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Join Banu Symington, a hematology-oncology physician, as she shares her expertise and insights on the topic of out-of-office infusions, discussing patient safety, experience, and the potential impact on cancer care.

Banu Symington is a hematology-oncology physician.

She discusses the KevinMD article, “A physician’s letter: Safeguarding patient well-being by opposing off-site infusions.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Banu Symington. She is a hematology-oncology physician, and today’s KevinMD article is titled “A physician’s letter: Safeguarding patient well-being by opposing off-site infusions.” Banu, welcome back to the show.

Banu Symington: Thank you so much, Kevin.

Kevin Pho: Now, for those who didn’t listen to your first episode, just briefly share your story and journey.

Banu Symington: I’m a Philadelphia girl, University of Pennsylvania educated. I never thought I’d end up in a rural setting, but I have. I’ve been practicing for more than 20 years in highly rural settings and have become a rural patient advocate.

Kevin Pho: All right, and for the rural hematology-oncology patients you see, tell us some of the challenges they face seeking oncology care.

Banu Symington: Many rural patients, I’d say more than in cities, often have to travel hours just for a routine visit, a routine appointment, and the necessity to travel makes many of them choose nonstandard therapies. They may choose a mastectomy instead of a lumpectomy with radiation, or they may choose to forego various adjuvant therapies. And telemedicine is challenging for them. Not only are they not necessarily medically sophisticated, they may not own an iPhone, an Android or a PC. We regularly have problems with the internet. Our hospital phone lines went down a week ago; can you imagine the chaos that would cause? So even televisits are challenging for these rural patients.

Kevin Pho: All right, and one of the issues you talked about was off-site infusions. Your KevinMD article is titled “A physician’s letter: Safeguarding patient well-being by opposing off-site infusions.” Give us some background and context before we talk about the article.

Banu Symington: I’m very active in my organization, the American Society of Clinical Oncology. I was at a state affiliate meeting in May, and they mentioned that three things were coming down the pike: white bagging, brown bagging and the potential for off-site infusions. They discussed these as remote possibilities. Within a week of coming back to the clinic, two different insurance companies sent me letters indicating they would not pay for chemotherapy delivered in the cancer center. They wanted me to write orders for patients to get their chemotherapy at an off-site, independent infusion center. I started trying to appeal this process, and that’s how the essay was generated: It was my letter of appeal to the insurance companies.

It turns out the insurance companies are rolling this out in rural settings first, because there are fewer rural practitioners and patients, so there’s less of a force to argue with them. I suspect that once they’ve done this for a while, they’ll say, “Hey, it’s been working great in the rural setting, so we’re going to roll it out in urban settings.”

Kevin Pho: Now, tell me what the current standard of care is when it comes to chemotherapy infusions. What’s it like now, before this new intervention?

Banu Symington: The chemotherapy is usually given in a center that is staffed by oncology-certified nurses, who are trained to deal with infusion reactions, and by physicians like myself, who are trained to treat infusion reactions. In many facilities like this one, the cancer center is within the hospital, so if there is an infusion reaction or a code that I can’t handle, the code team is in the hospital. We just call a code blue, and they come running. The ER is down the hall, and the ER physicians come down and take care of it. In this cancer center, between patients, I run back to the infusion center, talk to patients and address the questions the chemo infusion nurses might have.

None of these are options when a patient goes to an independent infusion center, and often the independent infusion center is staffed only by nurses. There is no provider, and I hate to use the term “provider.” There’s no physician and no nurse practitioner who’s oncology-trained to help mitigate reactions that may occur at the off-site infusion.

Kevin Pho: And who would normally administer an off-site infusion center? Would it be an offshoot of a hospital, or independently owned and operated? Who runs these off-site centers?

Banu Symington: In big cities, they’re often owned and run by big corporations like CVS or Walgreens. In our community, it’s owned and operated independently. It’s a private, for-profit center, but it’s not a hospital-affiliated infusion center.

Kevin Pho: OK, so tell us about some of the risks, and you touched on this earlier, if a proposal like this were to go through.

Banu Symington: An infusion reaction, with any infusion. There is nothing written in stone that says patients only have an infusion reaction with the first or second infusion. There’s also a risk to the provider, because they are still expecting me, and providers like me, to write the orders for the care to be delivered off-site.

