Your patients’ missed screening means advanced cancer: Here’s how to get patients back and how to treat them in the comfort of their own homes

Andrew Hertler: I increasingly think there is a real opportunity to give a portion of cancer care at home, not only with telemedicine visits, but some of the infusions and injections that are given to treat cancer can be administered at home as well.

Erika Grotto: Opportunities in oncology, today on HFMA’s Voices in Healthcare Finance podcast. Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today, I’m talking with Andrew Hertler, the chief medical officer at New Century Health. He was on our podcast in 2020 discussing the risk of deferred screenings and opportunities in oncology for telehealth. Today, we have updates on those topics and also discuss how workforce shortages will come into play. Later, we’ll have some exciting news about our upcoming Annual Conference in Denver. But before we get to all that, let’s check in with HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack to find out what’s happening in healthcare finance news.

Nick Hut: Hello, everybody. If you’re interested in healthcare policy at all, MedPAC’s annual report to Congress is really a trove of policy insights and really just a roadmap for Medicare payment policy. They just released this year’s report within the last couple of weeks, and if you work for a hospital or health system, probably the key point was that MedPAC recommends not taking the pandemic into account when calculating the payment update for inpatient and outpatient services in the upcoming year, which is 2023. So that leaves, basically, the regular statutory update, which right now is projected to be a 2.5% increase for inpatient services and 2% on the outpatient side. That’s subject to change due to various economic factors, but I wouldn’t expect it to change by more than a few tenths of a percentage point. And furthermore, MedPAC’s guidance isn’t gospel. There’s room for CMS to implement any sort of update that it sees fit. But my guess is they’ll more or less adhere to the recommendation. So Shawn, what do you make of that in terms of what went into that recommendation?

Shawn Stack: Nick, the annual March report to Congress, because of standard data legs, the most recent completed data the report is based on is recommending payment adequacy indicators from 2020, and in some of those cases they utilize data from 2021 like interim claim data, information on facility closure and beneficiary survey data, but for the most part they’re using adequacy indicators from 2020, unlike the inpatient/outpatient payment assistance adjustments that you’re talking about. But yes, they are not final yet. The commission did not recommend an update to the physician or other healthcare professional fee schedule, or the ambulatory surgical center fee-for-service payment system. So it’s going to be very interesting to see the reactions to that decision and to see what moves forward. But keep in mind, clinicians are eligible for annual performance-based payment adjustments through Medicare’s Merit-Based Incentive Payment System or their annual bonus worth 5% of their Medicare professional services payments through the alternative payment models. So it kind of begs to differ if they’re focusing on these alternative payment models to get more physicians in there to, you know, kind of push them toward that scope of service for payment increases.

Hut: Yeah, thanks for that, Shawn. That’s great insight on the physician side. I do see the logic to MedPAC’s stance in terms of, if you try to incorporate all these pandemic-related factors into an annual update, you kind of open a Pandora’s box where just the whole process of implementing the update becomes kind of unwieldy and maybe less than scientific. So I get where they’re coming from in terms of preferably using other payment mechanisms to address any financial distress that hospitals may be experiencing. Now, it’s unclear what those mechanisms might be, at least in the short term, now that the provider relief fund is out of money. But  more importantly I think is that the recommendation, while it makes sense in theory, it just might not match reality on the ground, given that, like you explained, 2020 data for the most part is used to determine the market basket that sets 2023 payments. And “market basket” for those who don’t know, just refers to pretty much all the costs of providing care, excluding non-operating costs, and it guides CMS in determining how hospitals should be compensated for providing healthcare. So all the inflation, especially in wages, that has taken place since 2020, is probably not going to be accounted for in that price update, and therefore in the payment update, that wouldn’t happen until 2024, so some hospitals could be left in the lurch, financially speaking. Anything to add to that, Shawn? I just threw a lot of dry, convoluted information at our listeners. Any context to be added there?

Stack: No, I agree with you, Nick. I think some hospitals are going to be left in the lurch during that period of time. One of the things that I peeled away from the MedPAC report and I thought was very interesting and I think folks really need to watch closely and listen to is the numbers on telehealth services and how much they grew in 2020. They accounted for 5% of the fee-for-service spending compared to only 1% in 2019. So this is not a surprise to anyone, and I’m sure it’s not a surprise to Medicare or MedPAC. But the recommendation was made to the secretary to require physicians and other healthcare professionals and home health agencies and hospices to start providing more information related to telehealth. So it looks like MedPAC might be telling Medicare that they need to gear up for maybe closely looking at telehealth services, how they’re being used, and if there’s any, you know, un-discretionary use of those services right now.

