Gordon Kuntz is a health care consultant and strategic advisor with over 30 years’ experience in a multitude of health care settings, working with payers and providers, and in technology and strategy. He began his involvement with oncology care pathways in 2004 as a consultant with US Oncology as they were deploying Level 1 pathways. He subsequently led payer strategy with ION Solutions, a division of AmerisourceBergen, where he gained familiarity with many other pathways vendors, especially in the context of the oncology medical home model. As senior director of strategy for Via Oncology, he deepened his knowledge of the pathway development process, physician adoption, and how both impact cancer center strategies. Mr Kuntz now provides support in strategy and product design as well as assistance in navigating the cancer care ecosystem to established and emerging companies.
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Cancer care, like many aspects of life during the COVID-19 pandemic, has been dramatically altered since stay-at-home orders and social distancing guidelines have been in place. There are numerous excellent resources, webinars, and articles being published to help practices with creative approaches to short-term strategies during the COVID-19 crisis.
But what happens when the stay-at-home orders are lifted? The discussion nationwide is now turning to when and how to responsibly re-open society and daily life. One thing we know for certain: life going forward will be substantially different from what we knew prior to February of this year. Much like air travel was irrevocably changed as of September 11, 2001, commerce and social interactions will be altered by the coronavirus for a long time.
The speed, depth, and duration of social distancing guidelines and the stay-at-home orders across most of the country have created economic and social disruptions in every sector. In this article, we will explore the long-term impacts of COVID-19 on cancer care. I hesitate to say “the permanent impacts” because, if nothing else, we have realized that things we thought were permanent and immutable are not.
Basic Assumptions to Ground Projections
To set the stage, there are a few key assumptions I am making in this commentary that seem reasonable given the situation as of the writing of this article:
- It will be at least 18 to 24 months, and possibly much longer, before a safe, effective, and durable vaccine is widely available to provide general immunity.
- Pending and active plans to re-open various states coupled with the current dearth of testing and contact tracing mechanisms may result in at least one and possibly two major spikes in cases over the next 12 months, each one possibly much larger than the one we experienced the last 8 weeks.
- The time horizon we are exploring here extends to about 5 years from now, based on the assumptions above.
Key Drivers and Subsequent Trends
With this as background, a few key drivers are already emerging that are shaping how cancer care is delivered now and in the future.
- Unemployment—Unprecedented numbers of workers have been unemployed overnight as businesses, hotels, restaurants, and seemingly all aspects of society shut down.
- Patient concerns about COVID-19—The public, including cancer patients, are afraid to leave home much less go to a hospital for lab or imaging services.
- Referral stream disruption—Primary care clinics, urology offices, surgeons, and other specialties that refer to oncologists will have been closed or have seen greatly reduced patient volumes for 6 to 8 weeks in many cases. Rescheduling that kind of normal patient load will take months given that most primary care provider schedules are normally close to capacity.
- Burnout and mental health issues—Mental health issues due to the trauma of treating COVID-19 patients will be disruptive to many health care institutions, and post-traumatic stress disorder and anxiety from dealing with the fear of infection day-to-day will have widespread and long-lasting impacts across the population.
Each of these drivers, in turn, create trendlines to watch.
Unemployment
Massive unemployment will create disruptions in insurance coverage for many people who cannot afford continuation of their employer-based coverage and may need to seek insurance on the individual market—likely with lower coverage levels—or through Medicaid. This may reduce income to practices through lower reimbursement rates and drive up bad debt because of a patient’s inability to pay out-of-pocket costs. Additionally, it is likely that many individuals will delay the kind of care that provides screening and early detection of cancers, so the cancers oncologists see may be more advanced at diagnosis.
