Cancer and COVID-19: What Comes Next
Cancer patients and physicians are fighting a two-front war. The first fight is with cancer — a disease that claims 600,000 lives each year in the United States, despite our best minds and medicines. In normal times, that battle is formidable — and these are not normal times. A second front has opened with the onset of the novel coronavirus, COVID-19. The virus preys disproportionately on the cancer demographic — older, immunocompromised, dependent on healthcare environments — with early evidence suggesting a risk of death three times higher for these patients. The speed of its advance has left cancer patients paralyzed in many respects, forced to choose between two terrible conditions to confront. Some are choosing to forgo or postpone cancer treatment, others to battle on and risk COVID-19 exposure; still others have the decision made for them as hospitals close cancer services to focus exclusively on the present crisis.
Our recent conversations with hospital and health system leaders have revealed that in the present two-front war, there is no uniform strategy. Each cancer provider is adapting as best possible, leaning on a set of continuously revised recommendations from professional societies like the American College of Surgeons and American Society of Clinical Oncology (ASCO). For many organizations, it is all they can do to manage in the present moment. Still, as organizations move out of the crisis mode introduced by the pandemic, they will need to quickly transition to preparing for what comes beyond the peak — even as COVID-19 persists as a threat. In this brief report, we highlight what we are hearing from the front lines of cancer care and provide three practical considerations for the immediate and longer-term future as cancer care emerges reshaped by COVID-19.
Among our cancer program clients, the current COVID-19 disruption has caused cancellation of routine screening and diagnostics, triage of cancer surgery based on stage and urgency, rationalization of chemotherapy and radiation therapy, and a steep decline in clinic visits to cancer providers. Taken together, these elements represent a tremendous disturbance to a normally evidence-based, time-conscious care continuum.
The disruption to cancer programs caused by COVID-19 is unprecedented, and for that reason there will be no reliable playbook for recovery and reopening. The right answers will likely be market, program and patient specific. Yet, as programs prepare for what comes next, we advance the following three recommendations as practical guidance that applies globally for all of those caring for cancer patients:
1. Cancer will not be postponed indefinitely, and it’s important to prepare now for the restart.
Quarantines and social distancing will not, unfortunately, slow the rate of new cancer incidence or progression. Cancer care will soon return to its (new) normal — with an emerging set of complexities. How long will the threat of COVID-19 contraction persist for the immune-compromised population after the broader populace has resumed normal activity? Will demand for care surge in a uniform pattern and timeframe, or will patients gradually return to comfort with medical settings? Will the current “war time” protocol changes to care — including increased adoption of neoadjuvant therapy and hypofractionation — endure once the crisis ends?
In the near term, we encourage our clients to focus on the demand recapture that will follow the COVID-19 shutdown. The extent of this volume will depend not only on the duration of the shutdown, but also on how providers have managed care delays and the extent to which patients experience lingering safety concerns and insurance disruptions. There will almost certainly be a surge in cancer surgery, followed some weeks and months later by downstream peaks for infusion and radiation therapy. Cancer program administrators should be organizing now for how they will manage access when these surges occur. This means coordinating with inpatient and ambulatory surgical leaders, planning for flex capacity from oncologic surgeons and other clinicians and care team members, and studying new operating models that extend capacity in infusion suites and on radiation treatment platforms. Recovery planning should account not just for known care postponement, but also for the broader unknown population of patients that have been reluctant to self-present during the shutdown, out of fear of either being exposed to COVID-19 or burdening health services unnecessarily. Both the known postponements and unknown underdiagnoses will likely inundate providers in coming months.
The longer-term impact of the expected demand resurgence will be felt at a market level. Cancer programs that can demonstrate the fastest, safest reopening of cancer services will likely benefit from a volume shift as patients seek quick resolution to suspected or known cancer diagnoses. Historical referral patterns and patient loyalties may be traded for expediency, to the benefit of stand-alone providers like freestanding NCI Cancer Centers and Cancer Treatment Centers of America, which could change the composition of cancer market share in larger markets. The magnitude cannot be generalized, as it will depend upon disparities in timing and access on a local market level — but the imperative is clear for cancer leadership to be planning for a quick and safe return to patient care and communicating proactively with patients to reestablish trust.
