At ASCO, Dr. Nina Balanchivadze of Sarah Cannon Research Institute at Virginia Oncology Associates and Dr. Kyle Lavin of the UNC School of Medicine shared insights on integrating behavioral health into oncology care. In this interview with BioPharma Boardroom, they discuss how collaborative care models are improving access for Medicaid-insured and underserved patients, enhancing treatment adherence, reducing barriers to care, and advancing health equity across the cancer care continuum.

Your ASCO presentation focuses on behavioral health engagement among Medicaid-insured and BIPOC patients. What disparities did your team identify, and what interventions showed the greatest impact?

A: Dr. Lavin: The exciting part about what we've done is that we've been able to show that for patients that enroll in a program like this, there's a higher proportion of Black, Indigenous, and People of Color (BIPOC) and typically underserved patients. 44% of the patients were BIPOC and around 19% had Medicaid as their insurance, and by being able to enroll in this program we evaluated their baseline depression/anxiety scores, which were significantly higher in the Medicaid population. Unsurprisingly, those who have fewer resources present with higher levels of depression/anxiety and a lower quality of life at baseline. This group also showed directionally greater improvement in depression/anxiety scores through the behavioral health interventions we were able to deliver. 

• The most impactful interventions are a combination of validated psychotherapy interventions, typically motivational interviewing and problem-solving therapy, and conducting those interventions in culturally sensitive and culturally appropriate ways. That combined with care coordination and navigation ensures that those experiencing distress driven by lack of access to resources are able to successfully gain access through care coordination.

Dr. Balanchivadze: The most impactful intervention was the design itself, and the access provided by integrating collaborative behavioral health directly into the oncology workflow and removing that copay barrier for the Medicaid patients, due to collaborative care billing codes. There was no novel therapeutic intervention but providing access to behavioral health resources for patients that are directly integrated in oncology care, was one of the biggest winners with regard to interventions.

Dr. Lavin: We know that patients are much more likely to access these services when they’re directly integrated into the oncology treatment plan and the way that we designed the model was to be able to reach out to these patients within 24 hours and be able to see them within a week. That access in terms of timeliness, and then, as Dr. Balanchivadze said, removing the copay for Medicaid and making the resources affordable, allowed patients to get the much-needed care that they deserve.

How important is integrating behavioral health into oncology care when addressing outcomes and treatment adherence in underserved populations?

A: Dr. Balanchivadze: Anxiety and depression is underreported and under-screened for, and we know that there is evidence that anxiety and depression affect adherence. I’ve said frequently that if a patient is too depressed or anxious to receive care, they may not show to appointments or come to receive care or treatment. Our study showed that 60% of the patients reported improved oncology visit adherence and over half of the patients reported improved medication adherence. This is very important for underserved populations because there are so many social stressors, other than anxiety and depression, that may affect adherence to medication and doctor visits, so I feel that these findings are foundational and groundbreaking.

Dr. Lavin: Foundational was the word that I was going to use as well. This should be foundational to cancer care and it’s what I’ve built my career around as a palliative care psychiatrist: bringing integrated behavioral health, specifically collaborative care, to the oncology population and other specialists. Think about the prevalence of depression, anxiety, substance use disorder, and how that can skyrocket when diagnosed with a serious illness like cancer. That can be made worse when a patient’s ability to access care is handled in a standard fashion: through a referral that isn’t followed up on, patients having to pay out of pocket, insurance does not cover it, they have a large copay, and/or experience super long wait times – there’s a lot of evidence that this collaborative care model with integrated behavioral health is the way that we should be doing this, and I’m incredibly excited about the results we’ve shown and it’s particularly relevant to this underserved population.

Virtual care models expanded rapidly during the pandemic. Which elements of virtual behavioral health support appear most sustainable and effective for oncology patients today?

