Prevalence of cross-state cancer care highlights urgent need for telehealth policy
Key takeaways:
- Tens of thousands of patients with cancer travel to other states to receive care.
- Individuals from rural areas cross state lines significantly more than those residing in urban communities.
Laws that prohibit clinicians from providing health care services to individuals residing in other states have impacted tens of thousands of Americans with cancer, according to results of a retrospective study.
In an investigation of more than 1 million fee-for-service Medicare beneficiaries, approximately 7% traveled across state lines to receive cancer care.
Patients who lived in rural areas traveled to other states for cancer care two to four times more often than those who lived in urban areas.
“We are increasingly a digital, remote, virtual, hybrid world, and that’s only going to accelerate,” Tracy Onega, PhD, MS, MA, MPAS, investigator at Huntsman Cancer Institute and Jon M. and Karen Huntsman Presidential Professor in Cancer Research, senior director of population sciences and professor in the department of population health sciences at The University of Utah, told Healio. “Developing the evidence base to bring the cancer care continuum into that world most effectively for all stakeholders, with patients at the center, is critical.”
‘It’s very limiting’
Telehealth use surged during the COVID-19 pandemic as the United States government relaxed licensure laws to allow clinicians to treat patients no matter their physical location.
However, waivers for interstate care expired in 2023. Most states ban or severely limit what clinicians can do if a patient is not present in the same state in which they are licensed to practice.
Healio previously reported results of studies that showed telehealth could be a safe alternative to in-person care in certain settings.
One study showed individuals who received remote radiation oncology care at Memorial Sloan Kettering Cancer Center had no added safety risks, saved money and expressed high satisfaction with the program.
Another study, presented at last year’s ASCO Annual Meeting, showed patients with non-small cell lung cancer who received early palliative care via telehealth had similar quality of life scores as those who received treatment in person.
“It’s very limiting in how one can provide that care to patients ... without the telehealth option,” Onega said. “You have to rely on the patient’s ability to come to you.”
Onega and colleagues investigated how many patients make those interstate journeys.
They used CMS data to identify patients diagnosed with breast, colon, lung or pancreatic cancers who had fee-for-service Medicare coverage between 2017 and 2020.
The study included 1,040,874 individuals (mean age, 76.5 years; standard deviation, 7.4 years; 68.2% women; 85.5% white; 78.5% lived in urban areas).
Frequency of cross-state travel for cancer care served as the primary endpoint.
Results
Results showed 6.9% of cancer care for the cohort had been delivered across state lines.
Patients traveled to other states frequently for surgical procedures (8.3%), radiation therapy (6.7%) or chemotherapy (5.6%).
Cross-state travel varied based on cancer type.
For example, a higher rate of individuals with pancreatic cancer traveled to another state for their care (16.2% for surgery; 8.7% for radiation; 6.1% for chemotherapy) than those with breast cancer (7% for surgery; 6.2% for radiation; 5.4% for chemotherapy).
Race and ethnicity also factored into travel for cancer care.
White patients traveled at higher rates for care (9.3% for surgery; 7.3% for radiation; 5.8% for chemotherapy) than Hispanic individuals (4.4% for surgery; 3.1% for radiation; 2.1% for chemotherapy).
Patients who lived in rural areas had significantly higher rates of cross-state travel (18.5% for surgery; 16.9% for radiation; 16.3% for chemotherapy) than those who lived in urban communities (7.5% for surgery; 5.7% for radiation; 4.2% for chemotherapy).
Researchers acknowledged study limitations, including the fact the cohort had been limited to fee-for-service Medicare beneficiaries.
Next steps
Huntsman Cancer Institute at The University of Utah serves a primary area of five states: Utah, Nevada, Wyoming, Idaho and Montana.
“If [individuals live in those states and] are going to an NCI cancer center, there’s a good chance it will be us,” Onega said, noting the institute also serves patients from other states, too. “As far as regional [locations], you’re talking huge distances and out-of-state travel.”
