Category: Covid19

30 Jul 2020

Curated Business/Tech GI Resources: July 29th, 2020


Curated Business/Tech GI Resources: July 29th, 2020
Video: Interview with Dr. Alaparthi: Gastroenterology Center of Connecticut joins Hartford HealthCare  (NextServices)
Learn how a multispecialty GI group made a decision to ally with a regional hospital – an option that allowed them to stay independent.
A Closer Look at Exact Sciences, The Company Behind Cologuard  (Gastroenterology & Endoscopy News)
In April, television viewers heard in an advertisement for Cologuard: “Even though you’re stuck at home, you can still be screened for colon cancer.”
Practicing Medicine In The Era Of Private Equity, Venture Capital And Public Markets (Forbes)
“A business imperative trumped a clinical one—in each case introducing potential harm to patients for the benefit of shareholders and investors.”
Indiana GI group breaks ground on new clinic with surgery center (Becker’s GI & Endoscopy)
Evansville, Ind.-based Digestive Care Center broke ground on a new digestive care clinic in Warrick County, Ind.
Women Physicians 2020: The Issues They Care About (Medscape)
Medscape surveyed more than 3,000 women physicians, asking what their major challenges were. Work-life balance was by far the most important issue for women.
DDW: Spotlight on the Pancreas  (Gastroenterology & Endoscopy News)
Elham Afghani, MD, MPH, an assistant professor of medicine at the John Hopkins Pancreatitis Center, highlights pancreatic research submitted to the 2020 Digestive Disease Week.
COVID-19-related delays could cause 10,000+ CRC, breast cancer-related deaths, model says (Becker’s GI & Endoscopy)
The National Cancer Institute created a model examining breast and colorectal cancer-related mortality in light of COVID-19-related screening delays.
Standard of care lifestyle counseling improves NASH, fibrosis in children with NAFLD (Healio)
“NASH or fibrosis improvements occurred in 52% of children and 20% of children saw improvements in both.”
How a Texas endoscopy center is navigating the pandemic to stay open and independent (Becker’s GI & Endoscopy)
“When the pandemic started, our priorities initially were to make sure we were prepared with enough of an inventory for PPE and other supplies,” said Louis Wilson, MD, a partner at Wichita Falls Endoscopy Center.
Physician Recruitment Drops by 30% Because of Pandemic (Medscape)
“Rather than having many practice opportunities to choose from, physicians now may have to compete to secure practice opportunities that meet their needs.”
Employer-related concerns of health care social media (Healio)
“If you wouldn’t feel comfortable sharing it in an elevator, then don’t share it on social media,” Katie Duke, ACNP-BC said.
10 GI groups growing in 2020 (Becker’s Hospital Review)
This article outlines ten gastroenterology groups with plans to grow their footprint, workforce or services in 2020.
Japan university creates device to protect against COVID-19 transmission during endoscopy (Becker’s GI & Endoscopy)
The device captures coarse droplets from patients undergoing EGD and reduces the diffusion of aerosol droplets.
What Docs Hate: Every Specialty Has Its Thing (Medscape)
What things do different specialists hate? – Gastroenterologists hate food allergy tests — at least in the opinion of Irish gastroenterologist Anthony O’Connor.
Video: Patient protection during COVID-19 at The Endoscopy Center at St. Francis (Indianapolis Gastroenterology)
Learn how The Endoscopy Center at St. Francis is protecting patients during the COVID-19 pandemic.
Video: Reopening endoscopy during COVID-19 (Healio)
Nadeem Baig, MD, from Allied Digestive Health in New Jersey, talks about adapting an endoscopy practice to reopen during the COVID-19 pandemic.

Headlines for GI

How real is Virtual/Augmented Reality in healthcare? (Exponential Tech Part 4) (NextServices)
Congress Aims to Keep Telehealth Momentum Going Beyond the COVID-19 Crisis (mHealth Intelligence)
New Medicare Pass-Through Code for Single-Use Endoscopes (ASGE)
The Role of Biomarkers In the Management of Barrett’s Esophagus (Gastroenterology & Endoscopy News)
New CDC Guidance for Healthcare Personnel Exposed to HCV (Medscape)
AI in healthcare: Microsoft’s Kevin Scott on how tech can treat a pandemic (McKinsey & Company)
Work-life balance dwarfs pay in female doctors’ top concerns (GI & Hepatology News)
6 months in: The COVID-19 crisis (HealthcareDive)
HHS Issues New Report Highlighting Dramatic Trends in Medicare Beneficiary Telehealth Utilization amid COVID-19 (HHS)
5 top-read stories in GI this week — Income stats, preserving autonomy & more (Becker’s GI & Endoscopy)
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COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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27 Jul 2020

Interview with Dr. Alaparthi: Gastroenterology Center of Connecticut joins Hartford HealthCare

 

Dr. Latha Alaparthi is from Physician Alliance of Connecticut (PACT) and Gastroenterology Center of Connecticut (GCC). She’s also the Vice President at Digestive Health Physicians Association (DHPA). As of July 1st, 2020, PACT GI Center joined Hartford HealthCare Medical Group.
In this interview, learn how a multispecialty GI group made a decision to ally with a regional hospital. Understand what steps PACT GCC took to navigate COVID-19 and what they are doing now to continue endoscopies safely. More importantly, Dr. Alaparthi reflected on how there could be more women in leadership positions in gastroenterology. And how physicians must take care of themselves first.
Watch this fantastic interview that’s soaked with unique insights you won’t get to hear anywhere else.
◘ Dr. Alaparthi’s journey with GCC
◘ The relationship between GCC and PACT
◘ “One of the things we wanted to do was make sure we stabilized our referral base”
◘ The pros and cons of being in a multi-specialty environment
◘ Insights on the big decision to join Hartford Health
◘ What became clear for PACT was to align with an entity that would allow us to remain independent
◘ Does life look the same or does it look different?
◘ How PACT navigated through this competitive landscape?
◘ “We will do what’s best for our patients”
◘ Navigating through the pandemic
◘ “The first few weeks were surreal”
◘ “One of the things that we did early on was to switch to telehealth”
◘ “We were one of the few ASCs that didn’t completely shutdown”
◘ Changes from the patient standpoint
◘  Testing thousands of COVID patients
◘ Staff challenges during COVID
◘ On physicians: “We need to make sure that we take care of ourselves to be able to take care of our patients”
◘ On why there are fewer women leaders in gastroenterology
“It’s basically like running a house”
◘ The future of GI post-COVID

 

