Primary care: ‘The first line of defense’ in assessing GI distress in patients

Gastrointestinal (GI) conditions are a significant part of health care treatments in the United States, and primary care physicians (PCPs) are “the first line of defense” to help patients presenting with ailments that go beyond mild, passing stomach aches.

GI ailments affect one in five American adults, with disorders tallying up to $112 billion in total health care spending a year. That money pays for diagnostic imaging, scoping, medications, emergency department (ED) visits and hospitalizations.

There are virtual solutions that are effective at the improving patient health while reducing financial costs. This year, the Peterson Health Technology Institute published “Virtual Gastrointestinal Care Solutions,” and evaluation of the latest treatment modalities and approaches to irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).

The report includes a patient guide and an overview for policymakers. In this interview, Peterson Executive Director Caroline Pearson discussed the findings and what PCPs need to know about virtual treatments.

This transcript has been edited for length and clarity.

Medical Economics: Regarding the report on virtual gastrointestinal care solutions, could you provide an overview of some of the key findings from that recent assessment?

Caroline Pearson: First, let's start with the conditions themselves. One in five adults suffer from some sort of GI symptoms on a regular basis. GI conditions are really a wide range of different diseases, so it can take a long time to diagnose people and begin to address their symptoms. It also drives a lot of health care spending. For most employers, GI-related spending is about their third-biggest line item, so it's really an area that would benefit from better care for patients.

We've seen growth in a number of virtual GI solutions that really aim to replicate what is recommended multidisciplinary care for patients. That's care that includes specialist gastroenterologist treatment including medications for some patients but it also includes things like nutrition counseling or gut-brain therapy for conditions like irritable bowel syndrome (IBS). What we've seen is about five companies included in our report building out solutions that really seek to integrate those additional support services, like behavioral health and nutrition, with specialty services to improve access to high-quality GI care.

And this was a great news story: We found that all of the solutions we reviewed are effective in improving patients' symptoms as well as their quality of life. And what was really interesting is these solutions can help reduce health care spending on the order of $2,000 to $3,000 per patient per year by not only avoiding symptom flareups, but helping patients understand when they need to seek emergency care — and hopefully avoiding hospitalizations or ED (emergency department) visits that may not be necessary.

Medical Economics: The report dives into two conditions: irritable bowel syndrome and inflammatory bowel disease. Those may be grouped together sometimes and may present with similar symptoms when patients go to their doctor's office. Clinically, they are different conditions that require different treatments. Can you talk about that distinction?

Caroline Pearson: Absolutely. We sometimes say that the only thing IBS and IBD have in common is the first two letters of their acronyms. They're such different conditions, and they really speak to the complexity of correctly identifying and diagnosing GI symptoms so we can match them with appropriate treatment pathways.

IBS is what we call a functional condition. It's really about symptom management, and it is considered a disorder of the gut-brain axis, so it typically responds well to tailored GI-specific behavioral health treatment that addresses that gut-brain axis, as well as nutritional support to identify foods that might trigger symptoms.

IBD is quite different. It is a structural condition where doctors can see visible changes in the intestines, and it is progressive, so we're really trying to focus on slowing disease progression. Many IBD patients rely on biologic medications to help manage their condition, and about a third of them may also suffer from IBS symptoms — so there is some crossover. But it is really important that physicians are separating the conditions and matching treatment appropriately.

Medical Economics: The report also notes something of a dichotomy between what are referred to as wraparound solutions and clinician-led solutions. Can you explain what those are and some of the commonalities and differences between those two treatment models?

Caroline Pearson: As you think about how you might replicate multidisciplinary care, it's helpful to think about two separate pieces. One is the clinician-led treatment that’s typically going to have a gastroenterologist as well as other medical professionals, they may be prescribing medications. Then there's a set of support services — nutrition counseling, care coordination, behavioral health therapy — that you want to pair with those traditional specialist services.

The two categories of solutions reviewed in this report deliver those services through different business models. The wraparound solutions focus on delivering support services through digital applications directly into the hands of the patient. Typically, they are selling to a health plan or an employer, and then they reach out to enrolled patients who may have GI symptoms or GI spending, and encourage them to engage with gut-brain therapy and nutritional supports to manage their symptoms more independently. The patient may also be receiving medical care from a primary care physician [PCP] or gastroenterologist, but they’re wrapping around that medical care to create a more holistic experience for the patient.

The other category that we’re calling clinician-led solutions is more fully integrated. It is actually part of a patient's provider network, and the gastroenterologists are directly contracted with the digital health solution. So the patient is seeing a gastroenterologist from the digital health company, receiving those wraparound services as part of an entire care plan. It's a more integrated offering, but it does come at a somewhat higher price point from a purchaser's view.

Medical Economics: That's a great segue into a question we always like to ask that brings it back to our audience. Primary care physicians may be the first point of contact for patients with GI distress. How do you envision the report's findings affecting primary care physicians in diagnosing, managing, helping to treat IBS and IBD?

Caroline Pearson: PCPs are absolutely the first line of defense here, they're going to be seeing patients first, and one of the things they need to do is figure out what resources are available to support the patient. In many cases, they may be making a referral to a gastroenterologist, but unfortunately, gastroenterologists have the third-longest wait time of any specialist in the country, and many counties do not even have access to them. So primary care providers may be thinking, "I don't have great referral options." The clinician-led solutions really seek to improve that network adequacy and improve access by taking that care and making it virtual. Primary care doctors should be aware that these solutions exist. They might want to engage their patients to see if they have access to one of these solutions, and that may give them a broader set of referral options — particularly for patients looking for specialist care.

