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‘Snowbirds’ with cancer can still take flight, but planning ahead is crucial.
FOR THE PAST 10 YEARS, in October, Gary Halgren, 69, has been packing up his car for the 25-hour trip to his winter home in Orlando, Florida. He and his wife look forward to escaping the cold Duluth, Minnesota, winters for the balmy Florida weather.
Since the fall of 2012, a new dimension has been added to his preparations. After a diagnosis of bladder cancer and surgery to remove his bladder, he must now make certain arrangements in advance. For example, he needs to touch base with the mail-order pharmacy and medical supply company to make sure he receives his medications and supplies during the five months he is away. He also must line up a physician near his Florida home.
“Fortunately, I don’t need much care while we’re away,” says Halgren. “I’ve been able to receive my supplies through the mail. Because I was treated at the Mayo Clinic in Rochester, Minnesota, it made sense to go the Mayo Clinic’s Jacksonville site during our time in Florida. My doctors from St. Luke’s in Duluth provided me with a thumb drive with my medical records, so the doctors here have all the information I need. Soon I will be having a routine procedure up in Jacksonville. It’s all worked out really well.”
Although it sounds seamless, Halgren’s transfer of care from Minnesota to Florida required attention and planning. For all cancer patients with similar travel plans, thinking ahead — with a focus on medical care in the winter location, gathering and transfer of medical records, accommodations for medications and supplies, and insurance coverage — is key to a successful sojourn away.
TRANSFERRING MEDICAL RECORDS
Many patients with cancer and survivors, especially those who live in cold climates, become "snowbirds" in the winter, traveling to warmer regions. In those areas, providers have observed a seasonal rise in the number of patients they treat. “We see an increase in volume of between 20 percent and 25 percent between October and March,” says Thomas Samuel, M.D., interim director of the Maroone Cancer Center at the Cleveland Clinic Florida, Weston, and a breast oncologist. “We see patients in active therapy, chronic therapy, hormone therapy and those who need periodic check-ins. We’re happy to work with these patients, but we also make it clear that we can’t guarantee that the care will be seamless. We ask that they bring their pathology slides, doctor records and images so that we can confirm the diagnosis. Sometimes we may even question the treatment plan in place, which may require the patient to talk to her doctor at home and reconsider her options.”
For patients coming from the Cleveland Clinic in Ohio, this task is considerably easier. Both sites use the same electronic medical record (EMR) system, facilitating a smooth transfer of information. In fact, even institutions that are not part of the same health care system may find electronic communication possible if they all use the same EMR. The most frequently used system is Epic.
Russell Hales, M.D., a radiation oncologist who is director of the Thoracic Oncology Multidisciplinary Clinic at the Bayview Medical Center, part of Johns Hopkins Medicine, says that the world of medical records is changing rapidly. Patients from all over the country come to his clinic to receive specialized care for lung cancer, and electronic communication has made treating patients from out of state easier and more effective.
“When working with a sister hospital that uses Epic, we can access outside records, because the two hospitals are speaking the same language and using the same platform,” explains Hales. “The system gives us the opportunity to share information quickly and to communicate with doctors from different states.”
Epic has a patient portal, called MyChart, that enables patients to access their records and find out their test results. It also has a feature that allows them to send emails to their physicians. In Hales’ experience, this option has proven to be empowering to patients, especially because, at his institution, there are safeguards ensuring that a member of the clinical staff receives the message promptly.
“I have a level of redundancy built into the system, so an email from a patient goes to six different clinical staff members,” says Hales. “There is little chance that a message will get lost in the shuffle.”
But for patients coming from less technologically advanced institutions, electronic communication may be more challenging. According to Lidia Schapira, M.D., editor-in-chief of Cancer.Net, the American Society of Clinical Oncology’s website geared to patients, and associate professor of medicine (oncology) at the Stanford University Medical Center, “most EMRs are not compatible Furthermore, they weren’t designed to transfer information. They were set up for reimbursement and recordkeeping. For these reasons, I think patients are advised to bring copies of their records on a flash drive or as hard copy.”
Schapira also sees many limitations to the MyChart feature. “It’s a great tool for scheduling a conversation and helping patients and providers stay connected,” she says.
“But patients shouldn’t depend on email in an emergency, just in case someone isn’t there to respond immediately. Then it’s best to call the doctor’s office or go to the emergency room.”
The bottom line for patients is that, because electronic communication is not foolproof, the best plan is to bring records with them when they travel. That could mean bringing hard copies and films or transferring everything onto a thumb drive, something many patients would have to do on their own, because most hospitals don’t provide that service.