The Transcribed Interview:
Praveen Suthrum: Hi Dr. Latha Alaparthi. Thank you so much for joining me today and I welcome you to our conversation.
Dr. Latha Alaparthi: Thank you. Thanks for having me.
Praveen Suthrum: You are part of the Gastroenterology Center of Connecticut and also the Vice President of DHPA (Digestive Health Physicians Association). So, I want to begin by asking you to share a little bit about your practice.
Dr. Latha Alaparthi: Thank you again Praveen for having me. I have listened to some of the other speakers on this and it’s very informative. So, I hope I can be useful to whoever is tapping into this. So, I joined the group in 2001, I actually met the then program director as part of my program at Yale-New Haven who was actually one of the three physician groups that founded this company – Gastroenterology Center of Connecticut. So, he recruited me to the group and I’ve been with the group since 2001.
The group is grown from a three-member group. By the time I joined it was a seven-member group. I was the seventh person. And now it is at 13 and soon to have three new physicians to be joining us from different parts of the country, including one of them being a Yale-fellow (New York) and one that’s transitioning from California to us. We’ve had some physicians who have joined us and then moved to different parts of the country. But we are 13 at this point and have three more joining us in Connecticut.
Praveen Suthrum: Okay. So, I know that there is a relationship between GCC (Gastroenterology Center of Connecticut) and the group called PACT (Physicians Alliance of Connecticut). Can you clarify what the relationship is?
Dr. Latha Alaparthi: Sure. Gastroenterology Center of Connecticut was an independent PC since founding until 2013 when it became part of the multi-specialty group. We’ve had a close affiliation with the Yale hospitals in terms of admitting our patients, taking care of our patients, teaching obligations, and appointments. In 2012, around that time it became clear that many hospitals, including Yale, were acquiring primary care groups in the area… which was troubling to us. It was troubling because that’s how we get our referrals. And one of the things we wanted to do is to make sure we stabilized our referral base. And one of the founding members along with a few in the community decided to brainstorm forming a group, that allows us to remain independent and secure at least part of our referral base, not all of it, but at least a good part of our referral base so that we don’t feel so threatened.
Praveen Suthrum: Did that happen? Did you secure your referral base?
Dr. Latha Alaparthi: Definitely. It has made us feel more secure. As I said before, it is not that all the referrals are coming from this group but majority do. And it definitely helps us in terms of feeling more secure.
Praveen Suthrum: So, this is a multi-specialty group versus a single-specialty group. What are the pros and cons of being in a multi-specialty environment as a gastroenterologist versus being in a large single-specialty group?
Dr. Latha Alaparthi: So, when PACT formed, it had internal medicine, gastroenterology, nephrology group in the beginning, and then its surgical group joined our group and more recently orthopedics. Majority of the physicians were for internal medicine. The way the group was formed was to make sure that the primary care physicians were always given enough of a voice to impact the long-term process of the company. Because that was really our main intention, to make sure that they were stabilized in order to help us stay secure with our referral base. So, initial issues with the company were just really learning to work with multiple physicians rather than running our own company.
So, if you can think of running a GI group versus a primary care group, they’re completely different. When you’re forming an MSO, a billing group that now has to cater to not only colonoscopy codes but also nursing home codes, that becomes a challenge. So, there was a significant amount of learning in that perspective. Plus, the electronic medical record system had to be catered to different types of visits. So, all that posed its own challenges. So, those I would say are the main challenges, learning to work with other physicians but in general, we learned a lot definitely in the first four-five years. Everything from day-to-day visits to navigating through HR, to billing, EMR, we had to almost start from scratch and build it up.
Praveen Suthrum: How did you manage to divide the cost and responsibilities because, like you said it’s two different worlds, and GI as a specialty is procedure-driven, primary care as a specialty is not as procedure-driven, so the earnings are different. How did you figure out how to work on the costs of the MSO?
Dr. Latha Alaparthi: So, MSO is based on the fee structure and the fee is the same. Our endoscopy center is not part of PACT. It’s actually completely separate from the medical practice. It is still a very much physician-owned entity. We have currently a four-room ASC in two different locations of our practice. So, in terms of cost allocation in the beginning there was a little bit of a give and take. Some units needed more help in certain areas and not others and vice-versa. So, in the end, I think it was a trade-off. For example, some primary care groups were on paper charts and they had to convert to EHR completely so that took a significant amount of time in the beginning. But in terms of this individual cost allocations, it’s all completely kept separate.
Praveen Suthrum: You’ve recently made a big decision to join Hartford HealthCare Medical Group. So, that’s a sea change from probably the existing structure or any of your previous structures. So, I was curious to know how you went about with your decision and the story behind that.
Dr. Latha Alaparthi: That’s a very good question and a tough one to answer in a small-time format but I’ll do my best. We, historically as you can think of are in the greater New Haven area catering to Milford New Haven suburbs and into the Guilford, Branford area along the shoreline. So, historically our practice has always been at the Yale-New Haven entities. We still are very much affiliated we have teaching affiliations; we have leadership positions at Yale-New Haven Hospital. What became clear for PACT is for it to align with an entity that would allow us to remain independent. And what PACT has been able to secure at this point is an ability to continue to remain independent with our structure and MSO intact. So, what we have done is to create a professional service agreement that allows us to remain independent and I’m really hoping that this will be a structure that will be alive for many years to come because I think it is very important for a group like ourselves who fiercely protect their independence to remain so.
Praveen Suthrum: Did Hartford have similar agreements with any other group in the region?
Dr. Latha Alaparthi: Well, as I understand, there are PSAs with groups but this is their first and only MSA.
Praveen Suthrum: The reason that I asked that question was because I wondered if you had a template or they had a template that they followed or are you familiar with similar arrangements in other parts of the country that you’ve said, ‘Oh they’ve done it this way, we can follow them’
Dr. Latha Alaparthi: Apparently not for the MSA. There have been templates within the state for PSAs and they followed that to a large degree but the MSA was unique.
Praveen Suthrum: Practically speaking how does this all work? Does life look the same or does it look different?
Dr. Latha Alaparthi: As of right now not much of a difference except for the change in the way we address ourselves when we pick up the phone. That has been one of the major changes. We have changed our name effectively from the 1st of July from PACT gastroenterology center part of Hartford HealthCare Medical Group. Obviously, that becomes a long introduction so we introduced ourselves as PACT gastroenterology center. In terms of the day-to-day work not much has changed but there’s a significant amount of work ongoing to see where we need to make changes and one of the big things that any company venturing into something like this looks for is to make their footprint known. And I believe Hartford Healthcare is no different and understandably so. There will definitely be more of a presence in terms of logos and signs and signage that will change in the next few weeks.
Praveen Suthrum: How did you navigate through the competitive landscape while making this decision with respect to other hospitals that I’m sure you’re close to and so on.
Dr. Latha Alaparthi: It’s a tough one and I’ve said this to many of my colleagues and as a physician that’s very passionate about what I do and the care I provide for my patients and really respecting my independence and wanting to practice the way we feel is best it has been a tough one to navigate and make sure that we are allowed that freedom as we go forward. And to that end, we’ve had to be very open and discuss this clearly with all sides. So, historically as I mentioned, and I trained at Yale so it’s my fellowship mentor and I know many people from that area and we work very closely at the same time we decided what’s best for us is to align ourselves with Hartford healthcare Medical Group for the prior reasons mentioned.
And so, we’ve been very open both sides stating that we will do what’s best for our patients and we will send our patients where their best cared for and where they feel comfortable. And so, to that end, I really don’t care for feeling like a pawn in territorial situations in states and I’m really hoping that both sides will respect that and we will continue to. I mean it is early stages, but we are led to believe at this time from the conversations we have had, I don’t believe they will really force us to change anything. Both sides have been very accepting, and very open in allowing us to be who we are and actually respect us for who we are.
Praveen Suthrum: Would this arrangement be restrictive for you to go see patients at Yale or there’s nothing like that?
Dr. Latha Alaparthi: No. In fact, in one of the smaller hospitals in Milford where are the only GI group and we have very much of a presence it’s a small hospital and I used to be the President of medical staff before it became part of the Yale healthcare system and now it is part of a Bridgeport hospital which is Yale healthcare system and I’m still the chief of GI there. My colleague David Hass who is the chief of GI at St. Raphael campus. We have leadership positions, I’m on the medical executive board of Yale-New Haven medical practice. So, we have a presence at Yale and I do not believe it will change the way we practice And I really hope it doesn’t come down to that because then I would have to fight for what’s right for my patients.
Praveen Suthrum: Okay. I’ll get to COVID now. Connecticut was one of the earliest affected states when COVID hit. How did you navigate the pandemic and how are things going now?
Dr. Latha Alaparthi: When COVID was sort of erupting in the New York region, we were wrapping up our DHPA meeting in DC. The last day of our meeting was very interesting. We had several meetings. I had I believe 12 meetings at the congressional offices and senate offices and it dwindled down to about three meetings and at the end of the day, we weren’t even sure if we would take our train back because of the New Rochelle shut down because the train Amtrak goes through New Rochelle. It was very interesting, the whole evolution of that. One of the people that was first diagnosed with COVID in Bridgeport hospital was a New Rochelle physician. A physician that lived in New Rochelle but practiced in Bridgeport who unfortunately has since passed; he was a pulmonologist.
So, that’s how things began for us and the first few weeks were surreal and I went from having a normal office day or at least seemingly normal office day that Monday after we returned to within two days to go into a complete shutdown and having to change all of our patients that were on schedule for endoscopies telling them that we don’t know when we will open again. One of the things that we did early on is to try and switch to telehealth. We had been doing telehealth in terms of telemedicine phone calls prior to this I was one of the first few physicians that was using it in my office. But we soon transitioned to telehealth and at that point, the biggest crunch was trying to find the right platform to offer telehealth to our patients that was easy to understand and was reliable in terms of connectivity. And then the endoscopy center. That was a huge issue there was so much unknown. What we could only fall back on were the experiences from Wuhan because we didn’t have any in our country at that time.
We were one of the few ASCs that didn’t completely shut down. We had about 5% of patients coming in per week. Those that absolutely needed their procedures and could not or should not be done in the hospitals for the reasons of COVID. We took extreme precautions like an hour in between patients and such just to make sure that those individuals were able to get through their procedures and since the opening, it has been a whole new paradigm. While we were in the first two weeks of the shutdown, I quickly got thinking that we will need to open our ASC at some point down the road when COVID is still here. We can’t be shut down forever. And we have an obligation to offer these procedures and diagnose patients in a timely manner. So, I came up with a format that I thought at that time made sense because I was very excited about the antibody testing which obviously has not panned out as we expected and I presented it to a few people at DHPA, the exec team and to one of the physicians who’s also a DHPA member and also on the AGA leadership and there was a significant amount of interest and that led us to work with AGA and DHPA and in developing that joint guidance along with all of us involved which was a very relevant practical step for us and still to this day is being used.
Praveen Suthrum: From the patient’s standpoint what kind of change did you notice? Like were they as open to come to the ASC? I know you’ve restarted but what is the sentiment right now?
Dr. Latha Alaparthi: Since we’ve reopened in the last three or four weeks it has been a whole different paradigm shift and now because of the guidances and the increased number of cases, one of the major steps that we take is testing everyone. We have developed a ten-day symptom log not just temperature but other symptoms that can affect gastroenterology in specific including bowel changes etc. We expect our patients to fill that symptom log and also have PCR testing within 72 hours of the procedure. So, testing, tracking, and reminding patients to keep their symptom log and making sure the results are in the chart before they arrive or the procedure or actually before they prep for the procedure has been a task of its own.
It has really put a strain on our staffing which is suffering, which is a whole discussion in itself, added complexity to what we do every day. This is in addition to what we have already done in the endoscopy center which is a significant amount of cleaning in between procedures and PPE that everyone is recommended to wear.
Praveen Suthrum: Are you contact tracing post-procedure? And how are you doing that?
Dr. Latha Alaparthi: So, fortunately to date we have not had anyone that has tested positive after the procedure. So, we have not had to elicit that but we do have a process thought through in place as to how we would contact trace if that were the case. So, what we do now is call patients a week to 10 days out and make sure that they have not had any new symptoms that are suspicious with COVID and also instruct them to call us back if they develop any symptoms within the few weeks after the procedure. Fortunately, we have not had any cases.
Praveen Suthrum: Okay. That’s good to know. How has your staff taken all this and how are you managing that?
Dr. Latha Alaparthi: Yeah. I think it’s a good question and a tough one as well. Well, before I get on to that I want to let you know that between our group and CTGI which is another major group in the state we have tested a thousand patients and we have only a handful of patients who have turned positive. That was at the beginning of the pandemic when the cases were still high so it makes sense. And I believe our case rate was 0.02% or so at the time of positive rate. So, it has been very low in terms of the risk and we continue to test everyone. Our staffing, due to the shutdown of business before furloughed for a couple of weeks until the loans became reality and we were able to bring back our staff. Few staff members went on FMLA or took unemployment because they just could not afford to come back because of young children. Because unlike many other companies that can work remotely. We cannot work remotely. We did stagger our staff when the social distancing was still a significant issue in Connecticut and we quickly created HIPAA reliable home access to some of our patients that could room a patient for me to do telehealth.
So, we had to do a significant amount of workaround to make sure that everything was in place. As many people have said, among my colleagues, we put on a significantly higher number of hours as administrators to take care of fewer people in the pandemic time because of the number of workaround and processes, that we had to recreate as we took care of our patients. As of right now we still have a shortage both on the practice side and the endoscopy side or in the hospitals and in our endoscopy centers because many nurses that were on the borderline, thinking about retiring have decided to retire and many with health issues have decided not to work for the right reasons and many with childcare issues and other obligations have decided not to return. So, it is significantly straining ones that are in the mix and having to absorb work for other staff members that are not in the mix. And this is something that I am trying to navigate through every single day including yesterday. Making sure that nothing that is fully associated with our patient care is compromised because of shortages.
Praveen Suthrum: As a physician, you are putting yourself in risky situations and you are taking care of your patients and then you come home, and then you have to take care of yourself and your family. So, how do you navigate these two worlds of taking care of your patients versus taking care of yourselves and I’m asking on behalf of all physicians.
Dr. Latha Alaparthi: So, like any other first responder or physician out there that is interfacing with patients, I think many don’t realize that we perform procedures that are aerosol-generating. And that’s one of the reasons why our societies have come up with such stringent guidelines. For example, recently restarting the manometry or motility study that we perform in our office we had to come up with clear stringent steps in terms of a precaution we take not just for the patient but for the nurse that performs the testing and for everyone that uses that room subsequently. So, yes, it is a real risk that we take every single day in terms of exposure.
One of the things we should always remember is to make sure that you think about yourself because it is apparent from the statistics and the deficits that we are seeing, we are a very valuable commodity and we need to make sure that we take care of ourselves to be able to continue to take care of our patients. So, in that sense, we use the appropriate PPE and we make sure that we don’t compromise on the steps we’ve put in place to make sure that the patients that are coming in are not high-risk patients. The other aspects are to make sure that there are things that we have in place to relax. Whatever it is that takes your mind off and really takes you to a different sphere. Physical health and of course, my pet peeve is ergonomics. Don’t forget that despite the PPE, to ensure that you’re taking care of all the things that you need to establish your endoscopy rooms to not physically strain yourself or hurt yourself.
Praveen Suthrum: So, Dr. Alaparthi, you are one of the few women physician leaders that I know of in GI. I have a twofold question here. One is that how did you reach the role that you currently have, you play multiple roles. So, how did that happen? The second more important question is why is that the case? Why are there so few women leaders in gastroenterology and medicine as a whole?
Dr. Latha Alaparthi: Thanks for that question. I’ll answer it the best I can with my own experience and maybe the second one I can’t answer fully but I’ll do my best. The first was really… working with my office staff and really handling some of the challenges that became known to some of my peers and my senior physicians and administrators, ‘Oh she is good at this!’ and most of the times it was out of necessity. For example, I was extremely efficient with my schedules because of necessity. I had two young children at home and I had to navigate through hospital rotations, seeing patients in the office, making sure my results resulted back to the patients, etc. When they saw that the billings were at the same as some full-time physicians, and they asked ‘How do you manage this?’
So, I went into looking at everyone’s schedule, I started involving myself in making schedules efficient. Sitting down with the physicians, and telling them how they can navigate through schedules. And some of the issues that came up on a day-to-day basis and how I could handle them diplomatically with the patient and the staff. That became known to some of my staff members who then asked me to take on some leadership roles which like any female physician I said no in the beginning because my children were still younger and in schools. One of my administrators waited until I dropped off my younger daughter at college and met me the next day. And that’s when I took over as a managing partner of our company.
It’s basically like running a house. You look at every aspect of what you’re doing on a day-to-day basis and also the business aspect of it. Making sure that it is efficient and every employee is taken care of. Financial aspects are met with and staying accountable to yourself and your company. One of the things that will engulf you is the number of hours you have to put into the company. So, my involvement was a slow trajectory and before I became a managing partner, I was a president of medical staff, just being involved in with the medical staff at the local hospital, Chief of GI at the same local hospital. So, I had been doing more leadership roles in the community and small leadership roles involved in the executive committee of my company just to help.
In terms of why there are fewer female physicians, especially in private practice, I can’t ask for the past but I do see many women rising into the rolls at this point. And I’m hoping that they’re able to see themselves as leaders just as good at understanding the business aspect of the companies. I believe that is the part that many of us, men and women don’t really get a significant amount of exposure during training. But early on in the group, it is important to pay attention and really get into the details and realize that it’s not difficult to understand once you put your mind to do it. And I’m hoping that… that will change going forward. As we know the double AMCs data and my own daughter’s med school class shows that there are more female positions and medical students now than in the past and I believe that this is a number that will continue to increase and it is important to engage everyone into the leadership mix.
Praveen Suthrum: So, my final question Dr. Alaparthi is, what is the future of GI post COVID?
Dr. Latha Alaparthi: I was thinking through, And I think it is going to be technology. Patients still rely on us and the stress increased recently has definitely worsened functional bowel diseases. I do think that we will focus a lot more on putting technology so that we can take care of patients remotely. And coming up with treatment algorithms that are slightly different from what they are at this point. And hopefully adapt some of the technology that’s available whether it’s social media platforms or along the lines, where we can address patients individually but yet in a group through platforms that are secure and are accessible to patients. I think that this is going to be a new paradigm in the future in trying to keep the social distancing which I believe will be in place for at least the rest of the year if not into the next year.
Praveen Suthrum: What do you see to happen if we fast forward four or five years from now?
Dr. Latha Alaparthi: So, I was about to read a pill cam right before this [interview] and I’m probably going to go back to reading it. So, I think we’re going to try and look for platforms like that for diagnostic purposes which are more wireless and remote that can give us the view that we need and for diagnostic purposes or therapeutic purposes that we can intervene and be therapeutic in terms of interventions or procedures we perform and actually fix things. Home-based testing to some degree, of the things that we do including the pill cam-type testing, will probably increase. In terms of technology, we really need to focus on the platforms that we have and one of the things, for example, even today when I have to take care of patients, I sometimes have to have three EHRs open, which to me, is so detrimental in terms of patient care. I really wish there was interoperability and a lofty goal would be to have a single platform. But interoperability or ease of transitioning from one to the other instead of having to print, scan or import information from one to the other two just so I have information in one place I think is really affecting patient care.
The last would be to make sure that we have patients that have access to the platforms that we are putting in place. I was working with the fellows two days ago in one of the Yale GI clinics and it was clear that several patients that otherwise would have had to take public transportation to come to clinics have really embraced the telehealth platform and they really appreciate the fact that the doctor will call them, go over the treatment options and make sure that they’ve done their testing, that is a very time-sensitive one especially for inflammatory bowel disease, cirrhosis, Hepatitis C, along the lines. And that’s the population that oftentimes has the least access to many of these platforms. So, I feel we need to really keep our minds and eyes open to ensure that while we are innovating that we are also making sure that people have access to them.
Praveen Suthrum: Dr. Alaparthi, thank you so much for all the insights. It has been tremendously educational for me and I’m sure people who are watching this will feel the same. Was there anything that you wanted to share before we close?
Dr. Latha Alaparthi: I think the challenges that we’re facing as people. I really want people to know that each one of us are going through the same things about COVID and the transition. But with the whole challenge, has come the thought process and it almost makes you feel you can innovate because you have a challenge in front of you. And I’m hoping that we all embrace it and bring new ideas to the forefront and make them work.
Thank you for having me.
Praveen Suthrum: Thank you.
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By Praveen Suthrum, President & Co-Founder, NextServices. 