A: Dr. Lavin: COVID did accelerate the use of these virtual care models though we’ve come back a bit and recognize how necessary some face-to-face human interaction is. I do think that the evidence and literature show that many patients, because they don't have the money to make it back to another appointment or the transportation ability to make it to see a separate provider in person, prefer virtual care. Patients can be more willing to be open and vulnerable in a virtual care model and talk about the things that are bothering them. One of the great things about collaborative care is when we think about traditional behavioral health under insurance, a lot is required to be done in person, however, these collaborative care codes are specific CPT codes that are approved to be done virtually which is more sustainable. The virtual aspect, done by phone or by video, makes it much easier to expand both to underserved and rural populations who have transportation as a limitation.

Dr. Balanchivadze: For oncology care specifically, virtual care can be difficult because oftentimes you want to examine the patient, get labs done, or they have to come in for chemotherapy treatments, etc. but where virtual care is important is in behavioral care, patient-reported outcomes, toxicity or adherence check-ins – those outcomes can be tracked without seeing the patient to understand how they are feeling and their opinions about the care they're receiving. Other components could be survivorship which is very integrated with behavioral health. For example, a patient’s cancer could be in remission or “cured,” but they could be waiting and worrying about their cancer coming back. I see survivorship as a niche area for virtual care and then by integrating behavioral health and patient-reported outcomes in a virtual manner, removes barriers of access, such as taking time off, attending multiple visits, various copays, which can be very important at multiple levels.

Q: What lessons from your study could community oncology practices adopt to improve equity in cancer care delivery?

A: Dr. Balanchivadze: From an oncology standpoint, it's important to screen patients for anxiety and depression and identify subtle signs and symptoms that a patient may exhibit. By integrating behavioral health directly into the oncology clinic with a patient who trusts you, they then don't have to navigate a new health care system that may require a different outreach and resources from the patient to try and seek an appointment, like a referral. As technology and medicine advance, we have so many treatment options that sometimes things get more complicated. We can simplify things as much as possible by putting everything under the same roof where access is easy and requires less time, logistics and money from the patient, can be the “recipe for success.”

Dr. Lavin: Access and engagement are really important in terms of the work that has been done with VOA. By using collaborative care and integrated behavioral health with patients that are being identified by their oncologist and are being referred directly to an extension of their team, they're much more likely to engage. We have a team of proactive engagement specialists who are able to call multiple times, make sure that patients don't fall through the cracks. Of the patients that are referred to us, 60% of patients enroll in care, and that's outstanding when you look at national averages. 

• If your oncologist says, "Oh, go find a psychiatrist" and makes a referral to the community, it's often single digit percentage of patients who are likely to enroll in that care. Bringing it all under one roof using collaborative care specifically, integrated behavioral health makes sense. By creating a model that allows you to bill those specific collaborative care codes, if collaborative care is covered by Medicaid in your state, you’re able to truly expand access to this care in a way that does not cause any further financial toxicity or distress which we know is an issue for this population.

Beyond access to treatment, where do you believe the oncology industry still falls short in advancing health equity?

A: Dr. Balanchivadze: One of the biggest issues could be engaging patients to understand any subtle cues they may share. When I first see a patient, my goal is to cure their cancer and I focus on what to do next, the following line of treatment, etc., and it can be hard to remember the patient’s life outside of cancer as there are so many things to prioritize. 

• I predominantly treat breast cancer in which there can be many disparities – I treat single moms, young moms, women who are in school, women who have to work and may miss appointments due to schedules. It’s important to pick up on these subtle clues as there is no “one size fits all model.” Cancer doesn’t define an individual, and physicians must holistically identify patient cues and with the least amount of difficulty for the patient, help them as much as possible – not just for their cancer, but as a whole.

Dr. Lavin: Another area in oncology where care typically falls short from a health equity standpoint is in access to clinical trials, and that oftentimes there's a lot of psychosocial distress that drives that. In discussing a model where we're thinking about patients more holistically, outside of the acute crisis or the cancer care specifically, there could be opportunity as we know that BIPOC patients typically are underrepresented in clinical trials. We showed that there was a large percentage of that population that engaged with us, and as part of care coordination even by connecting with the oncologist, because we're directly integrated with them, we can identify whether there are appropriate patients that are eligible to engage in clinical trials and can help decrease health equity disparities.

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