TIMING IS EVERYTHING
For Supriya G. Mohile, M.D., M.S., director of the Geriatric Oncology Clinic at the James Wilmot Cancer Center at the University of Rochester, in New York, working with cancer patients who are making seasonal travel arrangements is an important part of her job. As director of the one of the first clinics specifically designed to meet the needs of older patients, she and her team consider each patient’s full profile, including strength, fall risk and nutritional needs, before developing a cancer treatment plan.
Many of her patients — 65 percent of whom are over 80 — leave for the winter, but not before they have a comprehensive, individualized discussion with Mohile. “If patients are not in active treatment, travel is no problem,” she says. “But if they’re still receiving chemotherapy, I advise them to time their travel during a break.
Appropriate timing also should be considered for those receiving hormone shots and having periodic labs done.”
Sometimes, travel is simply not the best idea. “One of my patients had prostate cancer that was progressing,” Mohile recalls. “I told him that travel was probably not safe. But he moved ahead with his plans anyway. He had his wife and children to help him.”
To provide the optimal situation for her patients, Mohile often takes an active role in finding physicians for them in their winter locations. “I begin by contacting colleagues working in big medical centers, like the Moffitt Cancer Center in Tampa, Florida, but I also check out private practices to find out who is available and board-certified,” she explains. “Before my patients leave, I may give them a few names, along with copies of their medical records and enough medication until they get settled with their new doctor.”
Mohile sometimes remains actively involved with her patients while they’re away, but other times, the new doctors may take over entirely. In a few instances, a new doctor has questioned a patient’s treatment plan. When that happens, Mohile says, the patient usually calls her to talk through the differences in opinion.
“As a geriatrician, my treatment plans are conservative,” notes Mohile. “Sometimes other doctors want to escalate care. Then it’s up to the patient to make choices. Overall, my patients are on top of their treatment and can manage their care quite well.”
INSURANCE: A POTENTIAL ROADBLOCK
The final piece of the puzzle that travelers must consider is their insurance, including their coverage for medications.
Many older patients on Medicare may assume that their plans can cross state lines, but that is not always the case.
“If you have traditional (fee-for-service) Medicare, you can go to any doctor that takes Medicare, but if you have a Medicare Advantage plan, you will likely be limited to seeing only those doctors in the plan’s network,” explains Anna Howard, policy principal with the American Cancer Society Cancer Action Network. “That’s why it’s important that patients with cancer who are making travel plans talk to their insurance carriers before they leave town.”
If their plans don’t provide coverage out of state, people can use the Medicare annual election period (Oct.15 through Dec. 7 each year) to look at their options and decide whether they want to change to a plan that provides outof- state coverage.
Heath insurance obtained through private carriers for patients under 65 have similar problems. “Most health plans may not provide coverage in another state,” says Howard. “As was the case for Medicare, they are pretty limited.”
That leaves two other options: paying out-of-pocket for medical care or returning home for care. Both of these alternatives, says Howard, are only possible for patients with the financial means to pay their own way. Retaining coverage in another state for most medications tends to be a little easier. Because many plans have a mail-order component, often medications can be sent to the temporary address. If the drug plan has a contract with a large national chain, such as CVS, it may be possible to pick up the medications at a local store. This is why it is important to check with your plan before you travel.
Specialty medications, or those manufactured from living organisms, fall into a separate category. They usually must be purchased through specialty pharmacies. If they are oral medications, says Schapira, they may be delivered by mail on a regular basis. And if patients are seeing a doctor affiliated with an academic medical center like the Cleveland Clinic, there’s a good chance they can have their prescriptions filled at those facilities. “Anticipating your needs and planning ahead are key,” says Schapira.
Indeed, planning is the operative word when it comes to seasonal travel for cancer patients. Talking to their physicians, lining up new doctors affiliated with reputable hospitals, ensuring that medical records are accessible to all providers and making sure medications are accounted for are all part of the process — not to mention checking out the limits of insurance.
Despite these hurdles, most providers are supportive of travel, and many patients wouldn’t have it any other way.
“Travel is a sign of mental and physical health,” says Schapira. “Those who want to go are leading the life they want to lead. As long as they stay safe, I’m all for it.”
Halgren relishes his winter travel and advises patients to “talk to their doctors, and not let cancer stop you. I have a friend from Minnesota with advanced prostate cancer who comes down here every winter,” continues Halgren. “He has a team in both places, and he deals with his situation. Cancer patients like us are just not ready to stop having fun.”