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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24 Jul 2020

Curated Business/Tech GI Resources: July 23rd, 2020


Curated Business/Tech GI Resources: July 23rd, 2020
Illinois Gastroenterology Institute (IGI) Joins GI Alliance (PR Newswire)
“We are pleased to resume our 2020 expansion strategy, even during these unprecedented times and the continuing COVID-19 health crisis.” said Dr. Jim Weber, CEO of GI Alliance.
13 Interviews With GI Leaders – Private Equity To COVID-19 (NextServices)
These interviews provide insights on a diverse range of topics. From Private Equity to AI to Ancillary services to COVID-19. Watch them all now if you have missed them before.
Audio: Fauci to Medscape: ‘We’re All In It Together and We’re Gonna Get Through It (Medscape)
Conversation with Eric J. Topol, MD; Abraham Verghese, MD and Anthony S. Fauci, MD.
How Optum performed in Q2 & more — 10 ASC industry notes (Becker’s ASC Review)
10 updates on ASC companies and industry-relevant companies to note.
10 stats on GI compensation, debt, net worth & more (Becker’s GI & Endoscopy)
Gastroenterologists reported average annual compensation of $419,000, the sixth highest amount of specialty physicians.
PE-backed Texas Digestive Disease Consultants breaks ground on ASC — 4 insights (Becker’s GI & Endoscopy)
Southlake-based Texas Digestive Disease Consultants has a new ASC underway in Mansfield.
Early colorectal cancer screening benefits African Americans (Kaiser Permanente)
The American Cancer Society estimates that this year 147,950 people will be diagnosed with —and 53,200 people will die from — colorectal cancer.
Half of Recommended Biopsies Can Detect Microscopic Colitis (Medscape)
All patients with microscopic colitis who had biopsies of both the ascending and descending colon had positive slide review for at least one of the two sites.
Telemedicine revolution, deferred  (Politico)
Telehealth’s coronavirus wave has already begun to crest, laying bare some of the longstanding problems that inhibited the technology’s growth for years.
Obesity and the diet-microbiome connection: a conversation with a gastroenterologist  (Apple Podcasts)
Supriya Rao is a gastroenterologist. She shares her story and her expertise in obesity and the diet-microbiome connection.
ProciseDx Secures $10.5 Million Series A Financing Round Led by Biosynex, Forms an Independent Point-Of-Care Diagnostic Company (PR Newswire)
These tests use finger prick blood or stool samples and ProciseDx’s first menu is focused on GI physicians and includes inflammatory and drug monitoring tests.
Plunging Colonoscopy Rates May Signal Crisis Ahead (Medscape)
“We’ve made 32% fewer colon cancer diagnoses by mid-April compared with last year at that time.” Conversation with Jennifer A. Christie, MD; Carol A. Burke, MD and Klaus Mergener, MD, PhD.
‘We have to do a better job’: How structural racism in medicine harms both doctors and patients (STAT)
“I think that has to begin with medicine and the medical profession owning and just accepting their own role in perpetuating structural racism.”
‘This is the world without one vaccine:’ Addressing vaccine-hesitancy in IBD (Healio)
Talking to vaccine-hesitant patients about this topic can present significant challenges for gastroenterologists treating inflammatory bowel disease.
Treating Colorectal Cancer in the COVID-19 Era (Medscape)
“Our QUASAR group validated the Oncotype DX for colon cancer. The problem is that the risk factors associated with this assay for colon cancer are not as strong as for breast cancer.”
IBD Patients Can Learn Yoga From The Internet to Help Relieve Symptoms  (Gastroenterology & Endoscopy News)
An online video and audio series aims to introduce people with inflammatory bowel disease to yoga, meditation and breathing exercises from the comfort of their own homes.
6 new GI, endoscopy centers in June (Becker’s GI & Endoscopy)
Six surgery centers featuring gastroenterology and endoscopy services were opened or announced in June.
What’s Not to Love About Disposable Endoscopic Devices? (Gastroenterology & Endoscopy News)
Brian Lacy, MD, a professor of medicine at Mayo Clinic in Jacksonville, Fla., called the new findings “shocking.”

Headlines for GI

How real is Virtual/Augmented Reality in healthcare? (Exponential Tech Part 4) (NextServices)
3 Ways Predictive Analytics is Advancing the Healthcare Industry (Health IT Analytics)
Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19 (Health Affairs)
Physicians, Patients Give Telehealth High Marks During COVID-19 Pandemic (DHPA)
Audio: Your blueprint for diagnosing IBS (Clinical Care Optons)
Blood Test Could Signal More Severe COVID-19 Risk (Medscape)
Frost & Sullivan analysis calls 2020 ‘an unforgiving but transformational year’ for healthcare (Healthcare IT News)
Making use of the ‘new normal’ of wearable technology in clinical practice (Healio)
COVID vaccine tested in people shows early promise (MDedge)
Healthcare Industry Innovators Embracing Healthy Disruption (HIMSS)
Cedars-Sinai redeveloping GI facility after $25M gift — 3 insights (Becker’s GI & Endoscopy)
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COVID-19: The Way Forward for Gastroenterology Practices
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20 Jul 2020

How real is Virtual/Augmented Reality in healthcare? (Exponential Tech Part 4)

We have so many immersive experiences today that transport us to a reality that existed in dreams and fantasies earlier. Welcome to the world of Virtual Reality (VR). As the name suggests, it’s virtual and yet the experience is meant to feel real. A computer-simulated alternate world that you experience with sensory devices such as handsets and gloves.
Then there is Augmented Reality (AR), here the focus is the real world and there are digital elements superimposed. One of the best examples of this is in the Ikea Place app. If you wanted to see how an IKEA sofa looked in your living room, you just tap the product and use your phone camera to place the digital sofa in your living room to see how it looked.

 

So how does all of this fit into healthcare? Let’s check out some of the interesting applications in use.
In gastroenterology, the use of AR in the endoscopic unit helps improve the polyp detection rate, polyp classification, polyp size estimation, etc. Key to the AR technology is image processing and computer vision. Image processing allows the deconstruction of the image captured as a part of the input (camera) into a series of parameters and properties. The computer vision refers to the high-level image processing which allows the computer to interpret the image or series of images.
AED4EU is an app that uses AR to show all known Automated External Defibrillators in the location near you. AED4EU will also give you the phone number and address.
AccuVein uses augmented reality by using a handheld scanner over the skin and shows nurses and doctors where veins are in the patients’ bodies. It’s been used on more than 10 million patients, making finding a vein on the first stick 3.5x more likely.
These are just a few applications putting AR to good use in healthcare. Let us round up the overall benefits of AR and VR in medicine as it potentially promises to revolutionize treatment, therapy, training, and education.
1. Surgical Simulation, Training, and Education
Virtual Reality transports you directly inside the human body to access in 3D view even the tiniest of veins that otherwise would be impossible to see. Currently, medical students learn on cadavers, which are difficult to source and do not react as live patients would. In VR however, you can view minute details of the body in a 360° CGI (Computer-generated imagery) reconstruction & create training scenarios that could substitute common surgical procedures.
Case Western Reserve University and the Cleveland Clinic have partnered with Microsoft to develop a HoloLens app called HoloAnatomy to visualize the human body in an easy and spectacular way.
With Microsoft’s HoloLens Headset, app users are able to see everything from muscles to veins before their eyes through a holographic model. This has the potential to revolutionize medical education.