Hut: For sure. And the telehealth waivers that CMS handed down at the beginning of the pandemic are in place for five months after the expiration of the public health emergency, which is likely to be in July, but certainly, the stage is being set for telehealth to become a permanent part of the payment landscape, much more so than it currently is. I know you wanted to make a point about outpatient dialysis payments. What should listeners know about those?

Stack: So under current law, the Medicare fee-for-service payment rate for dialysis services is projected to increase by 1.2%. I’m not saying that this is a bad thing, but I am a little surprised MedPAC did mention, you know, the push and the focus on home dialysis or peritoneal dialysis being one of the center focuses in this area, but I really think that we need to see MedPAC and Medicare step up their insight over, you know, the renal care that’s being provided to its Medicare patients. This is one of the most costly areas or service lines for Medicare at this current time and has been for years, and we need to see more happen here to control quality and preventive renal failure care. So I think that’s something that a lot of us have high expectations for in the policy field, and as we know, the Medicare trustee fund is— the hospital insurance trust fund—is becoming deplete very quickly as we’ve heard over the last 10 years and is stated to become insolvent either by 2026 or Congress or the CBO is saying it’s gonna be insolvent by 2027. So we’re up against quite a bit of crunch here to find additional dollars, either through additional Medicare payroll tax going from, I think they’re estimating 2.9% to 3.7%, or a significant reduction of 18% in Medicare payments. So a lot to be concerned about coming up here on the next three or four years.

Hut: No doubt. That absolutely bears watching, as do the proposed rules for the various prospective payment systems. They’re likely to start dropping, especially with the added IPPS rule, maybe around late April. And we’ll definitely be keeping you all up to date at hfma.org/news.

Grotto: The sharp decline in cancer screenings at the onset of the COVID-19 pandemic concerned many people in the healthcare industry. And although there has been somewhat of a rebound, the numbers aren’t what they were before the pandemic. Additional challenges like workforce shortages make this a difficult time for patients and healthcare organizations, particularly in oncology. But according to my guest today, it’s also a time of great opportunity. Andrew Hertler is the chief medical officer of New Century Health. He was also a practicing oncologist for 30 years, so he’s seen cancer care from a few sides. This is his second time on our podcast, so we started out with a quick update on our last conversation.

In October 2020, you were on our podcast—and I will share a link in the show notes for anyone who didn’t listen or who might want to go back and listen again. We were talking about the risks being presented with the pandemic regarding delayed cancer screenings. Back then, again, it was fall of 2020; we were just starting to talk about it, but it’s borne out that patients who put off their screenings ended up coming into the system later, with cancers that had advanced. And in that interview, you pointed out the worst-case scenario, which is that a patient who had a curable cancer wouldn’t find out about that cancer until it was incurable. So I’d like to know your thoughts on, where do we stand now with diagnoses, and how many people are actually coming back to get those screenings?

Hertler: Well, those are very good points, and unfortunately, yes, predictions have come into reality. We know that screenings lagged tremendously, that in the period since the real onset of COVID in early 2020, new cancer diagnoses declined by, in various studies, 13-23% versus the pre-COVID era. Now, these people didn’t just stop developing cancer. They weren’t diagnosed. And we know that there’s been a good deal of progress with decreased cancer deaths over the last two decades. We’re very proud of that fact. And there were numerous contributing factors. But certainly one very important factor was our widespread screening and earlier diagnoses. And we know that screening fell in breast cancer, cervical cancer, colon cancer as much as 80-90% during the height of the pandemic. Unfortunately, those screenings continue to lag. We’re still 13% below our historical average in screenings in 2021. People are coming back. New cancer diagnoses are coming back to baseline, though in our own experience at New Century Health, we’re still just slightly below our pre-COVID baseline. But the diagnoses that are coming in are showing a bit more advanced stages, and people who had disease that might have been curable, very early stage, had not spread at all, now presenting with more widespread cancers, and this is the tragedy. Unfortunately, there are some projections—for instance, breast cancer is one example—it’s been estimated that there will be over 2,400 excess deaths due to breast cancer presenting in more advanced stages. So truly a tragedy, and we still need to work to get the screening back to baseline.

Grotto: What do you think is the way forward with that? Is it just kind of starting over and encouraging people to come back and get those screenings?

