Home cancer treatment faces challenges post-pandemic

When COVID-19 hit the U.S. in early 2020, radiation oncologist Dr. Justin Bekelman was ready for the challenge.

The director of the Penn Center for Cancer Care Innovation in Philadelphia and a team of clinicians already had plans in place to start the center’s Cancer Care at Home program. Within six weeks of launching in February 2020, the program went from treating 39 patients at home to more than 300 people.

“When the pandemic peaked in the summer, it was one of the key ways patients with breast cancer, prostate cancer, lung cancer and lymphoma were accessing treatment,” Bekelman said. 

Today, Penn Medicine is delivering care to approximately 3,000 patients through the program using 30 different cancer treatments, including chemotherapies and immunotherapies. The medical system treats about 19,000 cancer patients annually. 

Penn Medicine isn’t alone in embracing in-home cancer care. During the past three years a handful of other health systems, including Jefferson Health in Philadelphia and Fairview Health in Minneapolis, Minnesota, have begun treating cancer patients at home. 

Cancer treatment is big business and providing that care at home is not a new idea. It is estimated that 5% to 10% of oncology drugs are delivered at home globally, but the practice has been slow to gain traction in the U.S.

Approximately 1.8 million Americans are diagnosed with the disease annually. Cancer cost $209 billion to treat in 2020, making it the fourth most expensive disease, according to the National Cancer Institute. Delivering chemotherapy and immunotherapy drugs through infusion at home could save the healthcare system money by freeing up space in hospitals and outpatient facilities.

Treating cancer patients at home can be more convenient and less stressful to patients, especially for those who might otherwise have to travel far to a facility. Fairview Health cares for cancer patients from up to 60 miles away from Minneapolis. The hospital cares for approximately 380 of its 2,500 patients at home.

Brett Benfield, Fairview’s home infusion director, said brain cancer patients have especially benefited from home visits because many have a difficult time traveling for treatment.

Despite the benefits, a white paper issued Wednesday by the American Cancer Society outlined a number of challenges in delivering oncology treatment more widely to the home, including safety concerns, economics and patient acceptance. 

For therapies that can be transported, stored and delivered safely at home, an infusion nurse will travel to a patient’s home to administer treatment. Although the nurse remains in the home for the duration of the regimen, the patient could have an adverse reaction after the clinician leaves. Patients receiving in-facility treatments often remain on-site for up to an hour for observation. 

In the home “you are asking the patient and caregiver to be the eyes and ears and know what to do,” said Dr. Arif Kamal, the cancer society’s chief patient officer.

While economics is driving care into the home, it can also get in the way, according to providers. Although many private health insurance companies pay for in-home treatment, reimbursements can sometimes be less.  Big healthcare providers such as Penn Medicine can compensate for the shortfall by freeing more beds for other patients. The lower reimbursements can be a financial challenge for smaller oncology practices that rely more on revenue from site-based treatment.

Providers and the American Society of Oncologists say Medicare is an even bigger problem. More than half of patients diagnosed with cancer are over age 65. Medicare Part D covers part of the cost of in-home infusion, but not all of it. That means patients preferring home-based care must shoulder some out-of-pocket expenses.

Not only is that a disincentive to receive therapy at home for many patients, it could also contribute to healthcare inequality.

“The implementation of therapies at home worries us,” said oncologist Dr. Jyoti Patel, editor of the Cancer.net website. “It means rich people can afford to get treatment at home and poor people won’t be accommodated.”

Still, Patel said the home will be part of cancer care’s future once reimbursement issues are resolved and Medicare more fully embraces value-based care. 

A new generation of providers is poised to enter the market. Nashville, Tennessee-based Reimagine Care launched early last year with $25 million in funding from six investors. The company is partnering with the University of Colorado in Denver and the Center for Cancer and Blood Disorders in Dallas to provide in-home services such as remote patient monitoring, hydration and laboratory services to cancer patients. Reimagine Care Co-founder and CEO Devin Carty said the company also wants to move select infusions into the home.