 

Specialized training simulators can be created to improve surgeons’ skills in various scenarios. Simulated models help many surgeons, plan, and rehearse before the actual surgery, as a part of preoperative planning. These virtual models of the patients’ bodies can be made using the MRI, CT, and Ultrasound scans.
Such simulators can also be used by trainee residents and students in developing intuition and decision-making abilities.
AR enables experienced surgeons to remotely assist residents by using an Internet connection and therefore opens the way of excellent distant teaching. Compared to virtual reality (VR) simulators, where the whole simulation takes part in a CG (Computer-generated) environment, the main advantage of AR simulators is the ability to combine real-life objects with CG images, resulting in satisfactory tactile feedback.
By monitoring and transmitting the image of a surgical site between two distant stations, remote virtual collaboration is possible between two surgeons. This concept is sometimes referred to as “telepresence”. A VIPAR ( Virtual Interactive Presence Augmented Reality) system was used in an effort to allow communication between Vietnam and the USA.
Another interesting example of immersive training experience is the HumanSim system which enables doctors, nurses, and other medical personnel to interact with patients in an interactive virtual training environment. This measures the participant’s emotions via a series of sensors. Helps the medical professionals to develop more empathy for patients among other things.
2. Virtual reality diagnostics
Virtual reality is often used as a diagnostic tool in that it enables doctors to arrive at a diagnosis in conjunction with other methods such as MRI scans. This removes the need for invasive procedures or surgery.
3. Virtual robotic surgery
A popular use of VR is in robotic surgery. This is where surgery is performed by means of a robotic device that is controlled by a human surgeon, which reduces the time and risk of complications. The robotic device is accurate, meaning smaller incisions, reduced blood loss, and faster recovery.
Robotic-assisted surgery with Da Vinci surgical systems are cleared by applicable regulatory agencies for use in a number of different procedures such as colorectal, cardiac, urology, general surgery, gynecological, head and neck, and thoracic.
4. Treatment of phobias, anxiety disorders, and addiction
Combined with biosensors that monitor physiological reactions like heart rate and perspiration, therapists can assess how patients react to stressful situations in a safe, virtual environment. This is applied to the treatment of post-traumatic stress disorders and patients with various phobias.
VR can also be a useful tool to treat addicts and prevent a relapse from occurring by exposing them to the right stimuli.
VR can help people with autism develop social and communication skills. It can also diagnose patients with visual or cognitive disabilities, by tracking eye movement.
5. Patient Education
The ability to view the inside of the human body in Virtual Reality is not only useful for doctors, but also for patients. VR allows patients to be taken through their surgical plan by virtually stepping into a patient-specific 360° VR reconstruction of their bodily anatomy. This helps them in the understanding of the treatment.
6. Pain Management & Physical Therapy
VR’s healing capabilities are used in physical therapy and pain management too. UW Harborview Burn Centre uses the VR game, Snow World, to alleviate the pain for burn victims during wound care. VR distracts the mind from the source of pain and immerses the patients in an alternate world of snowmen, snowballs, and penguins.
VR for physical therapy has also been shown to be effective in speeding recovery. Allowing the patient to do their prescribed daily exercises in a virtual environment makes the activity more fun, keeps them in high spirits during a long recovery period. Today, we also have the option of having a digital physiotherapist at home by means of a VR avatar.
Future Trends and Challenges
The adoption of AR and VR in healthcare is forecast to grow even more quickly, with the value of the market increasing by 38% annually until 2025.
However, there are challenges in the mainstream adoption of these technologies.
► Cost is definitely one of the factors. These technologies are expensive. A lot of big investors like Google and Facebook have pumped billions into the VR market, allowing for some very powerful hardware like the Oculus Quest to hit the market. The total cost of ownership of the technology solutions will need to be contained if it is to be adopted widely.
► Mobility is another challenge. One of the biggest limiting factors with current technology is the need for restricting headsets, display units, and all the cords used to connect them. However, hardware devices have started to trend towards being “untethered”. Facebook’s Oculus headset that initially needed to be connected to a powerful PC, became available as the self-contained Oculus Quest version.
► VR requires higher bandwidths and superfast networks. 5G will open up new possibilities for these technologies. Data transfer speed of 3 gigabytes per second (as opposed to 100mbps for home broadband) would be required to stream data from the cloud. Rather than needing to be connected to PCs, viewing devices will upload tracking data to data centers on the cloud where the heavy processing will be done. The rendered images can be delivered back to the user in real-time thanks to the speed of 5G and other advanced networks.
► Lack of knowledge and research around AR/VR in health care. A quick search of research studies shows over 3,536 publications with “virtual reality” or “augmented reality” or “mixed reality” in the title since 1991. Unless there is more knowledge and useful research available, mainstream adoption will be slow.
► Regulatory/Policy/Insurance issues. As with anything new in healthcare, unless there is wide adoption of this technology, regulatory and insurance challenges will be a given.
As Facebook, Google, Oculus, Samsung, and Sony continue to aggressively market VR/AR experiences for consumers, more people will be exposed to it and interest will grow. That said, patient demand and pull will have a powerful influence on administrative and clinical decision-makers.
Healthcare facilities from across the globe are now utilizing immersive applications such as vein visualization, surgical visualization, etc. Development-driven healthcare professionals are researching areas that could potentially benefit both customers and businesses. While some of the hospitals are not equipped to handle these technological advances, many of them (including third party companies) are choosing to invest in the same.
A lot of the VR and AR applications mentioned above are still in their infancy. However, the potential for VR in the healthcare sector is huge, limited only by the imagination and insight of those creating and applying the technology.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices
Image Credit: Pexels.com

 

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COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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18 Jul 2020

Curated Business/Tech GI Resources: July 17th, 2020


Curated Business/Tech GI Resources: July 17th, 2020
Video: Dr. Weinstein (Part 2): “Adapt or die…standing still is not a zero risk option”  (NextServices)
In the interview’s second part, Dr. Michael Weinstein reflects on the future of GI post-COVID and most importantly, he contemplates on social disparity in gastroenterology.
Popular Heartburn Drugs Linked to Heightened COVID-19 Risk (Time)
Researchers found that respondents who said they used proton pump inhibitor (PPI) medications to treat their heartburn had anywhere from two to nearly four times the risk of testing positive for COVID-19.
The Rise of the GI Hospitalist  (Gastroenterology & Endoscopy News)
By 2016, hospital medicine had become the third-largest medical specialty in the United States, with more than 50,000 hospitalists practicing at about 75% of hospitals.
10M people likely to drop out of employer coverage this year due to COVID-19: report (Fierce Healthcare)
“The COVID-19 recession has disproportionately affected the lowest paid workers, who are the least likely to have work-based health insurance.”
Gastroenterologists continue down rocky road to recovery (Becker’s GI & Endoscopy)
Gastroenterologists continue to feel the resonating effects of the COVID-19 pandemic as they work to return operations to pre-pandemic levels.
Florida digestive health clinics merge — 3 insights (Becker’s GI & Endoscopy)
Jacksonville, Fla.-based Borland Groover partnered with GI Associates of St. Augustine (Fla.) to expand its reach into Northeast Florida.
The ‘Strange Fruit’ that haunts my days and dreams as a Black physician (Healio)
Global demonstrations against police brutality have been inspiring. Their occurrence during the COVID-19 pandemic only amplifies their power.
Video: Reopening Endoscopy Centers: Expert Advice (Medscape)
We’ve had nursing personnel call patients to say, “We’re open for business, and would you like to come in?” – Conversation with Klaus Mergener, MD, PhD; Carol A. Burke, MD and Joseph J. Vicari, MD.
Pennsylvania practice struggles to secure PPE & more: 5 GI industry key notes (Becker’s GI & Endoscopy)
Five updates from gastroenterology companies and practices from the past week.
Google trends of GI symptoms may be ‘harbinger’ of COVID-19 (Healio)
Plots of symptoms vs. cases over time demonstrated an increase in search volume followed by an increase in COVID-19 cases after 3 to 4 weeks.
The Regueiro Report: More From DDW 2020 (Gastroenterology & Endoscopy News)
Miguel Regueiro, MD from Cleveland Clinic, highlights several abstracts submitted to the 2020 Digestive Disease Week – Part 2.
Audio: Doctors on Social Media (Healio)
Dana Corriel, MD, founder of SoMeDocs, also known as Doctors on Social Media explores why social media is so important in today’s health care landscape, and shares some tips on how to get your feet wet in the space.
GIs, patients highly satisfied with telehealth during COVID-19 (Healio)
“The expansion of telehealth coverage by CMS and commercial payors in the face of the pandemic has helped us enhance the care experience and improve cost-effectiveness,” said Naresh T. Gunaratnam, MD, of Huron Gastroenterology.
Evolving Clinical Understanding of COVID-19 and IBD Management (Medscape)
A On-demand webinar from AGA and Medscape offering CME.

Headlines for GI

Looking for a post-COVID health-tech idea? Find it in 3D printing (Exponential Tech – Part 3) (NextServices)
Interviews with GI Leaders (NextServices)
Video: Guidelines Reveal Probiotics’ Limited Value for GI Conditions (Medscape)
Top in GI: Reflux treatment, AI and colorectal neoplasia (Healio)
Outsiders are looking beyond the pandemic: The four vulnerabilities they are likely to pursue (Paul Keckley)
Coronavirus outbreak is already upending health insurance premiums and copays for next year (CNBC)
Emerging therapies for IBD: Finding long-term treatment without steroids (Healio)
Don’t Overlook CRC in Patients With AFib (Gastroenterology & Endoscopy News)
Virus Tricks the Body Into Attacking Brain; Common Heartburn Drugs Linked to Coronavirus Risk (The New York Times)
Walgreens, CVS and Walmart telehealth offerings: 18 things to know (Becker’s Hospital Review)
Many U.S. Hospitals Already In the Red—Then COVID-19 Hit (Gastroenenterology & Endoscopy News)
A massive roadblock: An unusual case of gastric outlet obstruction (AGA)
On the Spot: Debates in Colorectal Surgery 2020 (Gastroenenterology & Endoscopy News)
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COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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14 Jul 2020

Dr. Weinstein (Part 2): “Adapt or die…standing still is not a zero risk option”

 

Dr. Michael Weinstein is the President & CEO of Capital Digestive Care. As the largest gastroenterology group in the Mid-Atlantic states, Capital Digestive Care cares for 70,000 patients every year. 
In the interview’s second part, Dr. Weinstein talks about how many aspects of the medical practice can be done remotely. He reflects on the future of GI post COVID, his experiences with the giants of gastroenterology (e.g. Dr. Gene Overholt, the father of endoscopy) and what must fellows in GI must focus on. More importantly, he deeply contemplates on social disparity in gastroenterology.
Don’t miss this deeply reflective interview
◘ Two learnings: Telehealth really works…staff can function well remotely”
◘ What’s the future of GI post-COVID?
◘ 30-40% of our visits will be in telehealth
◘ Profitability of ASCs may lag
◘ We’ll get into more chronic care, remote management (obesity, NASH, NAFL)
◘ Clinical research may be more complicated
◘ There were aspects of Scope Forward that predict our need to adapt to COVID
◘ “The last thing I’d like to see is a second wave – it would be a financial disaster”
◘ “Adapt or die…standing still is not a zero risk option”
◘ Doing nothing is not strategy
◘ Reflecting back when Dr. Weinstein was an early career gastroenterologist
◘ Learning from the giants of gastroenterology
◘ Learning from Minnesota GI
◘ “Listen twice as often as you speak. You have two ears and one mouth”
◘ The question early stage GIs shouldn’t ask first…
◘ Reflection on social disparity in gastroenterology
◘ How did we only end up with such a small percentage of African Americans [in Capital Digestive]?
◘ “George Floyd aside…COVID really increased our awareness how healthcare disparities influences outcomes”
◘ “AGA Governing Board – there’s certainly recognition…how did we end up here?”