Patient Concerns About COVID-19
Patient concerns about COVID-19 infections will persist at least until it is demonstrated that they have effective immunity either by having survived the disease (assuming we acquire durable immunity in this way) and/or with a vaccine. In the meantime, patients and practices will value safety in a different way than they have previously. In the past, “safety” referred to the side effects of a therapy; in the COVID-19 world, it also refers to the risk to a patient of being exposed to the virus via an emergency room (ER) visit or hospitalization, or even at the oncology practice. Oncologists have taken many steps in recent years to reduce avoidable ER visits and hospitalizations, but we should expect to see additional measures being used to avoid these situations.
Additionally, practices will continue to refocus their workflow from internal resource optimization to minimizing patient time in clinic. I would expect some measure of patient interaction time (number of individuals a patient interacts with multiplied by the number of minutes they interact with each person) to emerge as a key performance indicator for practices. Telemedicine use has sky rocketed. For example, the use of telemedicine and remote monitoring has jumped by over 50 times at Moffitt Cancer Center, and most providers expect it is here to stay.1
Other innovative ideas that have been put into use at oncology clinics include curbside lab draws and injections for those that can safely be done quickly, keeping patients safely in their cars. Especially in more temperate climates, expect patients to be asked to wait in their cars until the clinician is ready for them, eliminating waiting rooms. Cancer centers will migrate to smaller physical layouts with wider hallways to promote social distancing and limit the number of contact points and duration. Much more innovation will emerge in this area over time.
Referral Stream Disruption
The closing of nonemergency care, such as primary care clinics for routine physicals, urology clinics for routine visits, etc, will take a very long time to sort out and will become compounded with each spike in cases. Much like commercial airlines, these clinics run schedules at or near capacity. Also, much like flights cancelled by a hurricane or blizzard where it might take a week to rebook everyone, rescheduling 6 to 8 weeks of office visits in these specialties will take months—maybe as much as a year—once the practice is back up. If a primary care practice could squeeze in two extra visits per day to the schedule for rebooked appointments, it would take 8 to 16 months to rebook all of the appointment that have been cancelled (Box 1).2 This situation is somewhat offset by the use of telemedicine in other specialties, but the more intensive services needed to diagnose cancer may require an in-person visit for a conclusive diagnosis. Patient volumes are drastically reduced nonetheless and are not expected to return to pre-COVID-19 levels until at least late 2020.3
Burnout and Mental Health
Burnout and mental health issues have long plagued health care workers. Long hours dealing with unresponsive electronic medical records, high-stress environments, and the challenge of dealing with terminally ill patients is now compounded by the stress and trauma of dealing with COVID-19 patients for those who are working in hospitals.4 Add to that a dramatic uptick in anxiety and possibly other diagnosed conditions such as PTSD in the general population.5 We should expect nurses, especially in city hospitals, ERs and intensive care units, to retire or leave the profession in much larger numbers once this first wave passes and certainly after a potential second wave occurs. This will create an overall nursing shortage that will impact oncology in the long run, even if oncology nurses do not leave the profession directly due to the COVID-19 crisis.
Oncology practices have seen reductions of 10% to 30% of revenue in the last 6 weeks. As new patient starts are delayed due to referral sources seeing reduced patient loads, and periodic regional and general spikes in cases emerging over the next 9 to 12 months, financial instability will continue. Bad debt will likely increase due to a larger unemployed, uninsured, or underinsured patient population. Most practices will emerge from the stay-at-home orders with a smaller cash cushion than they started with, making the ability to be financially resilient a few months down the line if and when a new outbreak occurs all the more difficult.
What Success May Look Like in Oncology Practices Post-COVID-19
Over the next several years as we navigate the fallout and the new normal, a few features may emerge characterizing successful oncology practices.
Adaptable practices will win. Scale has its value, especially in financial matters, but adaptable, resilient practices who can innovate new ways of meeting patients where, when, and how they need to be cared for—and do it quickly—will remain viable and thrive. The level of innovation demonstrated in the last few weeks is exciting. If anyone had polled practices as of December 2019 to see who was planning for curbside lab draws, the answer would likely be zero. Now it is being done by some practices regularly.
