My perspective on gastroenterology is broad and deep – and not just because I once removed $420 from a patient’s stomach! As a practicing gastroenterologist, I specialize in irritable bowel syndrome (IBS) and related difficult-to-manage conditions. For a decade, I ran operations for a large gastroenterology practice. Academically, I focus on the broad forces shaping gastrointestinal (GI) care.

At the pandemic’s start, I led my multispecialty practice’s shift to virtual care. I’ve since personally used video, phone and messaging to care for countless patients, shared experiences with colleagues across the country, and closely followed the national virtual care boom. I’ve learned that virtual care is sometimes – but not always – the best tool for meeting patients’ needs.

Yet after pivoting to virtual care, GI practices are back to providing almost all care in person. This leaves a group of upstarts to lead virtual GI care forward, with some supplementing traditional GI care and others remotely diagnosing and managing GI conditions. These companies could meaningfully improve care for many, provided they can define the appropriate segments to serve and appropriately integrate with the local healthcare ecosystem.

The COVID-19 pandemic forced gastroenterologists to pivot to virtual care.

Gastrointestinal and liver diseases result in nearly 80 million healthcare visits each year. In early 2020, essentially all gastroenterology visits occurred in person. Within a few months, more than half were being conducted via telephone and video, making gastroenterologists the second-highest adopters of virtual care. They relied on virtual care to preserve care access, protect their patients, sustain their workforces and maintain revenue. In doing so, many realized they could provide most non-procedural GI care remotely.

However, simply replicating traditional in-person care over video brings limited benefits.

For most patients, video visits are more convenient than in-person visits. However, they require about the same amount of clinician time and often cost payers just as much. Additionally, video visits do not address widespread gaps in GI care, including attention to psychosocial factors, dietary guidance, coaching on self-management, monitoring in-between visits and evidence-based decision-making. As such, video visits alone are unlikely to make GI care significantly more accessible, affordable, efficient or effective.

Harnessing virtual care’s benefits will require new teams, technology, and workflows.

In the early 1900s, manufacturers started replacing steam-powered motors with electric motors, otherwise leaving their factories unchanged. They did not realize returns on their investment until many years later, when they radically redesigned factories and workers into modular units with smaller production lines, taking advantage of the smaller electrical motors.

Similarly, to realize the full potential of virtual care – and digital technology more broadly – gastroenterology practices must radically redesign care by reconfiguring care teams and rethinking who, when, where and how they meet each patient’s needs.

Yet, most gastroenterology practices lack incentives strong enough to motivate change.

When asked why he robbed banks, Willie Sutton famously replied, "Because that's where the money is." In gastroenterology, the money is in endoscopic procedures. For example, in 60 minutes I can perform one new, high-level patient consult (3.77 work RVUs) or two screening colonoscopies (6.52 work RVUs, plus facility, anesthesiology and pathology fees). Practices, therefore, optimize around GI procedures, which typically account for at least 70% of total revenue.

Gastroenterologists are among the highest-paid specialists. Their practices are highly sought after by hospitals (the average employed gastroenterologist annually generates $3 million in net hospital revenue) and private equity firms (who typically attempt to build market power, develop economies of scale and then sell the practice to another buyer).

Now that stay-at-home orders have long expired, GI practices have little incentive to provide care away from the office and even less incentive to use virtual tools to reshape care fundamentally. By early 2021, virtual care dropped to 13% of GI claims. Today, despite most payers still reimbursing virtual visits, the percentage is likely in the low single digits. Enter a group of virtual care upstarts with entirely different incentives. Some are aiming to fill the gaps in traditional GI care, others to diagnose and manage GI conditions remotely.

Some upstarts aim to supplement traditional GI care.

Many virtual GI care providers seek to address care gaps and respond to consumer demand by offering services that wrap around local GI care.

• Allay Health is developing a program to supplement local inflammatory bowel disease (IBD) care through personalized diet (GI dietician), behavioral health (GI psychologist), lifestyle changes (coaches) and limited direct medical care (nurse practitioner).
• GI OnDEMAND aims to help community-based gastroenterologists "turn [their] practice into a virtual tertiary care center" by providing on-demand patient education, genetic testing to determine GI cancer risk and access to a virtual referral network of GI dieticians and GI psychologists.
• Mahana is an FDA-approved digital therapeutic for adults with IBS that blends education, symptom-tracking and cognitive behavioral therapy (CBT). In a randomized trial, the Mahana prototype was superior to treatment as usual and equivalent to nurse-administered phone-based CBT.
• metaMe Health’s Regulora is a prescription-based, FDA-cleared digital therapeutic that provides hypnotherapy for IBS. It is not yet commercially available.
• SonarMD regularly tracks IBD symptoms between office visits. A nurse coordinator contacts individuals with rising risk and then notifies their local GI practice to intervene sooner to avoid emergency department visits and hospitalizations.
• Trellus Health analyzes data reported by adults with IBD to identify their needs, predict their disease course and assign them to a care pathway. A multidisciplinary team then helps coordinate and fill gaps in their GI care (e.g., preventive care and medication monitoring), support emotional health and resilience (via a human therapist and digital modules), monitor symptoms (to identify rising risk), and help navigate local care (e.g., preparing for doctor visits).
• Vivante Health uses a dietician, a health coach and an app (diet and symptom tracker, medication reminders, and condition-specific risk assessments and education) to deliver evidence-based disease and symptom-specific pathways to help individuals manage a range of chronic GI diseases and symptoms. In addition, Vivante integrates stool microbiome analysis and frequent hydrogen breath testing to identify the relationships between foods, symptoms, and gas production.