The Transcribed Interview:
Dr. Michael Weinstein: Most physicians within a month figured out a couple of things that they didn’t realize, one is that telehealth really works! You can actually do telehealth effectively. You can actually take care of patients; you can continue to provide healthcare and you can do it remotely. And the second thing that they have learned is those staff that were working in their offices, doing all that work in their offices, can actually function pretty well remotely. Their staff can work from home, a lot of that back-office services can be done remotely – scheduling, registration, claims, billing all this stuff can happen remotely and it doesn’t have to be under your direct vision. And if it can happen remotely with your staff, well then actually, maybe it can happen remotely in a platform where you do not have to worry about people working from home but somebody else can worry about the people who are working remotely.
Praveen Suthrum: What you just said naturally takes me to my next question, what do you see as the future of GI, post the pandemic?
Dr. Michael Weinstein: Certainly, what we see is that we’re probably going to continue to do telehealth. 30 to 40% of our visits will probably stay in telehealth. It may take a little bit of lobbying with the payors and Medicare although I think Ms. Seema Verma recently said “Oh we’re definitely going to have telehealth after COVID”. So, she still certainly feels it is an absolute necessity. The profitability of our surgery centers may lag. I’m not sure whether we will ever get back to the same profitability, at least not for a few years. I think some of the things that we will have to put in place – some of the provisions, some of the PPEs, some of the scheduling modifications to clean rooms, and things like that. I am not sure if we will ever achieve the same profit margins unless we can get a higher payment.
Praveen Suthrum: Don’t you see more cases coming from the hospital to the surgery centers?
Dr. Michael Weinstein: Yeah. But you know, our centers were relatively busy before. Does that mean we’re going to have to expand our surgery center with space and staff and open another room? Most groups probably have a backlog of three or four months of procedures. So, how do we catch up? Assuming that the patients still want to come in, how do we catch up? At some point, we will have to start doing six days a week. But that means hiring extra staff. I think roughly half of the ambulatory procedures in the country are still performed in hospital outpatient departments. So, there are certainly quite a few patients that might shift to ASC locations.
I think we will get into more chronic care remote management. You know it was already starting to happen before COVID. Looking at how do we manage the epidemic of Obesity and NASH and NAFLD and weight management, that’s more chronic disease management. We learned that our clinical research maybe more complicated at least for a few more months of getting patients enrolled into trials because of the number of visits. We are trying to avoid all the face to face contact. That may require some changes in how the sponsors want protocols to take place. And the standard paper binders for clinical research, there needs to be some change to make those electronic.
I have read most of your Scope Forward book, and there are aspects of it that almost predict the need to adapt to COVID. You didn’t know about COVID but the whole concept of innovation and adapting that you have written about, and talk to people about, it’s like… How did he know that we would have to actually meet and discuss and figure out how to adapt to our workflow? I’m certainly very nervous about what I see in Florida and Arizona and Texas. The last thing I would like to see here is a second wave. That would be a financial disaster if we had to close down again. So, I’m hoping we avoid that. I think most of my partners, certainly my older partners, who are in the high-risk groups for COVID, people who don’t do as well when they get infections; most of them are going to wait for a vaccine before they get comfortable. And that’s probably going to be February or March of 2021.
Praveen Suthrum: It is really a precarious time and whichever way I look at it, you know I read all the reports, from clinical to economic, the thing that I really come back to is that nobody really knows. And there are different estimates that keep changing by the week. Yeah so, the way I see it is you have to go with the flow and you figure it as you go along. You have a distant view; and you fold that future in; and you work in that direction but the situation can be very dynamic and it can change quite quickly.
Dr. Michael Weinstein: Adapt or die… adapt or die and that’s it. So, when we did our strategic planning, and some of the partners were very happy where we were, and their comment was ‘Why do we need to change anything?’ ‘We’re doing so well’ ‘Why don’t we keep doing what we’re doing?’ and the consultant said doing nothing is not a strategy. Standing still is risky. Standing still is not a zero-risk option, it is actually a very risky option. Stand still in the middle of a busy street, you’re going to get run over.
So, you have to constantly adapt. That doesn’t mean you have to get it right every time, you may sort of make a maneuver or make a change that doesn’t work out. You need to measure all of the changes that you make and determine whether or not the adaptation is moving you in the right direction. One of the best talks that I ever gave at one of the meetings was, ‘The 10 things I wish I hadn’t done.’ And it was hard to get to 10. I had to cut down from a list of 15 or 20, to get to the top 10 that I wish I had not done! On the other hand, I probably have that list and longer of the things I think, we did correctly. So, so far so good.
Praveen Suthrum: Dr. Weinstein, reflecting back on your own career, going back all the way when you were an early career gastroenterologist. I’m sure you had certain visions about healthcare and where GI would be at this point of time. So, where does that stand? Based on what all you’re seeing going on right now.
Dr. Michael Weinstein: What we’re able to do right now technologically in healthcare is amazing. But then you get a pandemic and you realize how fragile things are. When I first went into practice, I came out of my fellowship and I joined two gastroenterologists. They went from a group of two to a group of three and they had some close friends I could mention some names but, everybody knew this. So, one of my partners trained with Gene Overholt, one of them was close friends with Jim Frakes. You know, I was able to learn from the giants. Because my two older partners made me go spend time with these soothsayers. You know, Gene Overholt, the father of endoscopy, and Jim Frakes who was really this healthcare business savant.
I went up to Minneapolis to meet the leadership of the Minnesota GI group, and looking at how they saw gastroenterologists, and then just paying attention to what was happening in the Mid-Atlantic area, which was a lot of mergers of insurance companies and mergers of hospitals. So, I think within a few years of going into practice I already sort of had the notion that the only way we’re going to be successful is that we have to be more relevant and we need to have our own endoscopy centers. And with the support of my two partners, I built an endoscopy center in 1985 which was very early almost following the floor plan which Gene Overholt had built in Knoxville. So, lucky to do that.
I don’t think I could have foreseen the need to get this big but along the way that seemed to be an obvious change. And it’s not just GI practice, it’s healthcare delivery. I have a partner that likes to say that when he grew up, his father told him that he had two ears and one mouth, that he should listen twice as often as he speaks. So, the idea is to go listen to people who have been through the trenches and have figured out the good parts and the bad parts. Follow the good parts, avoid the bad parts, and pick and choose. So, I feel very fortunate to have been around a lot of those people over a 30-plus year career. It has been a privilege to lead and hopefully lead things a little better. I have three sons and I sort of pass on some wisdom as I said, you get along as you go through life. None of them went into healthcare, but the advice I gave them was, you know, as you go through life, try to pick up after yourself, don’t leave a mess, and try to leave the world a little better off than you found it. That’s the goal.
Praveen Suthrum: What advice do you have for early-stage gastroenterologists?
Dr. Michael Weinstein: Yeah. I love talking to young fellows, maybe because my kids are sort of around that same age. I think if you’re a fellow and you’re looking for a career, that you get to choose your career, you get to choose what you’re interested in and when you go talk to a group, probably the first thing you should ask is – firstly you should say what you’re interested in, what sort of career you see for yourself. Do you want to be an interventionalist? Do you want a career in IBD? Do you want to do liver? Or do you want to do esophagus work? What’s really your passion? Figure out what your passion is and if you’re talking to a group, does your ability to continue to follow your passion fit with the strategic goals of the practice that you’re talking with? The question that you shouldn’t ask first is – How much are you going to pay me? That’s not the first question to ask. First, explain what you love to do and why you want to do that and that’s what I would do.
I think an independent practice has the best of both worlds now. I think independent practice allows with the advent of larger groups. It allows the ability of somebody to subspecialize, to follow a passion within a big group, and to be fully supported in doing that. So, if you want a different equipment, if you want a different schedule to accommodate that kind of patient care, then it is probably easier to get that done in a bigger group then it is in an academic center. You know, they are coming out of their fellowship, they’ve got 30 years to practice. Again, you have to find something you like to do so that you can get up every morning and then do what you like to do. because if you like what you’re getting up to do it doesn’t feel like work.
Praveen Suthrum: Dr. Weinstein, I want to get to a final question and reflect on that a little bit. It is to do with the social disparity in healthcare. Now, whichever way you slice healthcare it’s quite apparent and all these years and probably decades, we’ve probably pushed this under the rug and it’s come to the floor now. So, I wanted to reflect that with you a little bit and read your thoughts.
Dr. Michael Weinstein: Yeah. I have sort of always considered myself very socially conscious but I was obviously been made apparent more so that as much as I thought that I was we weren’t. We got to a situation, and how we got there I’m not exactly sure but, I know that when I went on our website and I looked at all the photographs of all the physicians in Capital Digestive Care, we seem pretty diverse until you sort of start figuring out the ratios and the numbers and you go ‘How did we only end up with you know, such a small percentage of African-American partners?’ In Washington DC this doesn’t make any sense and I’m not sure how we ended up there. We did. And I don’t feel particularly good about it, I mean we have a lot of women partners, and there is certainly an obvious recognition that is in this Washington DC community, that the healthcare disparities led to some very bad consequences for COVID. And that’s the thing.
I think, George Floyd aside I think COVID really increased our awareness of just how much healthcare disparities can affect health outcomes. Because it is very clear that the percentage of deaths is so much higher amongst the communities who don’t have accessible healthcare, who have comorbid conditions that are poorly managed, obesity, hypertension… Their healthcare disparities, their inability to access healthcare, contributed to their deaths. And their inability to access health care has to be on all of us. We may not be able to fix the financing situation, Medicare, Medicaid coverage, fair payment, but that doesn’t mean that we should ignore the fact that health care disparities exist and that if we care about our communities then we need to provide that care.
I’m on the AGA governing board right now. There’s certainly a recognition. I think for everybody, the light went off and we went ‘How did we end up here?’ This is terrible. This was unintended to end up in this situation and we all want to do something; we all want to make it better because we see the problems but the first thing is that we need to understand why it happened. And one of the things I know in gastroenterology is for whatever reason unintended bias or unintentional bias or whatever it is, the African-American contingents in GI fellowship is 25% of what it should be based upon the population distribution. If 18 to 20% of the population is African-American and if 15 to 18% is Hispanic Latino, then how come the fellows are not equally distributed that way and they’re not, it’s terrible, it’s 10% of GI fellows that are ethnically diverse. We need to study that. We need to figure out why that happened and we need to do something to fix it. And it may take a generation, but if we don’t start on that road, we’re never going to get there.
Praveen Suthrum: Yeah and I’m so glad that you’re recognizing it at an industry level. So, what needs to happen that is not happening not just from the physician disparity standpoint but also the patient population, right? A lot of the problems that we see in healthcare don’t really originate in healthcare they go back to the community so it is more upstream. But then insurances don’t pay for going back and fixing problems upstream and where we are, we have created a system that pays for certain things and that doesn’t pay for preventing those things. So, what must happen if you had to freely reflect on ending this?
Dr. Michael Weinstein: There’s no doubt that we have to go upstream. Obviously, we’re a big group in the Mid-Atlantic area in Washington DC, Metropolitan Area, I am not saying that I have any ability to fix the problems in the country but I live in this community, I am a neighbor in this community, I am an employer in this community, and there are things that I can do for my employees, the children of my employees, the communities of my employees, and I may not be able to fix the whole region, but I can start fixing what I can actually affect.
I have to go upstream. I have already talked about providing internships for high school students, for college students spend time in our practice not from all over the country but just locally, that’s the local high schools, the local colleges. We’re going to have a paid summer internship and we’re going to try to increase the interest in healthcare and do things to promote healthier lifestyles in our community. If everybody would look just in their own communities, and if everybody did that there would be a huge change. So, I don’t have a solution for the whole country, I don’t have a solution for Maryland, but we’ve already decided what we are going to do at least in the community that we can touch.
Praveen Suthrum: Excellent. Thank you very much, Dr. Weinstein. Was there anything else that you wanted to talk about?
Dr. Michael Weinstein: No. Love talking to you, love listening to you, love to keep hearing about innovations and things that are on the horizon, new technologies, stuff like that, that will make it easier for physicians to provide healthcare. So, thank you for all you do.
Praveen Suthrum: Thank you so much for saying that and I really enjoyed our conversation and I’m sure that people who are watching this will also do. Plenty of insights right here. Thank you so much, doctor.
Dr. Michael Weinstein: You’re welcome.
_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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09 Jul 2020

Interview with Dr. Weinstein (Part 1): “This is about what you want to be in 2030”

 

