Updates in Telemedicine for Gastroenterology Practices in the U.S.

The U.S. COVID-19 public health emergency and related legislation facilitated a rapid acceleration of telehealth/telemedicine services by removing restrictions on patient and clinician location, waiving interstate licensure requirements, and providing for professional fee reimbursement on-par with in-person services. Telehealth claims have stabilized at 38 times higher than pre-pandemic levels as of July 2021.¹ In a recent national survey of hepatology practitioners, 98% were using telehealth to conduct appointments, 88% viewed telehealth favorably, and 35% felt that most patients preferred telehealth over in-person visits. At the same time, many studies show high patient acceptance and willingness to participate in telehealth.² Clearly patients and clinicians have rapidly adapted to telehealth services during the COVID-19 era. Yet many unanswered questions remain about the optimal use cases for telehealth, and whether it will remain such a prominent part of clinical practice moving forward. Herein we provide an overview of the recently published literature on telehealth use in gastroenterology (GI) and hepatology practices and discuss key issues that impact sustainability.

Is telehealth as clinically effective as in-person visits?

Data on telehealth effectiveness are emerging for management of many chronic conditions. In GI/hepatology practices, the data are limited. A study from the Veterans Affairs during the COVID-19 pandemic evaluated the association of clinic visit type on hepatocellular carcinoma (HCC) surveillance in a national cohort of patients with cirrhosis. In-person and telemedicine GI/hepatology visits were both associated with HCC surveillance imaging compared to no visits; however, HCC surveillance was higher for in-person visits than with telemedicine.³ Patient factors that affect telehealth visit quality and effectiveness include technology availability and digital literacy. A recent survey showed that 96% of patients with cirrhosis had internet access and 92% had a smartphone, however 43% were not routinely using their smartphones or tablets to connect to video visits, and 10% were unable to connect to video visits. To date, clinician- and health systems have focused largely on implementing telehealth programs and helping patients connect. However, little has been published evaluating patients’ ability to recall and understand after visit instructions and adherence to clinical recommendations as well as clinician adherence to evidence-based practices. To ensure the sustainability of future hybrid care models, research and quality improvement efforts are needed to identify and overcome telehealth barriers and to properly route patients to the best visit option based on the clinical and psychosocial scenarios.

Does telehealth improve access to care?

Numerous studies have illustrated improved access to GI and hepatology care. In particular, hepatitis C (HCV) treatment was improved with telehealth interventions such as Extension for Community Health Outcomes (ECHO) among underserved patients. There are multiple successful examples of collaborative primary and specialty care in the decentralization of HCV therapy using telehealth visits that result in high adherence to treatment initiation and follow-up (at times higher than with in-person care), high efficiency, and cost-savings. Chronic disease management programs via telehealth for IBD and advanced liver disease also show promise. In a video-telehealth enabled IBD care management program only 1.3% of patients required in-person visits and 0.9% needed immediate primary care referrals. Another video visit model for second opinion of advanced chronic liver disease was deployed between a tertiary care center in large GI practice in Pennsylvania. This program was highly efficient; most appointments were scheduled within 6 days of referral, 45% of patients had meaningful changes in clinical care, and 18% were referred for liver transplant evaluation. Several recent studies within the Veterans Affairs (VA), the largest integrated system of care in the U.S., showed that combining electronic consultations with video telehealth expedited liver transplant wait listing and reduced unnecessary in-person evaluations.

How does telehealth impact health equity?

Telehealth can expand access to care among patients in rural communities or where transportation, caregiving, or taking time off work may serve as barriers to in-person visits. However, the potential of telehealth to widen health inequities is an ongoing concern. Multiple disparities have been noted in access to video versus telephone services and broadband internet among racial and ethnic minorities, persons with limited English proficiency and older adults.⁴ Studies in hepatology and IBD practices shows that older patients, those who are Black/African-American and have Medicaid insurance are less likely to have video compared to telephone visits. Furthermore, non-White patients are less likely to highly rate providers as listening carefully to their concerns, and Black/African/American patients are less likely to use electronic health portals for clinician communication.² Surveys of IBD patients receiving telemedicine showed connectivity challenges in impoverished communities. Best practices to promote equitable access to telehealth include use of pre- and after-visit guides with accessible materials, integrated translation services, adaptations for audio and visual disabilities, and simplified technology (e.g. removing the needs for username, password, software download, etc.).

What is the future of telehealth regulation and billing?