Hertler: I think that’s a part of it. There are some other competing complications. One is simply availability of screening, in that all of these screening centers, say for mammograms, have a certain capacity. There’s only so many you can do a day. And literally getting access to the screening is challenging, to catch up on all those that weren’t done and perhaps some never will be caught up. People will just put off that screening completely. There also may be some reticence of people to go into healthcare facilities. Unfortunately, some of the people who have the greatest delays in screening are those who come from minorities or are socioeconomically disadvantaged. So we may need to not only encourage people to go back and get the screening but make it more available, even think about mobile screening programs, increased availability, going into neighborhoods. Some people don’t have to travel to healthcare facilities. It may take more than just simply saying, “Let’s get the message out” and have people come back for screening.

Grotto: We also talked in that interview, back in 2020, about opportunities to take patients out of medical offices and treat them in their homes. And there’s been a lot of movement in the last few years around hospital at home models for acute care as well as advancements in technology like remote monitoring for patients with chronic conditions like diabetes or COPD. And in that interview, we spoke about some opportunities in oncology to keep patients whose immune systems are suppressed away from other people but still getting the treatment they need, not to mention keeping them at home where they might be more comfortable. Where do you see the biggest opportunities, and do you think the payment pieces will fall into place to ensure these opportunities are possible and viable?

Hertler: I increasingly think there is a real opportunity to give a portion of cancer care at home, not only with telemedicine visits, but some of the infusions and injections that are given to treat cancer can be administered at home as well. Now, not all medications should be given at home. There are some that need more monitoring, more availability of emergency treatment should it be necessary than one would feel comfortable giving medications at home. But many of them, including some of the innovative and groundbreaking drugs can safely be given at home. There have been a few pilots and a few places where this is being done. There’s the obvious advantage you spoke of in terms of decreasing exposure to other patients when you go into a femoral therapy treatment facility. You’re sitting in a room with numerous other patients. Patients getting treated for cancer do have suppressed immune systems from the chemotherapy, so there’s a huge argument, particularly during a pandemic, for keeping patients at home. However, it’s proven incredibly popular with patients. There are some regulatory hurdles that would need to be cleared in terms of what’s covered by Medicare and what isn’t and what your status has to be to receive home therapy. There have been certain stipulations in the past that you have to be homebound to receive home care. But assuming we can get around some of these administrative barriers, I believe there’s a real opportunity here.

Grotto: So as we’re talking about changing the way that we deliver care to patients with cancer, we also have to talk about the issue of manpower. I found information going back to 2007, but it might go back even longer, that experts were predicting a growing need for oncologists and a dwindling oncologist workforce. And that was long before the pandemic, so today, we’re not only seeing these predictions from back then come true but they’re exacerbated because of the pandemic and all of the workforce issues that we’ve seen because of it. We have serious shortages of all types of healthcare workers. Looking at models like home care for cancer, we’re changing the way we deliver that care. We’re going to need to change the way our people deliver that care. So what’s your perspective here? What is our way forward with making good use of the people we have and delivering care efficiently?