Some temporary fixes will likely become permanent. Most people in the industry agree that it is likely that telemedicine and remote patient monitoring is here to stay. Patients generally like the convenience and, while it has its limitations, its long-term place as a means for delivering care is likely secure. Each innovation that has been tried should be evaluated for its role in providing convenient, quality care for the patient while reassuring them of the safety of social distancing. Drive-thru injections, curbside labs, minimizing visitors, etc, all should be evaluated less from a workflow efficiency standpoint than from a patient satisfaction and infection safety standpoint. Patients will continue to be concerned about close interaction, and some degree of social distancing guidelines will likely remain for years. Flexibility and adaptability are the watchwords: keep what is working and build a workflow to take advantage of it.
Pathways programs may need to consider “contact time” as a measure that receives primary consideration in recommending treatments. Oral oncolytics have become more common and are being used more frequently now. For infused therapies, the longer an infusion, the longer the patient is inside the clinic and therefore vulnerable to acquiring an infection from staff or another patient. This new definition of safety deserves a strong consideration in how treatment recommendations occur.
“Practices without walls” could emerge as a model of care. This model includes geographically dispersed practice locations with limited services and a smaller number of staff who can provide services in the community while minimizing contact points for patients, all the while connected to the main campus for support and expert guidance as needed. Similarly, we may see a growth in clinically integrated networks as practices collaborate for quality and help provide overflow capacity to each other within a geographic region. This may result in greater collaboration between hospital-based programs who have been and will continue to be highly stressed by the combination of COVID-19 patients and outpatient cancer services that often rely on visits to the inpatient facility for radiology, labs, and pharmacy. It is possible that the financial, staffing, and business disruptions brought about by the COVID-19 pandemic could convince some hospitals to divest their oncology service lines and create strong alliances with community practices.
New performance measures may emerge that balance financial drivers with business resiliency. The ability to weather a storm, a viral pandemic, or other business disruption will be a critical success factor for all practices going forward. The innovation we are seeing will undoubtedly continue, and new operational, workflow, and clinical delivery models will emerge. Cancer centers need to be flexible enough to try these quickly, adopting those that work for them and modifying others to fit their needs. Resiliency is the key to surviving difficult times, and it is as true for businesses as it is for individuals.
Conclusion
The impacts from COVID-19 will be with us in one way or another for years to come. Practices will have to adapt to service patients as the patients themselves deal with the impacts from both cancer and COVID-19. If there is a silver lining to this difficult time, it is that practices are adapting and showing that they care deeply about patients in a holistic way.
References
1. Drees J. 10 updates on telehealth amid COVID-19 pandemic. Becker’s Hospital Review. April 8, 2020. Accessed April 27, 2020. https://www.beckershospitalreview.com/telehealth/10-updates-on-telehealth-amid-covid-19-pandemic.html
2. Elflein J. Number of patients US physicians saw per day 2012-2018. Statista. August 9, 2019. Accessed April 27, 2020. https://www.statista.com/statistics/613959/us-physicans-patients-seen-per-day/
3. Shinkman R. Doctors say COVID-19 has slashed patient volumes, made finances shaky. HealthcareDive. April 13, 2020. Accessed April 27, 2020. https://www.healthcaredive.com/news/doctors-say-covid-19-has-slashed-patient-volumes-made-finances-shaky/575876/
4. Sullivan M. Worker well-being on the decline amid pandemic, OptumHealth survey finds. April 21, 2020. Accessed April 27, 2020. https://www.healthcarefinancenews.com/node/140010
5. Minemyer P. Prescriptions for antidepressants, anti-anxiety, anti-insomnia drugs jump 21% post COVID-19. Fierce Healthcare. April 16, 2020. Accessed April 27, 2020. https://www.fiercehealthcare.com/payer/express-scripts-covid-19-driving-up-use-behavioral-health-medications
