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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar. Today I'm really excited to be joined by a good friend, Dr. Juan Andino, who's an assistant professor of urology at UCLA specializing in men's health. Dr. Andino is also at the forefront of expanding access to telehealth care not only just for urology but for all of medicine in general. And today we'll be having a discussion on the path forward for telehealth care and urology. Thanks Dr. Andino for being here with us today.

Juan Andino: Dr. Talwar, what a absolute pleasure to be able to be here today and talk about something that obviously I'm very passionate about, I've had the pleasure to be able to do research in with great mentors, and that really has a strong policy and advocacy importance because there's a lot to be determined, and many of the things that we're still dealing with from the telehealth landscape of reimbursement are just extensions of the public health emergency that are temporary. And we'll talk a little bit more about that.

Ruchika Talwar: Absolutely. So let's dive right in.

Juan Andino: Thank you folks, UroToday team, for the opportunity really to be able to highlight this particularly as people from the American Urological Association start thinking about the upcoming advocacy summit. This is something that for the last several years, certainly since the pandemic, has been a topic of interest, and because all of the flexibilities that were associated to the public health emergency are changing, and some of them have been extended only temporarily, it's still particularly important to understand what the current state is. And so I'd like to start by highlighting some of the patient benefits. Many folks who have been living in this space are aware that really during the COVID-19 public health emergency was the first time that new patient visits became both allowed and reimbursed, and so this really has led to an expansion in the research and the data that supports their use from a patient benefit standpoint and avoiding things like travel time and financial toxicity.

I love highlighting this article from earlier in the year that shows that at a major tertiary academic center that focuses on treating cancer patients in Florida you can see that when they looked at the patients that underwent new evaluations, the roundtrip miles that were saved were almost close to 200 miles that patients were avoiding by engaging in their care using telehealth, they saved an average of 3.4 hours of drive time and about an hour and a half of time in these appointments. And the really critical aspect of this is look at these estimated cost savings for patients. So this was related to the cost of travel, gas prices, paying for parking, but also the wages, so taking time off work either a half day or full day, and that's what allows for these ranges. And you can really see it can be particularly important for patients because they're saving anywhere from $177 to $223 just financially.

That doesn't take into account the hours, three and a half hours almost of time saved by being able to connect with a specialist using video. And importantly, this isn't focused on just urology. This was for all newcomers for different forms of cancer treatments. And with provider shortages being something that our association and the AMA thinks about, it really highlights how telehealth can be a tool for connecting patients to the appropriate care. And physician perspectives have certainly changed. Back in 2019, the adoption of telehealth visits, video and audio, was really only in about the 28% range. Of course, during the pandemic, many people, many institutions, many clinics had to pivot and use telehealth to ensure that patients continue to have access to care. And it was really great to see that in 2022 respondents, so these are physicians, clinicians that are answering this survey from the AMA, that 88% really now see telehealth as a way to improve clinical outcomes and also to improve work efficiency.

And from the coding and reimbursement aspect of things, I highlight this study from prior to the pandemic, one of the concerns that consistently get raised is, well, telehealth is going to lead to lower coding, therefore lower reimbursement, and from a financial standpoint, many practices have been concerned about this, but this has really changed significantly. Ever since the 2021 billing updates where we can focus on medical decision-making, particularly as a surgical specialty, you can still really capture the complexity of the care that is being delivered. And as long as a physical exam or an in-office procedure evaluation is not required, really the level of coding and the level of reimbursement between telehealth and in-office appointments right now remains with good parity.

And so these are my arguments for the reasons that telehealth is worth continuing from a patient access standpoint of things, decreased travel time, cost savings for patients, reducing some of that financial toxicity that's associated with the US healthcare system. And then for the first time, because of the public health emergency and the COVID flexibilities, new patient visits actually finally have the potential to increase access to specialty care. Prior to 2020, it was really only established patient visits that were allowed in terms of reimbursement. There's high physician satisfaction, and physicians now are 88%, almost 90% of physicians rate video visits as a way to be able to improve efficiency and maintain or improve clinical outcomes. And finally, most of these visits when appropriately selected by a physician, by a clinician, they serve as a substitute for in-person care. And this really has been reflected in the updated coding changes since 2021.

And to really lock into the policy aspect and why this is still such an important topic that we need to discuss both within urology but across all of medicine is that the Consolidated Appropriations Act extended public health emergency flexibilities until December 31st, 2024. And so what does that mean primarily looking at Medicare because many private payers follow the lead that Medicare is setting as a standard? Well, from a Medicare standpoint, the originating site requirement, the need for patients to be in a healthcare facility and to be in either a rural or healthcare professional shortages area is no longer a requirement, that has been extended until December of 2024. So to summarize that, patients can do telehealth from home, which is obviously when it's most beneficial. For now, payment parity remains in place so that these video visits are paid the same as an in-person appointment as long as the billing level is the same.

And interestingly, audio only encounters are still continuing to be reimbursed, but the payment parity there is closer to an established patient visit as opposed to a new patient encounter. And that's because in many ways folks worry that the quality of the encounter may be a little bit less if it's audio, but there's a health equity lens that we need to look at. Many studies have actually shown that minorities, patients who don't speak English as a first language, people in rural areas or from lower socioeconomic communities actually have more difficulty connecting with video, and so audio only visits should probably still be an option so that we don't leave some patients out of the ability to connect through telehealth. And direct supervision, this is particularly important for any folks that are working with residents or who directly supervise nurse practitioners, PAs, APPs, this has also been extended to include virtual supervision in terms of billing guidelines.