Dr. Michael Weinstein is the President & CEO of Capital Digestive Care the largest gastroenterology group in the Mid-Atlantic states. He’s also the past President of DHPA (Digestive Health Physicians Association) and member of the governing board at the AGA Institute
Dr. Weinstein’s interview is loaded with so many insights that I’ll be releasing it in two parts. Each part deserves to be watched in full
How Capital Digestive Care grew to be 60+ providers is a story that’s relevant to many groups looking to consolidate regionally. In 2018, they went on a strategy planning retreat to decide what they’d like to be in 2030. That led to the partnership with Physicians Endoscopy.
Dr. Weinstein outlines the benefits of their MSO to private GI practices. Is there going to be a cash payout during transaction? How does it differ from private equity?
Don’t miss this one.
◘ February had 29 days and March had 300!
◘ How CDC ramped up telehealth?
◘  “Now we’re in phase 3. We have opened up our surgery centers”
◘ “So far, we’ve done over 2,000 COVID tests”
◘ Is this going to be the new norm? 
◘ “If we don’t give them [the staff] enough time, I’m afraid they’ll burn out”
◘ Are patients hesitating to come for endoscopy procedures?
◘ How Capital Digestive Care made the decision of partnering with Physicians Endoscopy
◘ “We started building a culture as Capital Digestive Care, different from the individual cultures”
◘ “We were getting all the private equity phone calls”
◘ What did Capital Digestive Care want to be by 2030?
◘ What doctors say: I want to be independent; I want to be in charge of my own life
◘ “To be successful we needed growth”
◘ “Everything in life is timing”
◘  The pros and cons a private GI practice should look at while weighing their options
◘ Is there money upfront in the CDC MSO model?
◘ “The one thing we tell everybody”
◘ “COVID certainly pulled back the blankets on few of the private equity deals”

The Transcribed Interview:
Praveen Suthrum: Dr. Michael Weinstein, you’re the President and CEO of Capital Digestive Care also the past President of DHPA (Digestive Health Physicians Association). Thank you so much for joining me today and I welcome you to our conversation.
Dr. Michael Weinstein: Praveen, it’s a pleasure. I have been looking forward to this. As we get a little older it is always nice to be able to impart a little wisdom.
Praveen Suthrum: So, I want to start by asking how are things going on with you and your practice in Maryland and DC, you’re in the thick of things. So, I’m wondering how are things there?
Dr. Michael Weinstein: Yeah. We say, it has been a very long year you know, very unusual year. February had 29 days and then March had 300! It certainly felt like that. It’s hard to believe that just four months ago, we were in a totally different world. Maryland started to peak with COVID-19 several weeks after New York and then we got very active, we were in the same boat as most of the practices in our country. Closing down our endoscopy centers, only doing emergency procedures, closing down our offices. I think in the first few weeks, we had two main goals. One was ‘How fast can we ramp up telehealth’ which I think everybody did and I think everybody did it with variable success. And the other was ‘How do we keep our inflammatory bowel disease (IBD) patients treated?’ ‘How do we keep our infusion centers open?’ because those patients are so desperately in need of regular infusions. Those were probably the two priorities. Then, the third priority was who can we partake of the Federal support dollars that were available. So, applying for SBA PPP money, making sure we got our HHS money, the first tranche the second tranche. Then making sure we had the legal counsel to advise us as to what we could qualify for.
We are a big group. So, we were having board meetings three times a week to review everything that was going on. Normally, our practice was to do board meetings once a month. We also furloughed 70/80 employees. Our endoscopy centers furloughed employees. It was scary. Now we’re in phase 3, we opened up our surgery centers a few weeks ago. And we were able to do that while we were doing COVID testing for everybody. COVID testing for patients, staff, doctors, everybody! All the staff and doctors get tested regularly. All the patients are tested two-three days before their procedure so that at least when everybody walks in the room, we can be very confident that everybody is negative. So far, we’ve done over 2000 COVID tests. We have only one asymptomatic patient that was positive, we have one staff member who turned positive. So, so far so good. And on follow-up phone calls, seven days and 14 days after the procedure, nobody who was COVID- positive. So far so good (fingers crossed).
Praveen Suthrum: Is this going to be the ‘new norm’ for the better part of this year and even leading up to next year?
Dr. Michael Weinstein: I think we are certainly going to maintain this testing, I’m sure for the next two or three months. It’s interesting, when we reopened our surgery centers, again, following examples of other regions, we opened at 30-35% of our typical volumes. Next week we will go to about 50% of our typical volumes and not until we get into August where we would be up at 75% to 80% of our normal volumes. So, the cases are stretched out a little bit, I think there’s more downtime. I think the staff needs a little bit more time to rest between cases. You know, they’re wearing full PPE so, all that masks, all that gloving, all that doffing and donning of the equipment is very tiring for the staff. If we don’t give them enough time, I’m afraid they’ll burn out. So, we’re going slowly. The day is about an hour and a half longer. And at this point, we’re obviously trying to catch up with the elective priority cases i.e. cases that we should have done two or three months ago or four months ago. We’re still not scheduling routine cases generally so the true routines cases are probably going to end up being delayed till September or later.
Praveen Suthrum: Is there any hesitation on behalf of the patients to come for the elective cases? Are there delays or cancellations? Or have they adjusted to the new norm?
Dr. Michael Weinstein: I think there is one group of patients who are just terrified of catching COVID and even though they’re due for procedure, they should have their procedure, they’re hesitating now saying well can I wait another month? Is it okay if I wait? And obviously, at this point trying to juggle as much as we are, is four weeks really going to make a difference? Probably not, then we’re letting those patients wait.
But then there’s another group of patients, who are so anxious whether or not they have colon cancer or esophagus cancer or they are so nervous about the fact that their procedure was due in April and now it’s July. So, they’re saying ‘oh I’m very overdue!’. So, there are two groups of patients – those who want to come in right away and those who are willing to wait. So, there’s a different fear factor for different patients. At this point, we can accommodate the patient’s wishes.
Praveen Suthrum: Okay. So, I want to go back in time a little bit. I wanted you to reflect on the growth of Capital Digestive Care and what led up to the size it is right now and how you went about your decisions to build a strategic partnership with Physicians Endoscopy.
Dr. Michael Weinstein: So, now let me spin a story. Capital Digestive Care is now a 74/75 physicians’ group but it was obviously not always that way. We did not grow organically to that size. 2007 there was a Gut Club formed and it was a meeting of about nine practices and some solo physicians and we started discussing the pros and cons of mergers of whether or not being a single large practice would be beneficial to the whole group. It took us a while to work through those issues, to figure how we would govern ourselves, what things we would do centrally, what things we would do as the legacy practices within those old offices.
We did work with the legal counsel quite a bit to try and make sure we met the definition of a group practice which for us meant centralizing certain things that define whether or not you’re a group practice. So, centralized billing and collection, finances, HR, policies and procedures, and every aspect that could be centralized and physicians were willing to give up we centralized. And that let us delve into the opportunities for providing ancillary services, particularly laboratory services.
We went live in 2009 as a single group. Everybody who was in the Gut Club did not stay in the single group. The solo doctors didn’t like the idea of not having complete control. They thought it’d be fair if they had a veto power and obviously that doesn’t work when a group of (at that time) 52/53 physicians. So, we did form a governed structure that everybody was in and formed a new group on January 1st 2009. That is so that the old entities could continue to collect their accounts receivable, they continue to own their assets, they leased any assets to the new corporation, and started as a new company on January 1st 2009. Probably one of the most interesting things we did is we went to all insurance companies before we went live and told the insurance companies what we were going to do. That on January 1st all these groups are going to be one new Tax ID number and how were they going to handle the billing and collection under the one Tax ID number for all these physicians who used to have contracts but had 8 different contracts. So, we settled that up with the insurance companies even before we went live.
Over the course of the next 10 years, did a lot of things as one company. We implemented a new EMR, converted three or four practices that had paper charts and converted those to electronic medical records in 2012, built an infrastructure network so that all the offices were connected, all the marketing was centralized and sort of started building a culture as Capital Digestive Care, different from the individual cultures that the separate practices had in their legacy years. That takes time. You know, you get married, but you have to sort of understand your spouse. And all your partners are now your partners while they used to be your competitors. So, it took us a while to work through those issues. Each of the original practices gradually grew.
We looked back in 2018 and we looked at the goals we had when we started, by the time we were in 2018, we had realized that we had pretty much achieved all those goals except the part about continuing to grow. And we were getting all the private equity phone calls, calls from the bankers and the brokers, I know Jim Leavitt very well, I know Jim Weber very well, we were sort of seeing some of the other things that were happening in the country and it was time for a change. We took a weekend, we listened to an Economics consultant from Carnegie Mellon and her main question to us was (it was 2018 at that time) she said, ‘What do you want to be in 2030?’ ‘What does your practice want to look like in 2030 or 10 to 12 years from now?’ ‘What do you want to be?’. What you have to consider is what’s going to happen to healthcare economics over the next few years that you will have to deal with in order to get to 2030. It was a good exercise. I don’t know if you have ever done any strategic planning or participating in any other strategic planning like that.
Praveen Suthrum: I have actually. And it is very interesting because a lot of times you don’t want to extrapolate the present but you want to do away with the present and come up with a different future. For Scope Forward actually, I tried doing that on behalf of the industry. So instead of taking the past to the future, re-imagined the future like you want it to be. So, I’m curious to know what was the outcome of the strategic planning exercise? What did you want to be by 2030?
Dr. Michael Weinstein: You know, if you ask most of the partners, independent and autonomous were probably the two main words that everybody used. ‘I want to be independent; I want to be in charge of my own life’. When they say they are in charge of their own life, they want to be able to manage the surroundings that they see with their own two eyes. How their staff works in their offices, what kind of scheduling they want to do. I have some partners who want to see at least four patients an hour and there are other partners who go ‘No, I only want to see a patient every 30 minutes.’ We wanted to be flexible enough to allow each doctor to kind of choose their own career. If they want to work four days, if they want to work five days a week, or they want to take off 10 or 12 weeks a year or whether they want to work 48 weeks a year. We wanted to maintain that flexibility, that independence, and that autonomy at the same time as being successful.
In our region, we looked at labor markets, what is going to happen in labor markets, how are we going to compete for our employees, how are we going to compete for associates, how are we going to find the next generation of partners. We looked at technology disruption, I know you’re obviously quite an expert on that. What’s going to happen in technology, artificial intelligence, maybe standard endoscopy may not exist. What could happen technologically that could change? We looked at service lines, what things are coming along that we might want to get involved with as far as clinical research, NASH and NAFLD, chronic disease management, imaging, and other things that are coming along that we should add to our care delivery. And we decided that the one common factor amongst all of these things, to be successful was that we needed growth. We needed size, in order to have an employee benefit plan and opportunities for employees that would be attractive. We needed size to be involved in other service lines that require much larger patient volumes to become cost-effective. We needed size to be able to compete against the big hospital systems and the payors which were obviously continuing to consolidate.
So, if size was the common denominator, the next question that she said was, ‘Now that you know what you want to be in 2030, we have to work backward.’ How do we achieve that growth, what are the ways that we can grow as a practice so that we can accomplish the things that we have as our new strategic goals. You know, we had options. We said we don’t need any help we can do this by ourselves. We can just go borrow money from the bank in order to grow our infrastructure, to attract other practices, we’ll just go borrow money. That was not particularly anything that most of the partners wanted to do because as you probably know doctors are generally a little bit risk-averse and the idea of borrowing money did not appeal to too many people. We said, well we could sell ourselves to the hospital. That was the group of doctors who basically wanted to throw their hands up and say ‘I give up’ ‘Let’s just go to the hospital system.’ if you’re familiar with the Mid-Atlantic area Hopkins is very powerful here. I think they have seven or eight hospitals now in the Mid-Atlantic area. MedStar is the other major hospital system in Maryland, they have 10 hospitals. And Innova Health systems in Northern Virginia have five or six hospitals as well. So, some people just thought the hospitals are going to win the game, we should just sell ourselves to the hospital. That seemed to be, you know, the ‘throw in the white towel.’
We looked at the option of private equity and what the typical private equity looks like. It looked a lot like selling yourself to the hospital. it looked a lot like taking a job not with the hospital but taking a job with the private equity company where you definitely lose a lot of control and you give up a lot of your future income for a payday. It seemed to us to be more of an exit strategy. Private equity didn’t sit very well with us, there were too many negatives and the last option was to find a strategic partner. Somebody who had similar goals for 2030. Somebody who was also looking to be successful for a decade or more.
And you know, everything in life is timing. Barry Tanner and I happened to be in a meeting together. We started chatting, he started talking about Physicians Endoscopy, we were talking about Capital Digestive Care. Physicians Endoscopy was trying to figure out how they could help all of their smaller practices. You know it is interesting, when we look at the private equity companies, they have resources but their definition of resources is money. That’s what they bring to the table, they bring money. They bring cash. They’re like a bank but it’s easier to get the money from a private equity company than it is to get it from a bank. Physicians Endoscopy had money but they were an ASC management company. So, they have a substantial team of personnel with 600 employees, with expertise in all of the same areas that we had, practice management expertise. So, we basically merged two teams of people and formed a new MSO.
Now we think we have had conversations with groups in the and the region that people are understanding of the goal, which is to take away the aggregation of the back office, run that as efficiently as possible, develop new service lines, new sources of revenue, and let the physicians do what they do the best which is to take care of patients and set their own schedules and have their autonomy and independence. That’s more or less it. It was interesting. In 2018 we were doing very well. In 2018 everybody was happy, everyone’s income was good, endoscopy centers were busy, we had a very busy anatomy laboratory pathology option, we had eight surgery centers, anesthesia ventures which most big groups in the country have. But the question is what are we going to need in 2030 because those four main areas are not going to be sufficient in 2030, we need to find other avenues.
Praveen Suthrum: From the point of view of the private practice GI group, how does the model look? Like if someone wants to come on-board, and they want to weigh this option versus a private equity option and versus doing it on their own. What are the pros and cons that they would look at?
Dr. Michael Weinstein: The main things that I heard, when I talked to the private equity bankers and brokers was, you can get a big payday upfront, in multiple of 30 or 35% of your income, you know which means you are going to give up 30 to 35% of your income forever but we are going to give you a big multiple upfront. So, it’s basically taking most of your money off the table and agreeing to work for some number of years in exchange for a payday and the way we are going to make things better in the future is that we are going to have “the second bite of the apple”. There’s going to be a flip. Three years, four years, five years, we’re going to get really big and we are going to flip it and then there’s going to be another big payday.
There is not a lot of discussion about how you re-acquire the income that you have given up, how do you repair the 30 or 35% of your income that you sold. Is there any opportunity to repair your income? I don’t think I have ever heard very good arguments about how a private equity company was going to do that. So, with a typical private equity deal, the pro is that you get a lot of money at the beginning and there is a tax advantage because you get that money as a capital gain…If you get that money as a regular income over the next several years, you are paying regular income taxes today is a tax arbitrage on the transaction. But it’s the exit strategy for everybody who is currently there. And it basically brings all the new associates into your practice at roughly 60% or 70% of what the old partners used to earn. Now the new partners will only earn 60 or 70% of what the old partners used to make. So, see that is the attraction for private equity. If you’re thinking you’re going to work only for five years or seven years, it makes perfectly good sense.
Our model is different. There is a transaction upfront, but not giving up 30 or 35%. We have created a management fee of 15%. A very small amount of your income which is placed into the MSO company to help the MSO growth. So, it’s an investment in a new ancillary. The new ancillary company is practice management services, you are investing in that company, you get to own a part of that company, and that becomes a new ancillary source of revenue. Particularly, again part of the alignment with Physicians Endoscopy, is that there are many small practices outside the region, that need practice management services that can just buy practice management services. They don’t need to join the platform group; they don’t need to join Capital Digestive Care. But within the region, the idea is to grow Capital Digestive Care into a much larger practice, into a more relevant practice when it comes to negotiating with hospitals, with payors, with employers, with value-based purchasing, is to become a relevant player for digestive disease management.
Praveen Suthrum: Well, one question that I have on this is, that you said there is a small transaction in the beginning and that’s 15%. Does that mean they are getting money upfront? Or there is no money upfront?
Dr. Michael Weinstein: Oh no, there is money at the beginning. You know in a typical private equity deal you are selling a 30 to 35% at a multiple and the way we have modeled our MSO is that you’re selling 15% but you’re selling it at a similar multiple. So, there is a cash and equity transaction and asset purchase in our model as well. It just leaves you with 85% or more of your typical income. So, you’re not taking that huge drop in the annual income but there is only a small drop in the annual income and there is much more likelihood that, that income can be repaired just by negotiating and having everybody up to the best contract, having everybody be able to participate in a very functional profitable laboratory. It is very easy for most groups to recapture the 15% that they are getting a transaction for. We have already had one group that gave up 15% of its pre-transaction income and after the transaction based on new contracts and pathology and other services, they’re actually going to make more money than they were in their practice. So, no decrease in income and they got a transaction.
Praveen Suthrum: So, let’s take the number 100. So, the value is 100, they get to retain the 85% and you have the 15% left and that, part of it they get cash, and part of it gets converted into equity into the new MSO. Is my understanding correct?
Dr. Michael Weinstein: Correct. So, it’s up to the group. They have an option. If they want to take it all as cash, depending upon the size they could take it all as cash. Or they could roll some of the cash into equity in the MSO as an investment. There is a tax arbitrage on that as well. The cash part of all these private equity transactions is capital gains. So, depending upon where you live you are paying 21 to 27% federal and state capital gains as opposed to regular income taxes which are probably 42 to 47% depending upon where you live, you’re paying regular income taxes. If you roll some of the transaction proceeds into equity, you further delay the tax. So, it almost becomes like another pension plan. You are taking some of your income and you’re putting it into this MSO, which you own a piece of. So, with the money you’re putting in, you’re basically improving the wealth of the value of the MSO. So, when the day comes when you want to sell your equity, in the model that we have it is much easier to move the equity around between partners at market value and when you sell the equity that’s when the tax is realized. So, you basically get taxed to further growth as well.
These are just the financial aspects. One of the things that we say in all of the groups that we talk to as far as joining Capital Digestive Care is that there are certainly some transactional benefits. There’s cash upfront, there’s an equity component, there is a tax arbitrage that sounds very interesting in the first year but after the first month, most physicians want to know how they’re going to recapture the income that they’re giving up. And for us, it was not about the transaction. We tell everybody that this is not about the transaction, this is about the strategy. This is about what do you want to be in 2030. And if you are 50 years old or 45 years old and you’re thinking you’re going to work 10 or 15 years or more then, a typical private equity deal is kind of risky. You’re giving up a lot of income forever and there’s not a lot of ways you’re going to repair that income and I’m not sure how they will recruit in the future.
I don’t think that they have had any trouble yet although COVID certainly pulled back the blankets on a few of the private equity deals. I think that there is an ophthalmology private equity deal that went bankrupt probably because of COVID but also probably because they were already overleveraged. They had already overleveraged the business. The largest private equity platforms were not able to partake in Small Business Administration loans. I think that there may be some other opportunities for federal support for healthcare companies that will hopefully get them through this terrible gully. It is interesting, most of my partners when COVID hit, said, “Mike, you did the most amazing thing, the timing was incredible”. The timing to do this with Physicians Endoscopy. And I’m going “I don’t think we did this because of COVID!” we had no idea that this pandemic was coming and now we feel that we’re actually probably a good position and that we did what we did!
_

