Closing the Satisfaction-Use Gap of Telehealth in Oncology

People with cancer, whether they’re undergoing treatment or are in palliative care, like using telehealth to interact with their oncologist. That’s what a number of studies in oncology have found. However, after telehealth encounters peaked in 2020 during the height of the COVID-19 pandemic, they have been steadily declining.
A high percentage of patients with cancer who use telemedicine — 74% — rated their first telemedicine visit as good as or better than an in-person visit, researchers from Memorial Sloan Kettering Cancer Center (MSKCC) in New York City reported in November in JAMA Network Open.
“What we found is that there is very high satisfaction with telemedicine that has remained consistent across the years from 2020 to 2023,” Sahil D. Doshi, MD, a medical oncology/hematology fellow at MSKCC who led the study, told Medscape Medical News.
Telehealth Adoption Needs Improvement
The latest estimates for Medicare fee-for-service subscribers show that telehealth, also referred to as telemedicine — the milieu of digital communication technologies that allow patients and providers to interact remotely — reached its lowest point in 2023 since the pandemic, with 6.7 million users vs 14.8 million in 2020. The percentage of Medicare recipients that use telehealth has progressively dropped by half in that time, from 48% to 24%. No data are available on telehealth usage rates among Medicare beneficiaries for 2024.
Centers for Medicare & Medicaid Services statistics do not specify telehealth use by specialty, so numbers in oncology are not available. However, researchers at Northwestern University reported this year that oncology was one of three specialties that showed an uptick in use in the second half of 2021, but that trailed off in 2022, and the proportion of telehealth encounters as a share of all in-person visits in oncology remained far below peak 2020 levels — around 12% vs 41%. Plus, a McKinsey & Company analysis in 2021 found that telehealth claims in oncology lagged behind 12 other specialties out of 23 specialties studied.
Chevon Rariy, MD, chief health officer of Oncology Care Partners (OCP), Nashville, Tennessee, told Medscape Medical News she would give oncology a grade of C for its adoption of telemedicine.
“With the pandemic we saw a rapid rise in telehealth service across the board, but specifically in oncology,” Rariy said. “Since then, the shift has significantly decreased, not nearly as low as pre-pandemic, but it has decreased and certainly slowed.” Today, telehealth is “heavily underutilized” in oncology, she said.
To get telehealth back on track, oncologists need to identify appropriate cases for its use and address technical and regulatory barriers to seeing patients with cancer virtually, said experts interviewed by Medscape Medical News.
Who Would Benefit Most?
One way to close the gap between high patient satisfaction and lackluster telehealth use is to identify the types of patients with cancer that would benefit most. At this point, that research is sketchy and needs more clarity before oncologists more robustly embrace the platform, Doshi said.
“It’s really trying to understand different clinical scenarios, different severity of symptoms, different acuity of visits — trying to better understand which patients are best suited for telemedicine,” Doshi said. One potential way it could help would be by easing the in-office visit burden of patients receiving chemotherapy treatments. “But I think to better understand that, we need focused studies,” Doshi said.
Demographic characteristics may provide a clue into what types of patients may benefit most from telemedicine. Alexander Boucher, MD, and researchers at the University of Minnesota, Minneapolis, reported high rates of satisfaction with telemedicine visits among hematology/oncology patients from the start of COVID-19 restrictions in March 2020 through the next 12 months. “But [there were] demographic differences, with a tendency to prefer telehealth if someone lived remotely, had lower annual income, did not have an active cancer diagnosis or were male,” Boucher said.
The take-home from his study is that a telehealth strategy must be personalized for each patient, Boucher said. “Ultimately, there was important patient feedback that there is a role for telehealth in oncology care, but a proactive and agreed-upon strategy among the patient and provider team for its use is the most effective use, and that would differ for different patients and disease groupings,” he said.
Defining what Rariy called “appropriate use cases” would further help identify the types of patients with cancer best suited for telehealth. These cases, she said, could include a preoperative consultation to set a patient up for a procedure, a postoperative visit to save the patient the burden of an in-person visit, nurse-led triage for real-time symptom monitoring “in a more robust way than just a phone call,” and care navigation.
Potential in Palliative Care
Patients in palliative care may also derive significant benefit from telehealth, according to a multicenter study this year in JAMA that compared between virtual and in-person visits for palliative care patients.
“We were very pleased to demonstrate and confirm the two modalities would be equivalent in patient-reported quality of life,” lead study author Joseph A. Greer, PhD, co-director of cancer outcomes research and education program at Massachusetts General Hospital in Boston, told Medscape Medical News. “We also noted that the improvement in quality of life from enrollment to about 24 weeks was similar between groups.”
The study looked at other measures as well, including mood symptoms, anxiety and depression symptoms, and coping skills. “Again, we found no differences between study groups,” Greer said.
The study also reported similar results for caregivers, outcomes that Greer said were “very reassuring.”
Greer said his group’s research showed that the vast majority of conversations palliative care clinicians are having with their patients focus on three areas: Developing a strong therapeutic relationship, talking about and managing symptoms, and focusing on coping skills. “You don’t necessarily have to be in person to have this conversation,” he said.