For IBS patients or other people who are suffering from GI symptoms, those wraparound solutions are also an option for primary care physicians to recommend directly to their patients. They can really help patients self-manage their symptoms and see real improvements in their day-to-day life and their day-to-day experience. That's another tool in the toolkit for a patient who may have their clinical care managed by that PCP or have other management for their clinical side of their care, but would benefit from that more multidisciplinary set of services.

Medical Economics: The report notes that for GI distress, usual care is fragmented and does not necessarily integrate providers such as dietitians or behavioral health specialists. What factors have led to that fragmentation?

Caroline Pearson: Unfortunately, the real multidisciplinary care team experience that includes specialists, nutritionists and behavioral health providers, is almost exclusively available at academic medical centers today. That is a great source of care, but it's not where most people are getting their care. Other settings just don't have those integrated resources that we know deliver the best clinical outcomes for patients.

I think it is resource availability, and it really speaks to one of the places where digital solutions can help close gaps in existing care models. Many of the support services can be delivered digitally, or they can be delivered by humans over a virtual platform, which gives these solutions the ability to scale and make those services available to patients who aren't being seen at academic medical centers and may be geographically dispersed.

Medical Economics: When you talk about the concentration of these services in academic medical centers and then the use of technology, can you discuss whether those support services have to take place face-to-face, or what technology is needed to make an effective virtual connection between physicians, other clinical support staff and patients?

Caroline Pearson: We're seeing so much technological advancement in terms of how reimagining service delivery can happen. Let's take the behavioral health component as one example. Whether it is patients with GI symptoms or people suffering from depression or anxiety, behavioral health treatment can be delivered through a wide range of mechanisms that are not just face-to-face in the same room.

We're all relatively comfortable with virtual Zoom-based or video chat-based modalities, but what we're also seeing is that asynchronous chat and video can be effective, as can digital app libraries. Modules, videos and exercises can all be done on an app with no human involvement and they deliver clinically meaningful improvements in depression, anxiety and GI symptoms. People often thought that best-in-class mental health care had to be live therapy, and we're quickly seeing that it doesn't have to be. For patients interested in those options, it really opens up a broader set of care models, many of which can be delivered in more affordable ways.

Medical Economics: Artificial intelligence (AI) has emerged and is developing across many areas of health care and other sectors. How do you see the growth of AI affecting treatment for GI distress?

Caroline Pearson: All health tech companies are beginning to integrate AI in many novel ways. One example in GI care is symptom monitoring. Part of the way we help patients avoid ending up in the emergency department is by tracking their symptoms so we can predict when they may be about to have a flareup, which is what often results in really severe symptoms and sends people seeking emergency care. AI algorithms can use patient-reported data to more accurately predict when symptoms are exacerbating, even before the patient may have recognized that trend. At that point, they can reach out to a nurse or a coach who can help that patient intervene to manage the symptom flareup before it becomes too severe, or to recommend how they should seek care in lower-cost or less acute settings. There is a lot of opportunity for AI to help us perceive trends we may not yet be seeing in our own self-reported symptoms.

Medical Economics: The report includes a policy overview that examines some of the treatment methods, outcomes and potential savings. From a policy standpoint, what could happen at the state level or the national level that would help improve treatment while saving money?

Caroline Pearson: This administration has been particularly interested in health technology and finding ways to accelerate its adoption. Most of the solutions described in our report are being sold into the commercial market — to both employers and health plans — but they have not had pathways to coverage in Medicare, particularly traditional Medicare. Given the really strong clinical findings and economic results, there is a lot of opportunity for Medicare to think about expanding access.

There is a program through the (Medicare and Medicaid) Innovation Center called the ACCESS model (Advancing Chronic Care with Effective, Scalable Solutions), and many of the wraparound solutions might be a good fit for a new track focused on GI care within that model. We also saw in the report some evidence that prescription digital therapeutics, some of those gut-brain therapies that can be prescribed by doctors, if covered by Medicare, could deliver a lot of benefits.

Medical Economics: At least as of right now, what has been the attitude among private insurers toward coverage of these types of solutions?

Caroline Pearson: We're seeing a rapid increase in adoption of GI solutions by private insurers, really because they understand it is such a big driver of health care spending and they're looking for better management approaches for those patients. As these companies have grown and begun to produce evidence about their effectiveness, we are seeing a lot more commercial insurers adopting these tools and making them available to patients. Our report really includes a strong call to action: Given these positive findings, we think most commercial insurers should be looking at how they want to integrate some of these solutions into their benefit design because it's really a win-win. Patients see the clinical benefits, and health plans — and honestly, the people, all of us who pay for them — get to see the economic benefits of avoided health care spending, which nobody wants. Whether they're the patient or the payer, nobody wants health care spending they don't need.

Medical Economics: What would you like to say to primary care physicians, or what would you like them to know?

Caroline Pearson: Primary care doctors already know how many of their patients have GI symptoms on a regular basis, and I would like them to know that there are digital tools that can help support those patients in managing their symptoms and quality of life. It is important for them to be aware that those solutions exist, and to think about recommending them to patients who might benefit.