Recognizing and Testing Telehealth Models in Oncology Care First
Introduction to the Quality Outlook: Cancer and COVID-19 – Looking Ahead to Telehealth Post-Pandemic Mini-Series
Tom Valuck, MD, JD—Blog Editor
The pandemic has dramatically impacted cancer care, leading to a reduction in preventive care, alterations and delays in treatment, and suspension of some clinical trials. Certain cancers, including lung cancer and leukemia and lymphomas, have ranked among the top four risk factors for COVID-19 mortality. While the pandemic has created challenges for providers participating in quality measurement and improvement programs, the evolving landscape has reinforced the need for policymakers to provide appropriate incentives and recognize new approaches to care delivery.
In the face of these challenges, telehealth adoption has become a critical strategy for providing continuous care while avoiding physical contact. In support, both the American Society of Clinical Oncology and the Taskforce on Telehealth Policy (TTP) have released recommendations for adapting care standards to improve access to and quality of remote care. In particular, the TTP’s recommendations to policymakers focused on incorporating telehealth incentives and measures into value-based alternative payment models (APMs).
Given the impact of COVID-19 on cancer care, the incoming Administration can strengthen Medicare’s oncology value-based payment models and quality measures. In this series, we will explore ways for CMS to incorporate telehealth in oncology APMs; the importance of preserving personalized medicine in telehealth delivery; recommendations for maintaining patient safety standards for telehealth; and the indirect benefits of cancer telehealth models, such as improving physician productivity.
Acceleration of the availability and use of telehealth, spurred by the COVID-19 pandemic, has created the opportunity and need for alternative payment models (APMs) that encourage implementation and enable evaluation of telehealth services. Given the ongoing transformational changes in oncology care delivery resulting from COVID-19 and cancer patients’ unique risks, the incoming Administration should identify ways to test innovative standards, incentives, and payment models for telehealth in its oncology APMs. The Taskforce on Telehealth Policy (TTP), a collaboration between the Alliance for Connected Care, the National Committee for Quality Assurance, and the American Telemedicine Association, recommended that CMS create programs that support telehealth:
“CMS should develop and pilot a program that empowers and supports patients receiving care remotely. Patients opting to partake in this virtual medical home model would have access to designated patient navigators and other tools to maximize data sharing, care coordination, patient experience and outcomes. The program should be designed to complement and enhance any existing care coordination or patient-centered medical home services in place and to fully integrate remote care into the health care system.”
The next oncology APM is an opportune starting point for recognizing and testing cancer telehealth services. The Oncology Care First (OCF) model is the Center for Medicare and Medicaid Innovation’s (CMMI’s) proposed continuation of the Oncology Care Model (OCM). While OCM was extended through June 2022 due to the pandemic, CMMI did not keep its original timeline for implementing OCF in January 2021 and has not yet described potential changes to the model because of the public health emergency. Although the new Administration may ultimately choose to pursue a different oncology APM, we believe cancer care will continue to be a priority for value-based payment. The OCF serves as a useful framework for evaluating how telehealth might be incorporated into future APMs.
The OCF shares design elements with its OCM predecessor, including monthly enhanced services population-based payments, performance-based payments, and accountability for Medicare total cost of care, during a six-month episode triggered by receipt of a chemotherapy drug. Transformation to a patient-centered care delivery model is a foundational component of the OCM and proposed OCF. Ensuring that patient-centered standards, care coordination requirements, and incentives for increasing access to services for patients through telehealth modalities should be a priority for CMS as the agency evaluates and finalizes its approach to whatever oncology APMs it chooses to implement. Below, we discuss recommendations to CMS for recognizing telehealth in APMs.
Incorporate Telehealth Best Practices into Program Redesign Activities: The proposed OCF requires that participants transform clinical practice to meet required care delivery redesign activities (eg, providing 24/7 access to a clinician with real-time access to medical records). CMS should consider adding redesign activities that require participating practices to demonstrate capability for providing routine telehealth services. Existing redesign activities could be clarified to note how telehealth should be incorporated. For example, OCF practices could be required to develop a personalized care plan for each patient that describes scenarios for telehealth services. CMS proposed a redesign activity for the OCF requiring collection of electronic patient-reported outcome (ePRO) data. CMS should connect the ePRO collection requirement to important telehealth capabilities, including remote monitoring of patient symptoms.
Provide Additional Enhanced Services Funding to Support Use of Telehealth: In order to help practices adopt telehealth systems for improving patient access and continuity of care, CMS should recalibrate planned OCF monthly prospective payments to account for this needed infrastructure. A recent Health Affairs article recommended CMS integrate components of the “Hospital at Home” model into OCF, including a separate module providing reimbursement for remote services (eg, nurse coordinators, 24/7 clinician telehealth access, remote vitals monitoring, specialty consultations, text-based symptom monitoring, predictive analytics). This approach aligns with the TTP’s virtual care model recommendation. Including additional monthly payments that recognize delivery of these services would help practices implement the technology needed to provide remote patient care.
Build in Quality Measures to Ensure Monitoring of Patient Access and Satisfaction: Oncology APM design should offer physicians the flexibility to provide telehealth care services to patients who need it and who will most benefit, such as rural patients or patients with limited ability to travel, in appropriate clinical scenarios such as routine care. APMs should include quality measures to help minimize the risk of overuse of less expensive telehealth services when in-person care is needed. Meaningful quality measures, including-patient reported measures that evaluate patients’ access to care and satisfaction with use of telehealth, can balance the total cost of care incentives of APMs. In 2020, the Agency for Healthcare Research and Quality (AHRQ) released an updated Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey that assesses the use of telehealth services. Similar changes will be important for cancer patient experience surveys, including the version currently used in OCM and intended for use in the OCF. Separately, the National Quality Forum (NQF) recently announced they will be convening a workgroup to update and enhance their existing telehealth framework, which may inform opportunities for measuring telehealth in oncology APMs. In later blogs in this series, we will discuss the role quality measures can play in assessing patient experience, safety, and other outcomes associated with telehealth services.
Provide Telehealth Waivers for Program Participation: While we do not yet know how broadly CMS will extend the flexibilities for use of telehealth after the public health emergency ends, the 2021 Physician Fee Schedule (PFS) final rule made some expanded services permanent. The Medicare Payment Advisory Commission (MedPAC), which has discussed a potential permanent expansion of telehealth in Medicare coverage, suggested a continuation of telehealth service coverage for Advanced APM-participating clinicians under the Quality Payment Program. Telehealth flexibility under APMs can incentivize participation in these arrangements. For example, participants in the Next-Generation Accountable Care Organization (NGACO) demonstration model had a head start managing the COVID-19 surge based on the availability of telehealth waivers for that program. Given the important role telehealth services have had for vulnerable cancer patients, telehealth waivers should be a part of future oncology APMs.
The COVID-19 pandemic has fundamentally changed the approach to delivering care for cancer patients, and telehealth services have become essential for ensuring access to screening and treatment. Future implementation of oncology value-based payment models should reflect this change and support implementation and measurement of telehealth services.