2. The digital health train has left the station, and cancer patients are onboard.
The explosion of telehealth resulting from COVID-19 has been well reported, with organizations like Novant Health going from “200 video visits a year to more than 12,000 a week” and Forrester forecasting over one billion virtual visits in the U.S. in 2020.[6,7], Perhaps more remarkably, telehealth has found significant adoption from cancer patients — a population once considered reluctant to substitute digital interaction for the high-touch model accompanying a complex disease. Moffitt Cancer Center reported its virtual visits were up 5,000 percent and the Center plans to continue to expand the program, offering new patients and those seeking a second opinion the option to meet digitally.
In the near term, there is good reason to believe the recent telehealth adoption will stick for oncology. Like other specialties, oncologists are overcoming a reluctance to embrace digital platforms, technology investment is booming for disease-specific applications and CMS is working to create reimbursement parity. Unlike patients of many other specialties, cancer patients will be grappling with unique, higher-stakes COVID-19 exposure risk until a viable vaccine is broadly available, meaning digital visits will continue to be an attractive alternative. For providers and programs, the imperative is self-evident, as we expect patients to continue being self-advocates, minimizing risk of exposure, and voting with their virtual feet in selection of providers that can meet their telehealth demands. As Dr. Philippe Spiess, Assistant Chief of Surgical Services at Moffitt, concludes: “telemedicine is here to stay."
The long-term implications for digital transformation in cancer care are manifold. At a minimum, we expect to see a proliferation of new platforms and use applications in cancer care, with a corresponding impact on demand for traditional care environments — facilities, staffing and equipment. As patients become more accustomed to these platforms, it is also possible that traditional market barriers to entry — like physical presence — will become less relevant, with patients embracing telemedicine not just for remote second opinions, but as an alternative for upfront cancer consults and treatment planning. These types of changes could have profound implications for academic medical centers and other tertiary/quaternary providers seeking footholds outside of the traditional geographies they serve.
3. COVID-19 will permanently alter oncology economics and care delivery.
The demands of COVID-19 are placing intense financial pressure on providers, largely a function of the evaporation of high-margin, elective procedures. The same strain applies in cancer, but is amplified by the loss to services that are traditionally downstream from diagnostics and surgery. Our clients already report significant declines in new patient consults for high-margin services like chemotherapy infusion and radiation therapy. With an estimated $20-25,000 in contribution margin per new cancer patient, maintaining the pipeline of new patients is critical to the financial health of the service line and to the broader organization.
In the near term, this financial distress in cancer care will manifest in continued and accelerated realignment of cancer providers. Since 2010, more than 1,200 oncology practices have been closed or acquired, due in part to the natural financial strains of managing an oncology practice. These strains are becoming fractures with COVID-19 and we expect distressed practices to increasingly seek shelter and collaboration with local hospital partners. The cancer care delivery and financial synergies realized through these new partnerships may be one of the few enduring benefits that emerge from COVID-19. We also expect to see a near-term change in oncology physician reimbursement models. In the present crisis, many of our clients have migrated wRVU productivity contracts to emergency salary guarantees as consults have disappeared. We suspect many of these compensation changes will find permanence in the post-COVID-19 era, as oncologists seek to de-risk their practices and decouple their earnings from pure productivity-based demand. A final near-term effect of the pandemic will likely be some cancer service rationalization, as providers are forced to weigh asset management and workforce constraints introduced by the financial impact of COVID-19. The nature and extent of rationalization could have a lasting and deleterious impact on access to outpatient cancer services, particularly in rural areas.
The longer-term strategic implications of COVID-19 on cancer care remain unknown. Will cancer patients emerge from the crisis with a new set of fears and motivators? Will multidisciplinary care experience a renaissance as groups of physicians preserve the comradery and coordination that accompanied the 2020 crisis? Will the essence of a cancer “center” transform as the distinctions blur between high-touch and high-tech care delivery?
While much remains unknown, we do know that the two-front war will soon return to a single focus on beating cancer. And when it does, there will be immense value in revisiting the market strategies and investment priorities that characterized the pre-COVID landscape and ensuring the cancer program is preparing to succeed in the world that comes next.
Click the graphic below to view a summary of impact from COVID-19.