Hertler: Well, you’re absolutely correct in all the numbers you cited. There has been a long-projected workforce shortage of oncologists due to an aging median age of oncologist retirements, and it’s all been exacerbated by COVID-19. I have not seen statistics distinctly about oncology, but I know the healthcare workforce fell by 3.5% from February 2020 to February 2021, and I know anecdotally, many oncologists who are getting near the point where they were thinking of retiring, the pandemic was enough to say, “That’s it for me, I’m leaving.” So there is a shortage. It takes a long time to train an oncologist, so there’s no immediate solution of simply encouraging people and training more oncologists. And the answer, as you suggested, is going to rely on how can we be more efficient, and though I don’t have an answer, I have a number of ideas of things that I believe are almost going to have to take place. Traditionally, the traditional model as an oncologists—and I practiced this many years myself—was, you got up every day and you went to the hospital and saw your patients in the hospital and then you went to the office and you saw every patient yourself every time they came in. You’d get on that treadmill, and you’d run as hard as you could. And as one person, you basically, you might have partners, but really what you had was a group of doctors who shared overhead. It was not a team approach. And I think first and foremost, we have to develop much more of a team approach, and we’re already seeing this to a certain extent, the use of hospitalists who take care of people in the hospital so you don’t need to go into the hospital. Oncologists are going to need to realize that they cannot see every patient every time they come in themselves. They’re going to have to willing to find physician assistants and nurse practitioners, and while the oncologist will still have to develop the treatment plan and use their expertise, use what they were trained for to devise those individual treatment plans, the execution and delivery of that care is going to have to be supervised to a large extent by physician assistants, by nurse practitioners, where they may see the patients when they come in for each treatment, and then instead of seeing the patient every second or third week, the oncologist may only weigh in halfway through the therapy and again at the completion, just to make sure that the outcomes are what was expected so that you can use the oncologist for what we’re most trained to do, which is to devise and oversee the treatment plans but not necessarily be involved in every step of the execution. Similarly, for follow-up visits, it’s traditional that patients will come in after they’ve completed their treatment for cancer, maybe every three months for a couple of years, every six months. I can remember patients coming in ten or more years after their cancer diagnosis, still, annually, for visits. And I’ll be honest. Those are fun visits for a physician. Those are your successes. And it’s a feel-good visit. But is it the most productive use of an oncologist’s time, and do you really need an oncologist, or could that care be served better or more efficiently by the primary care physician, freeing up more oncologist time? Use of virtual medicine and home chemotherapy is another way to increase the efficiency of an oncology work force, which is decreasing in size in terms of being able to do those visits, still spending time with the patient but a bit more efficiently and quickly. I think we sometimes overestimate the efficiency to be gained. You’re still going to spend the time face to face with the patient, and you’re still going to be documenting in the chart, but certainly in terms of the space—and we talked a little bit on screening about access to therapy—you don’t have a limited number of chemotherapy chairs when you’re doing some of the therapies at home. It opens up a much broader population that can be treated, and it also—in theory, an oncologist who is doing virtual visits and supervising chemotherapy at home could even work from home, as I am today, because what you need is your computer screen and the ability to connect with any of the team that is onsite with the patient. So it’s steps such as these that will increase the efficiency of the team and increase the availability of care to patients, that I hope will at least provide some of the solution to the problem.

Grotto: I’m curious what your thoughts are—I mean, you’re talking about shifting some of the tasks, as it were, or certain visits to a primary care physician or a nurse practitioner. How do you think that’s going to go over with the people who are taking on the work? I mean, if there’s a shortage of primary care physicians and they’re all of a sudden saying, “OK, now we’re expected to do this too,” how do you balance that part of it?

Hertler: That gets back to the overall workforce shortage, and I believe literally becomes a part of, where are the shortages most severe? Primary care physicians are certainly challenged. They have a lot of responsibilities, and you’re talking about survivorship care of patients, which in some ways could be regarded, “well, I’ve got to check their cholesterol, blood pressure, make sure I’m screening for diabetes, and now I’ve got these cancer care survivorship issues.” So that’s something that has to be weighed. Is this something that they can take on, and will the patient be happy with it?

Grotto: This conversation has been so interesting. I always love speaking with you, so Dr. Andrew Hertler, thank you for joining me today.

Hertler: Thank you very much for having me.

Beth Brousil: Hi, this is Beth Brousil, and I’m here with some exciting news about HFMA’s upcoming Annual Conference. As you probably already know, this conference is the premier event for healthcare finance professionals, and this year, we are in a new location. Here to give us some highlights is Katie Gilfillan, HFMA’s Director of Healthcare Finance Policy and Education. Hi, Katie.

Katie Gilfillan: Hi, Beth. Great to be with you.

Brousil:  So this year, we’ll be meeting in Denver, the Mile High City, and that’s a really exciting change, and I understand you’ve got some great speakers lined up. Can you tell us what people can expect?

Gilfillan:  Yes, we’ll be in Denver, at the end of June—the 26^th through the 29^th—and we’ll be offering both an in-person and virtual option to access to a variety of sessions within seven topic tracks and the opportunity to network and learn about healthcare finance solutions. Our theme this year is “Above and Beyond” as we take the Cost Effectiveness of Health initiative to new heights, exploring how we can sustainably deliver better health outcomes.

Brousil: That sounds incredible. Can you tell us about some of this year’s keynote speakers?