 

By Praveen Suthrum, President & Co-Founder, NextServices. 

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
button_download
09 Jul 2020

Curated Business/Tech GI Resources: July 8th, 2020


Curated Business/Tech GI Resources: July 8th, 2020
Navigating a pandemic: The importance of preparedness in independent GI practices (GI & Hepatology News)
Dr. Michael Weinstein of Capital Digestive Care discusses how COVID-19 has affected his practice and what young gastroenterologists should be thinking when starting their careers.
US insurers cutting telehealth coverage as COVID-19 cases surge (Becker’s Hospital Review)
After changing policies to cover telehealth more broadly during the pandemic, some insurers are scaling it back even as COVID-19 cases surge in some states.
CRH Medical Corporation Announces Majority Purchase of Central Virginia Anesthesia Associates (Yahoo Finance)
“We see continued opportunities to expand our anesthesia footprint across the balance of 2020.”
Lessons learned as a gastroenterologist on social media (GI & Hepatology News)
The first question to ask oneself is whether you are prepared to devote time to cultivating a social media presence and speak or be heard publicly.
Joint GI Society Statement on Measures to Prevent Transmission of SARS-CoV-2 Virus (ACG)
In their latest joint statement, GI societies (AASLD, ACG, AGA and ASGE) endorse the wearing of face masks and of physical separation in any public area to prevent the transmission of the SARS-CoV-2 virus.
AGA announces six-point commitment to equity (AGA)
The AGA Equity Project, an initiative to achieve equity and eradicate disparities in digestive diseases. Town Hall with AGA President Bishr Omary on Monday, July 13 at 11 a.m. EDT.
Liquid biopsy shows promise for early detection of pancreatic cancer (Healio)
A liquid biopsy has shown promise for the early detection and staging of pancreatic ductal adenocarcinoma.
Geographical Hot Spots for Early-Onset Colon Cancer (Medscape)
A new study has identified geographic hot spots across the United States, characterized by distinct patterns of early-onset CRC with worse survival among men.
Telehealth providers doing ‘more visits than humanly possible’ in a day draw CMS scrutiny (Becker’s Hospital Review)
Ms. Verma said the temporary lift of coverage restrictions and pay rate boost during the pandemic allowed virtual visits to surge.
Video: Reopening of GI Clinical and Endoscopic Services: Ensuring Patient Safety in COVID-19 Era (Mount Sinai Health System)
Dr. James Marion and Dr. David Greenwald discuss the reopening of GI clinical and endoscopic services and what is being done to ensure patient safety in a COVID-19 era.
The New Virtual Reality: How COVID-19 Will Affect the Gastroenterology and Hepatology Fellowship Match (NCBI)
Prospective GI fellowship applicants will face a unique set of challenges this interview season due to the restrictions imposed by the COVID-19 pandemic that may impact their candidacy.
Video: Practice of endoscopy during COVID-19 pandemic: APSDE-COVID statements (Gut)
Sixteen doctors were invited to develop this position statement of the Asian Pacific Society for Digestive Endoscopy.
Screening of gastrointestinal cancers during COVID-19: a new emergency (Lancet)
Even if cancer treatments has been maintained, screening has sharply decreased across the world.
WEO develops the first global survey on the impact of the COVID-19 pandemic on endoscopy (WEO)
An astonishing total of 252 centers from 55 countries responded to the WEO international survey, the first of its kind, on the impact of COVID-19 on endo units.