I would say the bigger issue isn’t so much risk as patient experience. A patient with cancer is anxious. A patient with cancer often doesn’t feel well. The expectation of the insurance company is that the patient will come here and see me, and I’ll use myself as the example. I will evaluate them, write their orders and send them with the orders to this off-site center. That is a very interrupted, inconvenient plan for someone who’s not feeling well. So, putting safety concerns aside, is that the way you’d want your mother to have her chemotherapy? The patients develop a relationship here with the nurses. They can certainly develop a relationship with off-site infusion nurses, but the accessibility of the physician, the ER and the code blue team is certainly psychologically reassuring for patients.

What bothers me about this, as well as about the brown bagging and white bagging, if you want to touch on those, is that they don’t even try to pretend that patient safety, patient experience, patient convenience or quality are factors. It is simply for their bottom line, their savings or profit, that they are making these changes. So medicine is drastically changing, and not to the benefit of the patient. I’ll just leave it at that.

Kevin Pho: Is there an argument to be made that sometimes these infusion centers may be closer, distance-wise, to patients, especially in rural settings, where, as you mentioned earlier, they sometimes have to travel hours to get to a cancer center?

Banu Symington: The only infusion center in this catchment area is just a mile away from here, so I doubt it. I doubt it. Maybe in urban areas there could be an infusion center that is closer than the cancer center, but not in a rural setting like this.

Kevin Pho: So where are we in terms of executing this proposal? Has it been implemented?

Banu Symington: Well, I sent in my letter of appeal, the one that was published on KevinMD, and it was denied. The insurance company said that, regardless of the arguments I made about patient safety and convenience, they were going to move ahead, only agreeing to pay if the treatment was given outside the facility. The patient who precipitated that first letter has withdrawn from care. She has elected not to go elsewhere to get her care, and not to pay out of pocket to get it here.

The insurance company also rebuffed efforts by the hospital finance manager to negotiate a better price. The finance manager said, “Our physician is very uncomfortable writing orders for an off-site infusion. Can we match the price of the infusion center, to guarantee that the infusions can be done where the physician can keep an eye on things?” They rebuffed that argument.

Kevin Pho: Now, is this happening only in your local catchment area, or is it happening in other rural areas across the country? Just give us a national scope.

Banu Symington: Since the state affiliate meeting, I’ve been in touch with members of that group, and there is one other rural physician who is encountering this. None of my urban colleagues have actually had to deal with it yet.

Kevin Pho: And tell us the sentiment of your oncology colleagues when it comes to this issue.

Banu Symington: Well, my colleagues in the American Society of Clinical Oncology think this is an inferior experience for patients. It is risky for the patient, it is inconvenient, and it’s a liability risk for physicians who agree to do this. The American Society of Clinical Oncology has issued some guidelines suggesting that no physician should be forced to deliver care in what they believe is a substandard way, but of course, these are society guidelines, and the insurance company doesn’t have to adhere to them.

Kevin Pho: Now, what if you simply refused to write an order for an off-site infusion? It seems like they could only do it with a physician’s order, and there are very few rural oncologists. What if you simply said no?

Banu Symington: That’s what I told my finance manager I plan to do. The insurance company may tell the patient that I am refusing to take care of them. That wouldn’t be accurate, but the nuances are hard for a layperson to understand. By coercing with financial matters, by saying, “We will pay if you go here, but not if you go there,” they make the patient kind of an ally in this argument, and the patient is kind of an unwitting ally. They just know they can’t afford a $10,000 treatment every three weeks. I may be able to talk to some of them and explain my concerns, but others may just go with their pocketbook. So the concern is that the insurance companies will portray the actions of an individual physician as abandonment of the patient. I have no financial motivation. I’m not reimbursed according to volume; I’m not reimbursed by the number of patients I treat. So they can’t argue that I’m making a financial argument.

On the other side, there’s a practical matter I need to mention, and I think I mentioned it in the letter: We lose money on Medicare patients and Medicaid patients. There’s a small profit made on privately insured patients, but that just makes it possible for a cancer center to operate without losing money. If you take away all the patients who provide a small profit, the cancer center is going to be operating at a net loss, and there are not many rural hospitals, which are already financially struggling, that will be able to maintain a cancer center operating at a loss. So they’re going to force the shutdown of cancer centers in these rural areas, which will just mean these patients have to drive farther for care, and more of them will forego care.

