lwn 2-4-21

FEBRUARY 4, 2021
WEEKLYNEWS.NET - 978-532-5880 13
Cancer treatment crosses a frontier
Harold Brubaker
The Philadelphia
Inquirer
PHILADELPHIA – As she
fights cancer, Lisa Oney is not
shackled to a hospital bed for days
at a time, stuck there while she is
infused with chemotherapy drugs.
She’s undergoing chemo at
home — even on the move. At
times, the life-saving medicine is
flowing into her as she drives to
make curbside pickups at Target.
Thanks to a new program at
Penn Medicine, Oney, 33, carries
her chemotherapy medicine in a
backpack with a small pump that
feeds the drug into her body. “I’m
able to walk around, and take care
of my kids,” she said. “I can go
places.”
Typically, her particular regimen
of chemotherapy would require
several five-day stays in the hospital
spread over 18 weeks. The
trouble was, Oney needed to be
home in Souderton to care for her
3-month-old son and 3-year-old
daughter.
“I couldn’t do that,” she said,
referring to the hospital visits.
“My husband wouldn’t be able to
work.”
Because of COVID-19, Oney
and her husband, Kevin O’Driscoll,
also can’t accept help from friends
and coworkers. The risk of her
catching the coronavirus or something
else is too great.
Chemotherapy at home is a
rising trend, driven by patient convenience
and the widespread fear
of hospitals during the pandemic.
But as much as patients love it,
antiquated health-care billing systems,
especially in Medicare, remain
a formidable obstacle to the
practice.
Penn’s shift of some chemotherapy
treatments to home started
on a small scale before the pandemic,
but then took off, according
to Justin Bekelman, the radiation
oncologist who directs the Penn
Center for Cancer Care Innovation
Under the at-home process, Penn
nurses drive to patients’ residences
to set up the complex lines and
do the injections involved in the
cancer treatment, which in Oney’s
case continues for days. After that,
the backpack-wearing patients are
free to go about their lives.
Bekelman said that Penn had
good reasons to launch the effort.
“It’s obviously patient-centric and
will enhance patients’ experience
of cancer treatment,” he said, “but
also our infusion suites were all full
up.”
Most experts see the move as
positive for employers and taxpayers,
who pay much of the cost
of health care. Insurers pay less for
patients who choose an at-home
option as opposed to infusion at
their main facility or even a specialist’s
office.
Aetna, a major health insurer
in the Philadelphia region, said
last year that a single infusion of
a specialty drug in a hospital, even
on an outpatient basis, costs more
PHOTO | PHILADELPHIA INQUIRER
Lisa Oney juggles her chemotherapy treatment bag on her right shoulder and three-month-old
Jack O’Driscoll in her left arm while daughter Fiona O’Driscoll, 3, has a snack in the kitchen.
than $20,000. The savings from
moving it to an independent outpatient
center can exceed 50%, it
said. Home treatments save about
the same, experts said.
But chemo in the home means
much less money for hospitals,
Bekelman noted, making it harder
to expand the treatments.
“We need a payment model that
keeps health-care providers whole
irrespective of where we deliver
the treatment,” he said. “That’s a
crucial incentive for health systems
to invest in providing more care at
home and other less expensive locations
— a shift that should ultimately
save insurers money.”
A more logical payment system
would promote changes such as inhome
chemotherapy. And there has
been some movement in that direction,
said Larry Levitt, a health
policy scholar at the Kaiser Family
Foundation. One approach would
be to uncouple insurance payments
from specific procedures, he said.
“The concept is to pay providers
a flat amount for certain patients or
conditions,” Levitt said, “and let
the providers figure out the best
way to deliver care, keeping any
savings they realize.”
He added: “The key is to build
in safeguards to prevent providers
from skimping on care.”
Not a new concept
Since at least the mid-1990s,
home health care companies have
talked about providing in-home
chemotherapy, but little has come
of it.
John Sprandio, an oncologist
with offices in Delaware and
Chester Counties, welcomes athome
chemotherapy, but cautions
that it is actually more costly to
provide than many realize.
“In terms of efficiency,”
Sprandio said, “it’s obviously more
cost-effective to administer these
drugs for the majority of patients in
a group setting where you have a
team of a dozen nurses and 28 or
30 treatment areas that’s equipped
to handle anything.”
Meanwhile, major trade associations
such as the American Society
of Clinical Oncology and the
Community Oncology Alliance
have formally opposed the practice.
