Issue: June 2020
Source/Disclosures
Source: Healio Interview
Disclosures: Berggreen reports he has an investment in American Well. Chey reports he is a consultant for GI OnDEMAND. Karlitz reports he is the chief medical officer of Gastro Girl and director of clinical operations of GI OnDEMAND. Asnis and Keefer report no relevant financial disclosures.
June 25, 2020
9 min read
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Telehealth in a Pandemic: ‘Just the Beginning of the Story’

Issue: June 2020
Source/Disclosures
Source: Healio Interview
Disclosures: Berggreen reports he has an investment in American Well. Chey reports he is a consultant for GI OnDEMAND. Karlitz reports he is the chief medical officer of Gastro Girl and director of clinical operations of GI OnDEMAND. Asnis and Keefer report no relevant financial disclosures.
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COVID-19 has accelerated the need for GI practices to use telehealth as a way to deliver patient care and has forced GI practices to rapidly transition to telehealth.

Among the platforms GI practices have used to assist in their transition are GI OnDEMAND, a joint venture between the American College of Gastroenterology and Gastro Girl Inc., doxy.me, Medisprout, FaceTime, Skype, or a practice’s own electronic health records. ACG recently published a guide meant to help GI practices rapidly deploy telehealth.

William D. Chey, MD, consultant for GI OnDEMAND, professor of gastroenterology and nutrition sciences at the University of Michigan, said the silver lining of COVID-19 was the rapid need for practices to adopt telehealth.
William D. Chey, MD, consultant for GI OnDEMAND, professor of gastroenterology and nutrition sciences at the University of Michigan, said the silver lining of COVID-19 was the rapid need for practices to adopt telehealth.
Source: William D. Chey, MD.

The ACG telehealth guide provides insight on a number of important factors a practice should consider including development of a practice telehealth policy, process for scheduling, choosing a platform to best reach patients, documenting telehealth encounters during visits and change capture.

Additionally, the guide suggests practices also should consider these key factors in choosing a telehealth platform, which include HIPAA-compliance (required outside of the current national emergency), appointment reminders, scheduling capabilities, e-prescribing, billing support, provider support, messaging capabilities, access or use of online forms, revenue cycle management and real-time video conferencing ability.

Healio Gastroenterology spoke with GI experts on their experience with telehealth and how COVID-19 impacted their current use or required them to quickly transition to telehealth.

Rapid Need for Telehealth

“Some providers had been using telehealth before COVID-19,” Jordan J. Karlitz, MD, director of clinical operations of GI OnDEMAND, told Healio Gastroenterology. “However, there was a 4,000% ramp up right after the pandemic started, consistent with a massive mobilization of telehealth services due to COVID-19 specifically”.

Jordan J. Karlitz, MD
Jordan J. Karlitz

Karlitz, an academic gastroenterologist in New Orleans, also said telehealth has expanded the way providers interact with patients especially now that it has become necessary to keep both the provider and patient safe in the setting of the pandemic. Before COVID-19, telehealth could be of benefit for patients because it reduced the time and cost for patients who no longer needed to take time off work, arrange childcare and pay for gas and parking, according to Karlitz. Such benefits also apply during the pandemic and will likely be significant drivers of telehealth use going forward.

William D. Chey, MD, professor of gastroenterology and nutrition sciences at the University of Michigan, told Healio Gastroenterology, he tried to get telehealth implemented into his practice previously, but the university resisted due to concerns about reimbursement. He said due to COVID-19, the whole process was accelerated and now uses it almost every day.

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Chey, who serves as Senior Director of Nutrition and Behavioral Health Services and Supprt for GI OnDEMAND, also said, “Telehealth has been a lifeline to continue to interact with and care for my patients at a time when face-to-face isn’t practical or safe.”