Kevin Pho: Now, you mentioned the other things coming down the pike, brown bagging and white bagging. Briefly touch on those.

Banu Symington: These are all part of the same plan to help save insurance companies money or maximize their profits. White bagging is where they send the chemotherapy drugs to our pharmacy for us to infuse, so the pharmacy will not be able to charge that small profit on the drugs. That’s one thing. A worse thing is brown bagging, where they deliver the medication to the patient, and the patient brings it in. The concern there is that many of these medications have to be handled a certain way and kept at a certain temperature, and if a drug is not in your hands all the time, you can’t guarantee that it’s been treated the way it should be treated. You may end up delivering an ineffective therapy.

While we were trying to negotiate, and remember, the insurance company rebuffed our efforts, we said, “The physician wants to supervise this and make sure it’s delivered in a safe environment. At the very least, we would do white bagging. Send us the drugs. We’re willing to forego any profit on the drugs. Let us give the drug in a safe manner.” And they just didn’t want to negotiate.

Kevin Pho: Now, tell us what your professional organization is doing to fight these proposals. What’s ASCO doing?

Banu Symington: We are meeting with Congress annually and bringing up these topics as things Congress should be against. But the insurance lobby is so powerful, so rich. I won’t name names, but even senators I respect highly are getting huge donations from Big Pharma, and it’s hard to turn them away, and from insurance companies. I think of them as kind of hand in hand, because they are the representatives of for-profit medicine. My overarching theme, as I age and as I deal with these issues, is that for-profit medicine has to go. It is culpable for many of the things that are eroding health care right now.

Kevin Pho: Now, are these initiatives spearheaded by private insurers? What’s Medicare doing?

Banu Symington: Medicare is not doing this. Can you believe it? When Medicare looks like the best and safest alternative, it’s something to be concerned about. Medicare wants their patients to be seen here and treated here, and Medicaid as well. It’s private, for-profit insurance companies that want this. What’s concerning to me is that Medicare Advantage is getting a bigger foothold in many communities, and Medicare Advantage is really an HMO product, where it’s a private insurer that’s administering the health care. They are initiating many of the same things for Medicare patients that they are initiating for non-Medicare patients.

Kevin Pho: So we could have a scenario where a patient who has Medicare Advantage cannot have their infusion in a hospital cancer center, whereas a traditional Medicare patient can. Is that a plausible scenario going forward?

Banu Symington: It is a plausible scenario. And the irony is that when you sign the contract to be a Medicare provider, you agree to give Medicare patients care of the same quality as everyone else. But now we are going to be inadvertently giving Medicare patients better quality care. And maybe Medicare will decide to lower their standards, and everyone will be treated off-site. I don’t know. But it is certainly not an experience I would want any of my relatives to have.

Kevin Pho: We’re talking to Banu Symington. She’s a hematology-oncology physician. Her KevinMD article is titled “A physician’s letter: Safeguarding patient well-being by opposing off-site infusions.” Banu, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Banu Symington: Take-home messages: I think we need universal health care. I think all of these initiatives are based on the desire for profit, and I think universal health care removes the profit motive from medicine and will eliminate these issues, just as it will eliminate the prior auth struggles we’re all having. Had I known 30 years ago, when I went into medicine, that medicine was going to be so degraded, I would not have chosen to be a physician.

I’ve sort of switched from advocating only for rural patients to advocating for all patients, especially older patients and patients who don’t have a spouse or partner who can advocate for them, who can sit at their bedside. Medical care is deteriorating; many of the essays on your site point to various aspects of this. So we need to somehow unite, not to roll the clock back, but to go back to a situation where the physician can choose the treatment based on what they believe is right for the patient, not waste hours on prior authorizations, and not struggle with insurance companies about brown bagging and off-site infusions. In a universal health care system, there won’t be a profit motive, and no one will be suspicious that the physician is doing something to enrich themselves. We need to go back to an earlier era of medicine, where the patient didn’t have any reason to doubt that the physician was advocating for them.

Kevin Pho: Banu, thank you so much for sharing your insight, perspective, and time, and thanks again for coming on the show.

Banu Symington: Thank you, Kevin.