It originally was going to end at the end of this year, but because of policy and advocacy efforts, including the AUA sending in arguments for the importance of this since the pandemic, it has been extended as well until the end of December 2024. The DEA recently changed some of their rules and regulations. The controlled substance prescriptions was also due to end this year. But again, thanks to advocacy efforts from the AUA and other institutions, it has also been extended to match the temporary flexibilities that are in place until the end of December of next year. And what has the most variability right now is Medicaid and the private payers at a state by state level. So there's significant variation. Either your hospital or your clinic billing department really needs to be engaged and involved. And if they don't have a sense of how those rules are changing, often the local and regional state medical societies can provide some excellent guidance.

I just wanted to cover a little bit of that information, and I'll leave this up for our listeners and our readers of the article, we did get a chance to put together a comprehensive narrative review of a lot of the new data that has come out during the pandemic relating to exactly those public health extensions that I discussed in the last slide. And so for folks who are interested in this area who are going to be involved in advocacy efforts I just wanted to put a plug for this article as a resource because we cover patient perspective, physician perspective, but also clinical outcomes where the data is accessible and available, as well as hospital related metrics, things like efficiency, no-show rates, and the data really supports that telehealth is a wonderful tool that we can continue using moving forward.

Ruchika Talwar: Thanks so much. What a comprehensive, awesome overview of such an important topic. I think you covered all of the major points of telehealth care, its advantages and some of the concerns that were historically cited. I think most physicians and most physician organizations agree that telehealth was one of those silver linings that came from the pandemic, because, as you said, it addresses so many barriers to care from a health equity perspective, from a resource perspective, and from ensuring patients are able to follow up without needing to take time off of work, reducing financial toxicity and things like that. So we've talked a bit about the advocacy focus here, and obviously this is yet another temporary extension only through the end of 2024 for some of these benefits. What is your advice to the urologic community? What can we do to make sure that these telehealth benefits for ourselves and for our patients are here to stay?

Juan Andino: Yeah, 100% that's probably one of the most important and key questions and things to be looking at and thinking about over the coming year and two months is anybody who's using telehealth, anybody who has the capability to do research and look at their own internal data, think about writing it up. Is there something that you're doing differently because of the pandemic, a new workflow, a new way to allow patients to connect and have follow-up and have care? And if you can demonstrate continuously good and appropriate clinical outcomes, improved efficiency in the clinic setting, many people frame these research articles or research publications as a QI project, but all this data is very important and it's what we use to be able to sit down and speak with legislators, lawmakers, people in their offices to say, "Here's the data that supports this used. Here's the patient satisfaction and the surveys that show that they really want this to continue, they really want this option to be able to connect with their clinicians, with their doctors, with advanced practice providers using telehealth for their convenience."

But also because in many cases it's very appropriate, you're mainly having a conversation and either reviewing labs or imaging, and so it really seems to serve when used appropriately as a substitute for in-person care and being able to use data to back up the argument of we want this to continue, it's going to be really important.

Ruchika Talwar: Absolutely. Couldn't agree more. And before we wrap up here, what is your advice for some of those physicians who are still not fully on board with the concept of telehealth? What's your compelling argument to them?

Juan Andino: Yeah, 100%, I think one of the biggest challenges is people seeing telehealth as, well, we have to create an entirely separate workflow for this system. And really I think when you've reframed that and think about telehealth as this is just another way to either get patients access to the clinic and to get care or to facilitate continuity of care, many people are finding that clustering telehealth visits, having a half day, for example, I have two half days during the week of telehealth appointments, and being able to cluster those telehealth visits together can help with the workflow and being able to maintain that patient follow-up. The other aspect too is how do you relate that to how you currently order labs, to ordering follow-up, to setting up surgical appointments. So really the more you can integrate that into how your clinic your practice currently works, the better it's going to be, the more straightforward.

The folks who have tried to design telehealth as this totally separate workflow and way to connect with patients end up generating a little bit of extra work, as opposed to saying, "Okay, what are our current systems and processes and how much of this can we just directly transfer over to telehealth?" It's just the appointment, it's going to be using this video camera instead of using a clinic room. And if there are any tweaks for things of following up, labs, who's going to schedule the appointment afterwards, that is the design piece that takes a little bit of time and it takes input from the other folks in the clinic, not just the clinician. So if your scheduler typically sits up front and they schedule people for a follow-up as they're walking out of the office, well, how is that going to be communicated if somebody has a telehealth appointment?

To use our clinic as an example, we have a pool where the different three, four schedulers that help set up appointments for the men's health clinic, I send them a message at the end of a telehealth appointment, say six week follow-up with X, Y, Z labs. And that way, even though the patient's not physically walking out of the clinic, our schedulers get that message and they're able to reach out to them directly, either with a portal message or with a phone call to schedule those next steps.

Ruchika Talwar: Yeah, absolutely. Well, thank you so much for taking the time today to share your expertise in this area, and I know that we're all really fortunate to have you doing this important work and advocating for telehealth care on our behalf.

Juan Andino: Dr. Talwar, thank you so much for having me, and to the UroToday team, fantastic to be here and to get a venue to highlight some of the new data that's out there, but the continuing work that we need to do to make sure that this is not just a temporary extension, but an option for us to be able to use moving forward.

Ruchika Talwar: Absolutely. Couldn't agree more. Thanks so much to our audience for joining in, and we'll see you next time.

Juan Andino: Bye everyone.