I applaud these virtual providers for using evidence-based approaches (except Vivante’s breath testing) to address many shortcomings of traditional GI care. Because they do not provide direct medical management, their major clinical challenge is integrating with local care. The easy option is to share care summaries with patients’ GI practices, but these tend to wind up in the trash or buried as a static PDF within the medical record. It is far more effective to communicate critical updates and suggested actions directly to the right care team member on the ground.

Here, SONAR MD is perhaps best, first incentivizing participating practices with supplemental revenue (generated through SONAR-submitted care management codes and later a portion of any shared savings payments) and then establishing clear connections with designated practice nurses who ensure individuals with rising risk receive proper follow-up care. Conversely, companies that enroll patients through employer channels face much greater difficulty integrating with local providers.

These upstarts must also demonstrate they improve outcomes or reduce the total cost of care. Vivante self-reports that employers realize a 15% reduction in GI healthcare spending among employee participants. In a propensity score-matched cohort analysis, SONAR MD users had $350 lower costs each month. And before it spun out of Mount Sinai, Trellus users had 90% fewer emergency department visits and hospitalizations. Of course, all this requires engaging patients, something many virtual care providers struggle with.

Finally, they must develop sustainable revenue models. Vivante offer risk-based pricing to employers who only pay for results. SONAR MD shares savings (from reduced ED visits and hospitalizations) that accrue to their payer partners. Others are struggling to become a covered benefit with individual insurers.

Other upstarts are directly diagnosing and managing GI conditions remotely.

Without any legacy baggage, these virtual-first upstarts are intentionally designing care from the (virtual) ground up to meet consumer needs more effectively and efficiently.

• Oshi Health provides purely virtual “integrated GI care.” Consumers start with a video visit with a gastroenterologist, PA or NP to establish a diagnosis and outline management. They then meet with a GI dietician and behavioral health specialist, use a symptom tracker, and receive regular check-ins from a health coach. A care coordinator helps connect those needing in-person services with local options. Follow-up clinical care is available, urgently if required. Currently operating in several states, Oshi recently secured funding to expand.
• Bold Health’s rather bold mission is to "transform the gut health of millions with the most convenient, effective and efficient care." (Disclosure: I am an advisor). Moving beyond their Zemedy app for IBS, Bold is now developing an entirely virtual model of integrated GI care delivered by a tech-enabled, multidisciplinary care team (gastroenterologists and NPs, dieticians, therapists, coaches) and using digital therapeutics.

Unlike many gastroenterologists, I am excited by these virtual-first providers’ potential to improve care for many with GI conditions. Providing convenient access over multiple digital channels could enhance accessibility and patient experiences. Using an integrated treatment approach that addresses behaviors, diet and lifestyle could improve outcomes. Aligning financial incentives (e.g., fixed monthly payments) may reduce unnecessary testing and drive those needing in-person services to lower-cost sites. And developing new tech-enabled, team-based workflows could boost clinician productivity and wellbeing.

However, it is not possible to provide all GI care exclusively online. Virtual-first providers must develop protocols with clear thresholds for in-person services. They may use APIs to order local (even at home) lab tests and imaging studies. However, it is more challenging to identify and connect patients with the right local GI or surgical practices for consultations, procedures and infusions.

Along these lines, they are challenged to define the right patient segments to serve. The best fits are likely those with low or moderately complex GI conditions (e.g., straightforward GERD, constipation and IBS) who do not require in-person assessments and prefer virtual to in-person care (many do not). Although this is a large market, it excludes those with more complex conditions (e.g., severe Crohn’s disease and severe functional GI disorders), who account for the bulk of GI healthcare spending, potentially limiting these virtual-first providers’ overall impact. Oshi is conducting a research study to help answer some of these questions.

Ideally, virtual-first GI providers will move beyond already crowded employer channels to develop referrals from traditional, advanced and virtual-first primary care practices. And without any procedural revenue, they must generate high enough margins from value-based contracts to pay gastroenterologists. They need at least some competitive-enough salaries.

The rate of change is both slowing and accelerating.

In many ways the pandemic has been healthcare’s iPhone moment, moving virtual care from abstraction to reality. Still, GI care has already snapped back to the in-person status quo, leaving upstarts to lead the way forward. If they gain enough traction, traditional GI practices will eventually be forced to also embrace virtual care, alone or with the right partners. The opportunities are too great to ignore.

Spencer Dorn, MD, MPH, MHA is a gastroenterologist, professor and vice chair of medicine for care innovation at the University of North Carolina.

He thanks the following people for sharing ideas and information about their work: Ali Arjomand and Victor Bian (Allay), Elena Mustatea (Bold Health), Dr. Jordan Karlitz (GI On Demand), Caroline Hosteler (Mahana), Dr. Sameer Berry and Sam Holliday (Oshi Health), Dr. Larry Kosinski (Sonar MD), Monique Fayad and Dr. Laurie Keefer (Trellus Health) and Dr. Simon Matthews (Vivante). Also, big thanks to Dr. John Allen and Joe Connolly for providing feedback on earlier versions of this essay.