Telehealth could allow patients to have follow-up visits and discuss symptoms, adverse events and other topics related to their cancer care without travel burdens.
It also could reduce care fragmentation, such as a patient traveling for surgery but getting chemotherapy locally, Onega and colleagues wrote.
Onega emphasized the need for more data to push for change.
Future research could investigate how often individuals with other insurance types, such as Medicare Advantage, travel to other states for cancer care; the cost-effectiveness of telehealth; and how much time patients spend outside of an operating room or receiving inpatient treatment when they travel, she said.
Addressing licensure concerns and expanding telehealth would benefit patients, but equity concerns could remain, Theodore M. Johnson II, MD, MPH, chair of the department of family and preventive medicine and professor at Emory University School of Medicine, and colleagues wrote in an accompanying editorial.
“Any remedies that state legislators and the medical community can offer to better support these patients and their families, particularly for those in isolated rural communities, would be welcome,” they wrote.
‘We are all patients’
In December 2023, Shannon MacDonald, MD, radiation oncologist at Massachusetts General Hospital and associate professor at Harvard Medical School, filed a lawsuit against New Jersey’s telemedicine and telehealth licensure laws.
Sean McBride, MD, MPH, radiation oncologist at Memorial Sloan Kettering Cancer Center, filed a similar lawsuit in California.
“Medicine is only becoming more complex and specialized,” MacDonald told Healio. “The U.S. has such strong specialists in medical research. It’s a shame that we don’t act like one country and allow it for all citizens.”
MacDonald said the news on her lawsuit has been “quiet for a long time,” though the California suit has had some “counters.” She acknowledged the process could take a few years.
Whether the federal government will take action remains unclear.
Project 2025 — a federal policy agenda published by The Heritage Foundation, a conservative think tank — encouraged changes in state laws and federal regulation to redefine, for the purposes of telehealth, the locus of care to where the physician resides rather than the patient.
“With such a definition, states could continue to reserve their powers to establish the standards for licensure and scope of practice,” the document reads. “The providers could ensure continuity and consistency of care no matter where their patients might move while maintaining the licenses that make the most sense for them.
“Americans are far more mobile and technologically advanced today than they were when most health care laws were written. Telehealth has become increasingly important, particularly during the height of the COVID-19 pandemic. It also has great potential in rural and other areas where there are shortages of health care providers.”
The document also endorsed some of the arguments MacDonald and McBride used in their lawsuits.
There are other ways to promote telehealth without changing the locus of care, Onega said. These include licensure reciprocity between neighboring states or allowing clinicians to continue care of established patients.
Some states, such as Florida and Arizona, have created registries that allow clinicians to get telehealth licenses, as opposed to full licenses.
“I’ve been told at meetings it made it much simpler,” MacDonald said. “It is less expensive, but the only colleague I know who tried to do it said, practically, it was not an easy, simple form to fill out. You had to get a ‘registered agent’ who has legal obligations in the state of Florida. He didn’t even know what that meant or who it needed to be and was ultimately told by the hospital that he should obtain a full license.”
MacDonald remains “hopeful” these lawsuits will prompt change.
“We are all patients,” she said “We all have family members with cancer or rare diseases. Being an American, I would hope that we could access the best care in America, and not just the best care in the state that we live in.”
References:
- Johnson II TM, et al. JAMA Netw Open. 2025;doi:10.1001/jamanetworkopen.2024.61028.
- Mandate for Leadership: The Conservative Promise. https://static.project2025.org/2025_MandateForLeadership_FULL.pdf. Published April 2023. Accessed March 25, 2025.
- Moen EL, et al. JAMA Netw Open. 2025;doi:10.1001/jamanetworkopen.2024.61021.
For more information:
Shannon MacDonald, MD, can be reached at smacdonald@mgh.harvard.edu.
Tracy Onega, PhD, MS, MA, MPAS, can be reached at tracy.onega@hci.utah.edu.
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