Why Oncology Is Different for Telehealth
A boilerplate telehealth model that may work in mental health or endocrinology, both specialties that have far more telehealth use than oncology, according to McKinsey and the Northwestern University study, probably would not work as well in oncology, said Doshi, who explained the nuances that a successful telehealth model in oncology must address.
“There are two big things,” he said. “One is the aspect that the oncology patients often have very frequent visits with their clinicians, especially patients on treatment who have visits every several weeks, sometimes on a monthly basis, sometimes even on a weekly basis — and that’s a very significant time and financial burden on the patient and their caregivers in terms of travel, if they have to stay in a hotel [and] their caregiver has to take off work that day.”
Just saving patients that time and cost presents “a lot of opportunity to improve that through telemedicine,” he said.
“The second is that with oncology, there are different side effects with treatments, so communication is especially important between patients and clinicians,” Doshi added. “There’s a lot more communication, so showing that telemedicine is equal in safety and care is going to be important in going forward. That’s where the role of prospective research studies is important.”
To generate that research, the National Cancer Institute launched the Telehealth Research Centers of Excellence initiative, which supported Doshi’s research.
Technical Barriers to Telehealth in Oncology
To embrace telemedicine more fully, oncologists must deal with a number of potential barriers. They range from broadband and technology access for patients to a host of unsettled regulatory and reimbursement issues.
“There’s the importance that ensuring the digital divide or access to care isn’t worsened or exacerbated by only relying on the necessity of the patient to have the access to technology,” Rariy said. Before she joined OCP, Rariy oversaw virtual health at Cancer Treatment Centers of America, now City of Hope, where she developed a system where patients could go to a community facility, such as a primary care doctor’s office or a community library, and participate in a telemedicine visit.
“It’s important to take into account the digital infrastructure that might be required and then partner with the rest of the key players in the ecosystem,” she said. The key is to get information from the telehealth encounter to the patient’s provider in a timely way, Rariy said.
The technical issues are ever present, whether it’s a matter of patients learning to use their desktop or smartphone device in a secure way or just having broadband access in their community, Doshi said.
Reimbursement and Regulatory Issues
The reimbursement landscape is also uncertain, Rariy said. Regulations on virtual visits that were lifted during the pandemic now face an uncertain future.
“During pandemic we saw once we had a blanket approach to reimbursement and licensing, you took those complexities away, then we were able to provide access to care in a more robust way,” Rariy said. “But once those restrictions were no longer lifted, there has been that underlying uncertainty around reimbursement and there’s that underlying complexity of the licensure across states.”
States play a significant role in regulating telehealth. As of October 2023, 29 states had laws that require insurers to implement telehealth payment parity, and more than 20 states were considering regulations to ease licensure requirements for telehealth, according to the American Medical Association. But many states restrict the use of out-of-state providers via telehealth, Rariy noted.
Medicare telehealth regulations put in place during the COVID-19 pandemic have been extended through 2024, but Congress hasn’t yet acted to extend them. Three other pieces of federal legislation to expand the use of telehealth — the Telehealth Expansion Act to allow individuals with high-deductible health plans and health savings accounts to access telehealth services before meeting their deductible, the Medicare Telehealth Privacy Act to allow providers to keep their home addresses confidential, and Telehealth Benefit Expansion for Workers Act to expand telehealth access for workers — all face sunset if the current Congress does not act before it adjourns December 20.
One regulation that was relaxed during the pandemic allowed providers to prescribe opiates for pain via telehealth, temporarily lifting the requirement for an in-person visit to do so, Greer noted. Shortly after the 2024 election, the Drug Enforcement Administration extended those remote prescribing flexibilities for controlled substances for 1 year through 2025.
A Hybrid Approach?
A successful telehealth program in oncology cannot forgo in-person encounters, “not only for the opportunity to do accurate examinations, but the ability to share diagnostic and/or difficult information, pick up on nonverbal cues, and the ease of doing visits with family members and multiple team members,” Boucher said. “However, a pendulum swing toward totally in-person feels too paternalistic and controlling to be considered optimal.”
A hybrid approach could include alternating in-person and virtual visits, he said. “For example, I have a couple patients who I have asked to do visits more frequently than previously needed (ie, every 2 weeks instead of every 4 weeks and previously all in-person) but there is a cost to that (travel, parking, time, school missed), so we have decided that we would alternate in-person and video to balance the ledger while still staying in touch.”
To design successful telehealth strategies in oncology, healthcare systems should proactively survey patients and families and providers, Boucher said.
“Medicine is always dynamic, but delivery of care tends not to keep up,” he said. “At best, it is more slowly reactive and most often tends toward status quo comforts, even if they are inequitable, just because it is easier.”
Doshi and Boucher reported no relevant financial relationships. Rariy is an employee of OCP. Greer reported financial relationships with Blue Note Therapeutics, BeiGene, GlaxoSmithKline, and Oxford University Press.
Richard Mark Kirkner is a medical journalist based in the Philadelphia area.
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