clin Oncol. 2009;27(25):4082-4088. doi:10.1200/JCO.2008.19.4225