Laurie Keefer, PhD
Laurie Keefer

“We have been using telehealth since 2016 as a core part of our subspecialty medical home for [inflammatory bowel disease (IBD)],” Laurie Keefer, PhD, a professor of medicine at Icahn School of Medicine at Mount Sinai, said. “About 40% of our visits within the medical home were conducted over telehealth before COVID-19.”

Eric L. Asnis, MD, FACG, a gastroenterologist in private practice at Green Mountain Gastroenterology, said his institution implemented telehealth just prior to the COVID-19 pandemic, around February. He sought to decrease no-shows at the office.

President of Arizona Digestive Health, Paul J. Berggreen, MD, said 2 days after the Arizona governor announced the locked down, his 52 physician group institution – the Arizona Endoscopy Center – still needed to deliver care and there was no longer a way to do it. Berggreen and colleagues looked at various telehealth platforms that were useful, cost effective and easy. Now they are almost exclusively seeing no patients in the office.

Patients, Providers Accept New ‘Norm’

Keefer said GI lends itself to telehealth. Some patients with diarrhea or bad abdominal pain may cancel due to travel concerns, but with telehealth they can remain at home and physicians can still see them. She interviewed some health care providers on their experience with telehealth and found physicians liked to see patients in their own home, with pets or family members. They also noted visits were shorter compared with in-person visits.

Keefer said most of her patients prefer telehealth visits. Some were hesitant at first and still wanted to come to the office but as telehealth became necessary during the pandemic, patients realized the similarities and even benefits.

“Several of my patients have said it feels the same,” Keefer said. “I thought it would seem weird to see people only on video, but I feel just as connected and I feel like they’re just as present in the visit.”

Paul J. Berggreen, MD
Paul J. Berggreen

Berggreen said there is a high-level of acceptance for telehealth among patients. Patients like the convenience and while some patients still prefer coming to the office for a face-to-face personal connection with their physicians, not many patients said they felt uncomfortable with telehealth.

“Like any question where there are different answers for different people,” Chey said, “there’s not a one-size-fits-all. Many patients that I have talked to at the end of the visit said it was a lot better than they thought it was going to be. Patients love the convenience.”

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He said some of his patients even conduct their video visits or phone calls in their cars during work hours. People appreciate that they can speak with their doctor from the comfort of their home or work without a long drive, he said.

Keefer said in IBD, physical exams are still important and with telehealth, hard to perform. GIs also still need to send patients for lab work to monitor biomarkers and patients need to come in regularly for infusions. She said there are pros and cons to telehealth and noted physicians may still see patients in-person if they need a physical exam.

Karlitz said it depends on the specific GI condition, but many things can be done via telehealth especially when a physician already knows a patient. For instance, GIs can use telehealth visits to assess symptomatology in IBS and IBD patients. It can also help risk stratify patients for GI procedures. For example, telehealth visits can be used to ascertain detailed cancer family histories to help determine when colorectal cancer screening should begin.

Chey said physicians can find creative ways to perform a physical examination. He said it may be a worthwhile endeavor for physicians to begin cataloging things they can do during a video visit that can allow them to assess different aspects normally covered in a physical examination.

“All of us are getting increasingly creative in terms of the ways we interface with a patient through a modified physical examination,” he said.

Source: Adobe Stock.
Source: Adobe Stock.

Telehealth, Reimbursement During the Pandemic

Keefer said during the COVID-19 pandemic, insurance companies are reimbursing telehealth visits at the same rate as in-office visits. She said this may not continue after the pandemic is abated but hopes it does.

“I hope that the satisfaction the patients have with telehealth will drive some of the efficiency of visits; you can see more patients in a day,” she said. “If you do use telehealth, maybe it will convince insurance companies to pay for this type of care, but I am not 100% sure.”

Keefer, who is based in New York, said with telehealth visits you can only see patients within your state. During the COVID-19 pandemic, psychologists like her are able to see patients within the tristate area. If this continues after the crisis is over, she said it would improve the quality of care significantly if patients can see physicians, especially IBD experts, from a broader geographic area and not just a local GI.