A summary of issues that facilitate or impede telehealth use is shown in Figure 1. Interstate licensure requirements to deliver out-of-state services have returned; as of January 2022, only 19 states have long-term or permanent interstate telemedicine waivers.^{5, 6} Without these waivers, a clinician cannot deliver telehealth to a new or established patient if the site where a patient is physically located at the time of the visit (originating site) is in a state where that clinician does not hold a license. A solution for some practices may be the Interstate Medical Licensure Compact, which has been in effect since 2017, and streamlines the ability for physicians to practice in multiple states.⁷ Although 33 states participate in the compact, implementation has stalled in many of the most densely populated areas in the Northeast and on the West Coast.⁷ An additional wrinkle is that many medical malpractice policies apply only to the state where the clinician is physically located…

Figure 1.

Key issues in telehealth and remote monitoring in gastroenterology and hepatology practice

Abbreviations: HCV - hepatitis C virus, IBD - inflammatory bowel disease, LEP-Limited English Proficiency

*Patient-generated data codes with lower reimbursement that auto-generated codes; **Data mostly from research trials rather than clinical practice or pragmatic trials

In a fee-for-service (FFS) model that applies to most of GI/hepatology practices in the U.S., the future of widespread payment parity (e.g., similar reimbursement for in-person as video visits) is uncertain. Payment parity is still largely in effect during the current public health emergency; however, 26 states have no permanent payment parity laws, and some have limited parity only for mental health services. Even with similar reimbursement for physician fees, providers at hospital-based clinics may be losing revenue by missing additional facility fees. Multiple pieces of legislation have been introduced to protect telehealth, remove restrictions on geography and originating site, and extend audio-only telehealth. Useful guidance on setting up telehealth programs and information about regulation and reimbursement is publicly available.⁸

How can telehealth be improved?

There are two avenues for improvement in telehealth and GI practices. The first is to better identify which clinical and psychosocial patient scenarios are better suited for telehealth vs. in-person care, and to develop processes for scheduling patients accordingly. The second involves new models of care and/or technologies to overcome the limitations of telehealth. One such model would be to incorporate visits by home health workers into the telehealth clinician visit to provide vital signs and basic physical exam data, as well as information about the home environment. To bill for the telehealth visit during a home care visit, a pre-existing relationship with the practitioner ordering home health must be in place prior to initiating home health services.⁹ This requires coordination to ensure the provider of record for the home care episode is the same one conducting the home care visit. An additional limitation is the fact that home health agencies may be separate corporate entities from those of clinicians.

Another way of overcoming the limitations of telehealth is with technology. Though the increased uptake of smartphones, wearables and peripheral devices, there has been a tremendous growth in available patient-generated health data that could be used for remote patient monitoring (RPM).³⁸ In GI/liver disease, RPM has been evaluated in research studies that deployed behavioral interventions or hybrid care models. Several non-alcoholic fatty liver disease (NAFLD) studies have used combinations of mHealth apps, personal fitness trackers, and live video or telephone lifestyle and nutrition monitoring. These have shown feasibility, acceptability, and promise in improving weight loss, glucose control, physical activity, and liver biochemistries, but are not routinely integrated into clinical care. In IBD, telehealth models have incorporated home-based fecal calprotectin and remote monitoring of disease activity and quality of life. Results have been variable, with only about 50% of patients engaged; however, participating patients had improved quality of life and decreased hospitalizations. A recent analysis showed that a comprehensive RPM intervention in the Netherlands that included medication adherence, a personalized care plan, tailored monitoring intensity based on symptom severity, and secure communication access to the IBD team was cost-effective with a mean annual cost savings equivalent to $615.

Recently, an important development is a Centers for Medicare & Medicaid (CMS) 2021 Final Rule that revised RPM reimbursement for data transmission between patient and the care team. RPM applies to established patients only and allows the provider to bill every 30 days for automatically collected data. Data cannot be patient generated to qualify for higher reimbursement levels (e.g., quality of life data is not reimbursable) must be digitally transmitted for at least 16 of 30 days.³⁷ Examples of barriers to RPM include modest reimbursement, variable patient adherence, provider workflow disruption, device restrictions, and lack of clarity which provider will be reimbursed as only one provider may bill for data review.

A key question is how to implement hybrid care models with in-person, telehealth, and RPM that improve the patient and clinician experience, increase efficiency, and are financially solvent. Part of the answer may lie in value-based and capitated payment models or those with hybrid FFS and bundled payment structures. For example, the Kaiser healthcare system has integrated remote glucose monitoring via digital applications with telephone and video visits. There are growing examples of accountable care organizations and large specialty care practices that leverage the electronic health record to establish population-based approaches to care and combine remote monitoring with routine and on-demand telehealth visits.¹⁰ Though more challenging in a FFS model, with ongoing reimbursement and legislative changes, integration of telehealth and remote monitoring with in-person visits may be feasible.

Conclusions:

Telehealth has had unprecedented growth during the COVID-19 public health emergency and is likely here to stay, though the degree of penetrance remains uncertain. The future will require regulatory flexibility, sustainable payment models, technical support for patients and clinical practices, and investments in digital and broadband infrastructure.