In statements last year, they
cited a fear that patients might have
a bad drug reaction with no doctors
nearby.
Richard Snyder, chief medical
officer for the parent company of
Independent Blue Cross, said he
was convinced that the trend was
safe.
“Physicians and hospitals tend
to be creatures of habit,” Snyder
said. “We keep doing what seems
to work for us, and so we’re not inclined
to change our habit of giving
the medication in a hospital or a
higher-cost setting.”
Snyder described Penn as being
at the forefront of moving chemotherapy
to the home, where the patient
is probably as safe as possible
from exposure to COVID-19 and
other infections.
Penn’s Cancer Care at Home
program ramped up from 39 patients
in March to more than 300
within a month as patients were
eager to avoid hospitals. In all of
last year, nearly 1,500 Penn patients
received in-home chemo.
Currently, patients with breast
cancer, prostate cancer and lymphoma
are candidates for the program,
Bekelman said. Penn hopes
to add patients with lung cancer,
head and neck cancers, and others,
but that depends on higher reimbursements
and other changes to
insurance plans.
Bekelman said the goal wasn’t
to transfer all cancer care, but to
establish that it can be done safely
off premises.
He noted that there were some
limits because the risk of side effects
was too severe with some
chemo drugs.
Other Philadelphia-area providers
of cancer care are not as
active. Jefferson Health’s Sidney
Kimmel Cancer Center has helped
only 50 or so in-home patients in
recent years. Fox Chase Cancer
Center said it has no plans to join
the trend. Nor does MD Anderson
Cancer Center at Cooper hospital
in Camden.
Nationally, CVS Health has
joined Penn in trying to move
more chemotherapy treatments to
homes. This month, CVS, which
owns Aetna, announced that its
infusion unit, Coram, would work
with Cancer Treatment Centers
of America to do that, starting in
Atlanta.
The insurance problem
Limiting wider adoption of inhome
chemotherapy is a legacy
payment system that provides
much larger reimbursement
when the treatments are done at a
hospital.
Comparisons for such costs at
different sites are hard to find. But
a 2019 report showed that the average
claim for an injection of infliximab,
used to treat autoimmune
diseases, was about $3,100 in a
physician’s office, compared with
$5,800 in a hospital’s outpatient
department. Bekelman said that
the same pattern holds for chemotherapy
drugs and that reimbursement
at home is similar to in a physician’s
office.
Jefferson’s Sidney Kimmel
Cancer Center has received widely
varying reimbursement rates for
home infusion. Some plans reimburse
“on par with on-site infusion,
Offer available to new subscribers only
while others reimburse at very
low levels or not at all,” Karen E.
Knudsen, a top oncology expert at
Jefferson, said in an email.
Timothy Kubal, an oncologist
who directs the infusion center
at the Moffit Cancer Center in
Tampa, Fla., predicted that much
more cancer care could be provided
in the home within a decade,
“but in between now and then,
there’s going to be a lot of conversation
about what’s the right rate.”
The patient’s perspective
The bulk of the cancer patients
Penn has been treating at home —
instead of at an infusion center —
are receiving injections for breast
and prostate cancer. Penn Home
Infusion nurses work around the
patients’ schedules to they don’t
have to lose time at jobs, Bekelman
said.
Avoiding a hospital stay, as
Oney, the patient from Souderton,
is doing, is an even bigger deal
during the pandemic.
“We have generally seen
that being in the hospital can be
tough, no family, food is different.
Depression can set in, so overall
I think this is a good trend if patients
can manage at home,” said
Kelly Harris, CEO of the nonprofit
Cancer Support Community
Greater Philadelphia.
Oney was diagnosed with lymphoma
in November, just two
weeks after her son was born.
Before she began receiving steady
treatment at home, she was given
her first round of chemo in the hospital
to ensure that she didn’t have
an adverse reaction.
There was none. But on one later
evening, Oney, a neonatal nurse
at Grand View Hospital in upper
Bucks County, got a headache as
soon as the infusion started — possibly
because she had forgotten to
take the medication out of the refrigerator
ahead of time.
Oney got a quick response from
Penn’s on-call oncologist, who told
her to take ibuprofen. “It’s all very
connected,” she said.
Although being home doesn’t
head off the miserable side effects
of chemotherapy, she considers it
a blessing to avoid those overnight
hospital says.
Local news on your doorstep
Home delivery starts at only $4.50 per week.
50% off your first month of home delivery
when you use coupon code dailyitem
at checkout at www.itemlive.com