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Asnis said there is confusion regarding whether insurers should reimburse for telehealth visits. There was controversy whether Medicare would cover telephone visits, which are considered telehealth visits, at a much lower rate. His practice recently received news that telephone calls were going to be in parity with regular office visits.

Eric L. Asnis, MD, FACG
Eric L. Asnis

“Initially they weren’t reimbursing telehealth visits the same as an in-office visit,” Asnis said. “When the pandemic started, a number of insurers said they would reimburse telehealth visits the same as an in-office visit during the pandemic. What happens after?”

The ACG said during this pandemic, physicians need to stay up-to-date with coverage policies for individual commercial payer mix, while also monitoring Medicare and Medicaid.

“At least 41 states and the District of Columbia have parity laws in place requiring commercial insurers to reimburse for telehealth,” the ACG guide stated. “More states are allowing new and established Medicaid patients to be scheduled using telehealth under the current national emergency. To encourage social distancing, several states are allowing real-time audio-only to replace videoconferencing requirements for telehealth visits.”

According to the ACG, people need to be aware whether their states temporarily allow practices to conduct real-time audio-only telehealth visits. If not, Medicare has two options: either an e-visit or virtual check-ins. The guide further states it is important for health care providers to consider local Medicaid and commercial payer polices and their state’s requirement for coverage by commercial insurance for telehealth.

Chey noted there are modifiers that University of Michigan uses to bill telehealth and currently video visit rates are the same as office visit rates. He is not sure if this will continue but people will need to better understand the business model for this to be successful. With telehealth, physicians will use the infrastructure of their offices at a much lesser degree. He said one of the challenges after the pandemic will be the reorganization of health care to include the liberal use of video and telephone visits.

“How do we do that in a way that acknowledges and accounts for the reduced infrastructure and space necessary for video and phone visits?” he said. “In other words, you are paying for the infrastructure and the staff, but you may not use to the same degree if you are using video and phone visits. Perhaps we will have face-to-face visits several days per week and then do phone and video visits a couple days a week. The good news is that once we are able to get efficient systems in place, we may require less space and personnel to operate our practices.”

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Berggreen said the regulations that were set in place for COVID-19 may change once the pandemic is over. Physicians may only be able to use HIPAA-compliant platforms and documentation requirements will be tightened up.

“If the pandemic doesn’t ramp down and is a persistent problem for the next month, even a year or 2, we are going to have to turn to telehealth,” he said. “Most of us around the country who are involved in forming the policies really think this is going to be the turning point for telehealth. For those physicians who were always resistant to this, this pandemic has opened their eyes to some degree. It will be highly adopted if the government ends up being proactive and wise enough to make those adjustments.”

The ACG said telehealth requirements during this crisis are significantly broader than before and may significantly change when the national emergency ends.

The ‘New Normal’

One downside Chey said is that immediate access to telehealth may create unrealistic expectations regarding patient interaction with a physician. He said it is important to ensure physicians align a patient’s expectation of access to health care with the health care provider’s ability to provide the service.

According to Asnis, even if after the pandemic is over, telehealth is going to play a major role in how physicians see patients in the future even if it is not the primary method of interaction between health care providers and patients.

Karlitz said the pandemic has given people a crash course on how to use telehealth and many have noted its benefits. COVID-19 has increased the need for telehealth, so people are becoming more used to it and the technology behind it. He believes that even when the pandemic wanes people will still more likely use it in the future.

Chey said that while we are currently fixated on virtual visits with doctors; the next phase is to create virtual care networks that provide access to important ancillary services such as nutrition counseling and behavioral interventions that are currently only available in large practices or tertiary care centers.

“One of the great silver linings of this pandemic is rapid uptake and adoptions of telehealth and video visits,” Chey said. “Telehealth is just the beginning of the story. In the new age, we will not require patients to come to us, we deliver care to them.”

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