Gilfillan:  Yes, we’ve got a really great lineup this year. Dr. Karen DeSalvo, she is chief health office at Google Health, and the recipient of the 2022 Richard L. Clark Board of Directors Award. And she will be telling us why her career, which has been focused on improving health and eliminating disparities, led her to Google. Also Dr. Zeev Neuwirth, he is chief of clinical care transformation and strategy at Atrium Health, he will speak on taking a unique approach to navigating the transition to a consumer-oriented value-based healthcare market. And, Dr. Kelli Harding, assistant clinical professor of psychiatry at Columbia University will be telling us about the science behind kindness and happiness. We also have Joel Selanikio. He is a physician and entrepreneur that will challenge us to think differently about the future of health, and the intersection of health, technology, and business — understanding the origin of current trends and the implication of recent advances for healthcare. We’ve also got D.J. Vanas, an internationally-acclaimed leadership and personal development speaker and author. He will share a unique, powerful perspective from Native American culture on what the warrior role is (and what it isn’t) about and how we can emulate the principles of that role to stay strong, clear and moving forward through navigating change into disruption and performing setbacks into opportunities. And we’ll also be introducing our new HFMA National Chair, Aaron Crane.   

Brousil: That’s quite the lineup. Thank you so much for all the great information about the upcoming conference.

Gilfillan: Thank you, and we can’t wait to see everyone in the mile-high city in June. 

Grotto: Voices in Healthcare Finance is produced by the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is our director of content strategy. Our president and CEO is Joe Fifer. Registration is open for our Annual Conference. It’s taking place June 26-29 in Denver. You can take a look at the agenda and speakers by going to our website, hfma.org, and clicking Education & Events. And if you want to reach me or any other member of our podcast team, we would love to hear from you. Email us at [email protected].

The sharp decline in cancer screenings at the onset of the COVID-19 pandemic concerned many people in the healthcare industry. And although there has been a rebound, the numbers aren’t what they were before the pandemic. Additional challenges like workforce shortages make this a difficult time for patients and healthcare organizations. On this episode of HFMA’s “Voices in Healthcare Finance” podcast, Andrew Hertler, MD, chief medical officer at New Century Health, discussed how the pandemic has changed oncology care and how current challenges might affect the future of cancer care.

Deferred screenings mean advanced disease

Hertler first appeared on the podcast in October 2020, discussing the dramatic decrease in cancer screenings since the beginning of the pandemic. At the time, he said he feared patients coming back with advanced disease, something that today he says has borne out.

“The diagnoses that are coming in are showing a bit more advanced stages, and people who had a disease that might have been curable … are now presenting with more widespread cancers,” he said. “Breast cancer is one example. It’s been estimated that there will be over 2,400 excess deaths due to breast cancer presenting in more advanced stages.”

Only part of this issue is due to patient reluctance to come in for screenings, Hertler said. An additional challenge is limited availability in screening centers.

“There’s only so many [screenings] you can do a day,” he said. Some organizations may never catch up by continuing to conduct business as usual, so creative solutions such as mobile programs may be necessary, he said.

Delivering care outside of hospital walls

In addition to conducting screenings outside of hospitals or medical offices, healthcare organizations also can consider keeping patients safe and comfortable by delivering care in their homes. Telehealth visits can help, but treatments, too, can be done in a patient’s home, Hertler said.

“I increasingly think there is a real opportunity to give a portion of cancer care at home, not only with telemedicine visits, but some of the infusions and injections that are given to treat cancer can be administered at home as well,” he said.

People receiving cancer treatment are immunosuppressed, so going into a hospital can mean serious illness if a patient is exposed to something contagious, such as COVID-19, Hertler said. Keeping patients at home limits their exposure. In an age when inpatient hospital-at-home programs are gaining momentum, healthcare organizations may be open to exploring several types of care delivery at home, so long as regulatory hurdles can be cleared, he said.

“There have been stipulations in the past that you have to be homebound to receive home care,” he said. “But assuming we can get around some of these administrative barriers, I believe there’s a real opportunity here.”

Changes in the workforce

 A growing patient population, paired with a dwindling oncologist workforce, means that care delivery must change from a workforce perspective, Hertler said.

“There has been a long-projected workforce shortage of oncologists due to an aging median age of oncologist retirements, and it’s all been exacerbated by COVID-19,” he said. “The answer … is going to rely on how we can be more efficient.”

It’s possible that some care may be shifted to other people, such as physician assistants, nurse practitioners or even primary care physicians, although workforce shortages across healthcare could make that prospect challenging, he said. Virtual visits also may provide some efficiencies, as well as opportunities for more patients to get treatment.

“You don’t have a limited number of chemotherapy chairs when you’re doing some of the therapies at home,” he said. “In theory, an oncologist who is doing virtual visits and supervising chemotherapy at home could even work from home … because what you need is your computer screen and the ability to connect with any of the team that is on site with the patient.”