By Dr. Fredrick Ashbury, PhD and Devan Birch, BA
In March 2020, the World Health Organization declared Covid-19, the disease associated with the beta-coronavirus SARS-COV2, a pandemic. As of the end of March 2021 Covid-19 has already been diagnosed in more 143,000,000 people worldwide and more than 3.1 million people have died. In theUnited States, these numbers are more than 32,000,000 and more than 578,000 deaths, respectively, according to Johns Hopkins University. Cancer care has had to change dramatically in response to the pandemic.
These changes in cancer practices (as well as other health settings) include reallocation of human resources and physical space to support patients with covid-19. To protect staff and cancer patients from contracting the disease, there has been an amplified use of telehealth, as well as other remote patient monitoring technologies, and changes have also been made to patient schedules (e.g., delaying visits or extending the interval between visits).1 There is no question that these and other changes have had profound psychological, social, and financial impacts on clinicians, hospital staff, patients, and their loved ones.
1 Ueda M, Martins R, Hendrie PC, McDonnell T, Crews JR, Wong TL, McCreery B, Jagels B, Crane A, Byrd DR, Pergam SA, Davidson NE, Liu C, and Stewart FM. Managing cancer care during the Covid-19 pandemic: agility and collaboration toward a common goal. J of the National Comp Cancer Center Network 2020;18(4):doi:https://doi.org/10.6004/nccn.2020.7560/
We examined the extent to which two community oncology practices experienced changes in inpatient volumes during the pandemic. We compared the number of new patients diagnosed in each practice month-over-month in 2020 to 2019 (referred to herein as “new patients”). Data for practice 1, a medical oncology practice, are presented in figure 1 below, and for practice 2, a multi-disciplinary oncology practice, the new patient numbers are shown in figure 2 that follows.
In 2020, Practice 1 had 2019 new patients. As the chart shows, the number of new patients dropped dramatically (by ~33%) to 1413 new patients in 2020. Practice 2 saw an even more profound impact on the number of new patients enrolled. In 2019, Practice 2 reported 3758 new patients compared to 1917 new patients in 2019 (a 49% reduction).
Financial toxicity refers to financial difficulties cancer patients face throughout their course of care. These challenges include loss of employment income or decreases in compensation (as well as any out-of-pocket costs of cancer care worsened by expensive novel targeted therapies and immunotherapy drugs not covered or partially covered by their insurance providers) – a form of “double hit”. Financial toxicity can also describe the deleterious financial impacts cancer practices and cancer practitioners incur as the result of policy changes, installing state-of-the-art infrastructure, and adjustments and redeployments of any human and physical resources when reacting to emergencies or other priorities (such as those brought about by the pandemic). How the pandemic has adversely affected the financial situations of community oncology practices has received recent consideration. The restructuring of resources has meant declines in the number of new (as shown in our data above) and continuing patient consults. eHealth technologies, such as telemedicine, have been of some marginal benefit to ease revenue loss chiefly in smaller community practices.2 Deployment of these and other eHealth solutions to smooth patient-provider engagement contribute to escalating practice financial toxicity. In addition, delays in patient treatment and/or follow-up care schedule changes have aggravated revenue losses. The government has compensated some patient engagement strategies (education and remote monitoring), but whether or not these mechanisms will be long-term is currently unknown. As such, how long practices can survive post the pandemic becomes a major uncertainty.
2 Rubin R. Covid-19’s crushing effects on medical practices, some of which might not survive. JAMA 2020;324(4):321-23.
Covid-19 has seriously disrupted cancer care for patients and practices. The durability of practice adaptations and opportunities to identify mechanisms to support oncology care delivery, particularly in the community, post the pandemic, is essential. Lessons from these practices need to be aggregated, reviewed and, those found to be meritorious, adopted in other practices as quickly as possible. The ultimate beneficiary of a stable oncology practice base in the patient.