Headlines for GI

Looking for a post-COVID health-tech idea? Find it in 3D printing (Exponential Tech – Part 3) (NextServices)

COVID-19 Update: Fauci Warns of 100K Cases/Day, HCQ Trial to Resume (Medscape)

Interview with Dr. Byrne (AI in GI): “There’s a tidal wave of AI coming and we should prepare for that now” (NextServices)

Donning a New Approach to the Practice of Gastroenterology: Perspectives From the COVID-19 Pandemic Epicenter (Einstein)

7 Recent reports on Endoscopy (Healio)

COVID-19 and the Digestive System (American Journal of Gastroenterology)

Use of a new face shield for patients of the endoscopy unit to avoid aerosol exchange in the COVID-19 era (Video GIE)

RAAS inhibitor use may reduce 3-year colorectal cancer risk in certain patients (Healio)

We Came to the US to Practice Medicine. Now, the Pandemic Won’t Let Us (Op-Med)

Principles of GI for the NP and PA – A Virtual Course: Get on top of upper GI disorders (AGA)

Australian GIs debate whether to test patients with only GI symptoms for COVID-19 (Becker’s GI & Endoscopy)

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COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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02 Jul 2020

Curated Business/Tech GI Resources: July 1st, 2020


Curated Business/Tech GI Resources: July 1st, 2020
3 insights from Dr. Michael Byrne on AI on GI (Becker’s GI & Endoscopy)
Becker’s GI & Endoscopy covered our interview with Dr. Byrne about the potential applications of AI in GI.
Surge in Colonoscopies May Tax Resources After COVID-19 Delays (Medscape)
An expected surge in the number of people seeking colonoscopy after the peak of the COVID-19 passes could cause physicians to rethink patient prioritization, could create a strain on endoscopy capacity, and might raise the specter of detecting colorectal cancer in more patients.
Functional heartburn or refractory reflux disease? (AGA)
AGA has released a new Clinical Practice Update providing best practice advice to diagnosis and treat functional heartburn.
COVID-19 substantially reduces endoscopy procedures worldwide (Healio)
New data revealed a substantial decrease in endoscopy procedures around the world of more than 80% during the COVID-19 pandemic.
CRC Screening at Age 40 Seen Cost-Effective (Gastroenterology & Endoscopy News)
These findings are relevant in light of the increasing incidence of CRC among people under 50 years of age.
The AGA Research Foundation provides over $2 million in funding to promising researchers (AGA)
The AGA Research Foundation funded 17 awards in the 2020 awards cycle.
First Subjects Enrolled in Docbot’s Pivotal Study of its Ultivision™ AI Gastroenterology Imaging Platform to Detect Adenomas During Colonoscopy (PR Newswire)
“Despite the U.S. spending more than $20 billion per year on 18 million colonoscopies, colon cancer remains the second leading cause of cancer death.”
Reinvent Health Care to Beat Covid-19 (Wall Street Journal)
Important surgeries can continue, but doctors need to be paid more for managing outbreaks.
Walmart divulges plans for ‘healthcare supercenters’ (MedCity News)
Walmart has been designing a different kind of supercenter — one focused on healthcare.
Gastroenterology compensation, debt & ownership: 5 statistics (Becker’s GI & Endoscopy)
Gastroenterologists are more likely than other specialists to have a net worth of under $500,000, but they’re least likely to still be paying off school loans.
4 private equity GI deals announced this year (Becker’s GI & Endoscopy)
There have been four private equity deals in gastroenterology in 2020.
Investors predict the winners and losers in America’s shift to digital health during the pandemic (CNBC)
Venture capitalists poured $3.1 billion into the sector during first quarter 2020, according to Rock Health.
Patient Navigators Boost Diagnostic Follow-up After Positive FIT  (Gastroenterology & Endoscopy News)
“Navigators increased the rate of diagnostic follow-up after a positive FIT by 32.5%.”
Telehealth may be cost-effective for IBD patients (Healio)
For patients with inflammatory bowel disease, telehealth was cost-saving and had high probability of cost-effectiveness.
ASMBS: Bariatric surgery ‘medically necessary’ during COVID-19 pandemic (Healio)
Bariatric surgery can improve obesity and the related diseases that increase risks for worse COVID-19 outcomes and should not be considered an elective procedure.
Video: Many People Lack Protective Antibodies After COVID-19 Infection (Medscape)
An article tried to answer the question of how protective those coronavirus antibodies are. And, at first blush at least, the news isn’t great.
Video: Colorectal Cancer Highlights from ASCO 2020 (Medscape)
Dr Benjamin Weinberg from the Lombardi Comprehensive Cancer, discusses key studies from the ASCO 2020 virtual meeting for patients with metastatic colorectal cancer (mCRC).
Video: GI Societies join forces to promote diversity within the field (Healio)
In this interview, President of AGA Dr. Bishr Omary discusses the joint statement by various societies. They pledged to create guidelines to end racism and social injustice in GI.

Headlines for GI

Looking for a post-COVID health-tech idea? Find it in 3D printing (Exponential Tech – Part 3) (NextServices)
67% of patients say telemedicine is better than in-person visits, survey finds (Becker’s Hospital Review)
For Better Clinical Trials, Engage Patients (Gastroenterology & Endoscopy News)
These are the 2020 CNBC Disruptor 50 companies (CNBC)
Doomsday Scene: COVID-19, Flu, Measles, & Winter. Here’s Our Plan (Medscape)
10 things to know about gastroenterologists and GI centers | 2020 (Becker’s GI & Endoscopy)
The Coronavirus Pandemic’s Wider Health-Care Crisis (The New Yorker)
Wearable Tech May Detect COVID-19 Infection Before Symptoms (Medscape)
In scleroderma, GERD questionnaires are essential tools (MDedge)
Industry Voices—4 predictions for healthcare analytics in a post-COVID-19 world (Fierce Healthcare)
The Affordable Care Act Is On Center Stage (Again): Myths, Flaws And What’s Next (Paul Keckley)
COVID-19 Update: New CDC Guidance, Antibody Concerns (Medscape)
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COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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01 Jul 2020

Looking for a post-COVID health-tech idea? Find it in 3D printing (Exponential Tech – Part 3)

From printing food to organs, 3D printing is a fascinating exponential tech industry in the making. This week we shall delve into its application in healthcare.
In this article, you’ll understand where the opportunities are in this upcoming field.
• What is 3D printing?
• Bioprinting and its uses in regenerative medicine 
• Other applications of 3D printing in healthcare
Current challenges and future of this promising technology
To put it simply, 3D printing is a process of making 3D solid objects from a digital file. It’s an additive process, wherein an object is created by adding layer after layer of material. Until finally the desired object takes shape.
3D printing in healthcare: Four core areas
As per the report published by Allied Market Research, the global 3D printing healthcare market accounted for $972.6 million in 2018. It is expected to reach $3.69 billion by 2026, growing at a CAGR of 18.2% from 2019 to 2026. Here are the four major areas.
1. Bioprinting tissues and organoids (grow from stem cells)
2. Manufacturing customized medical and dental devices
3. Manufacturing surgical tools
4. Producing patient-specific anatomical models
► 1. Bioprinting tissues and organs
Bioprinters are 3D printers with one key difference. Instead of using materials such as plastic or metal, these printers deposit layers of biomaterial. That means these printers use cells to build living tissues. That eventually become blood vessels, bones, heart, or skin.
In the early 2000s, researchers discovered that living cells could be sprayed through the nozzles of inkjet printers. That didn’t damage the cells. But the problem was cells need a nurturing environment to stay alive: food, water, and oxygen. Such an environment is made possible by a micro gel that has vitamins, proteins, and other nourishing compounds. Researchers plant the cells around 3-D printed scaffolds made of biodegradable polymers or collagen so they can grow into a fully functional tissue.
For example, this method could be used to “print” a bladder, a simple organ consisting of only two types of cells. Here are the steps:
a) Scan a patient’s organ to determine size and shape
b) Create a 3D model from the scans
c) Using degradable polymer, print scaffolds to help cells grow in 3D
d) Place the organ in the patient’s body
e) Watch the scaffold slowly disappear after surgery
Isn’t it fascinating? There’s more.
In a landmark achievement, Tel Aviv University has 3D printed a small heart using human tissue. While the organ itself is smaller than one would need in a transplant, it is a massive step forward for bioprinting. Here the bio-inks used were “personalized hydrogel”, extracted from the fatty tissues of the human test patients.

 

Bioprinted bones are made with a durable and regenerative biomaterial capable of fusing with a patient’s natural bones over time. Eventually being replaced by them.
Researchers in South Korea developed 3D printed artificial corneas. Meanwhile, an Australian bio fabrication center called BioFAB3D built a handheld cartilage printing device called the BioPen. The BioPen is filled with stem cells derived from a patient’s fat. That helps in creating and implanting custom scaffolds of living material into failing joints.
Wake Forest School of Medicine has designed a printer that can print skin cells directly on to a burn wound.
Bioprinting also has its uses in clinical trials. It can use 3D printed tissues and organs without conducting trials on animals. Loreal, the French cosmetics major, partnered with 3D bioprinting company Organovo to 3D print human skin. This helps test their products before they get to market.
As this amazing area evolves, organ donations will be a thing of the past. The space of regenerative medicine will bring hope to many people around the globe.
You could even be printing your own personalized medicines soon. The possibilities are truly exciting.
► 2. Manufacturing customized medical and dental devices
3D printing has made manufacturing of medical devices less complex, much faster, more cost-effective, more customized, and easier to sterilize.
Prosthetics – 3D printing has completely transformed the prosthetics industry. Now you have perfectly fitted devices that are more cost-effective as well as functional.

 

Surgical guides – Both dental and medical surgeries require precision. A 3D printed surgical guide can help a surgeon line up holes, incisions, and implants as per the patient’s anatomy. Now with 3D printing, these guides can be produced rapidly to specifications.

 

Implants – 3D printing produces fine mesh structures at no additional cost. The organic structure of the device reduces the risk of rejection after the surgery is complete. These customizable implants are usually manufactured with 3D metal printing. This makes them strong, sterile, and matched to the patient’s needs.This is a test done on a sample of blood. It looks for cancer cells from a tumor that are circulating in the blood or for proteins in the blood due to the response of the immune system to the cancer. This will help in detecting cancer at an early stage.
► 3. 3D printing surgical tools
Sterile surgical instruments, such as forceps, hemostats, scalpel handles, and clamps, can be produced using 3D printers.
Not only does 3D printing produce sterile tools, but some printers based on origami, allow for the printing of tools that are precise and small in size. These instruments can be used to operate on tiny areas without causing unnecessary extra damage to the patient.
► 4. Preparing patient-specific surgical models
Creating 3D anatomical models from CT scans or MRIs is becoming increasingly useful for both doctors and patients. While these models help doctors prepare for their complex surgeries, they serve to educate patients about procedures. This helps not just reduce patient anxiety and recovery times but improves pre-operative planning and operating room efficiency. 
Source: https://formlabs.com/blog/3d-printing-in-medicine-healthcare
In the words of Dr. Alexis Dang, an orthopedic surgeon at the University of California San Francisco (UCSF) and the San Francisco Veteran’s Affairs Medical Center:
“Every one of our full-time orthopedic surgeons and nearly all of our part-time surgeons have utilized 3D printed models for care of patients at the San Francisco VA. We’ve all seen that 3D printing improves performance on game day.”
These 3D printed models are also widely used for training. For example, 3D printed endoscopic biopsy simulators are practical and useful tools in endoscopic training.
Three challenges before 3D printing goes mainstream in healthcare
As you can imagine, a regulatory and legal framework is still in the works. The scope for 3D printing is vast – from drugs and biologics to implants and prosthetics.
Beyond regulatory challenges, there are several technical challenges to overcome. These include costs of equipment, biocompatible materials, and interoperability between software and hardware.
Finally, there’s the economic hurdle of getting paid from insurance companies. While an FDA-approved 3D-printed joint implant may be reimbursed, 3D models of a patient’s anatomy and professional fees often are not.
Crossing these hurdles paves the way for the future.
3D printing in healthcare: At the cusp of an exponential curve
Consider these areas where 3D printing can be a gamechanger.
◘ A typical kidney transplant can cost more than $300,000. 3D printing has the potential to reduce that number to less than $100,000.
◘ Almost 114,000 people in the U.S. are on the waiting list for a life-saving organ donation. 3D printed organs can eliminate these queues forever.
◘ There are nearly 2 million people in the United States with amputations. 3D printed prosthetics can get people back in motion faster than ever before.
◘ The average price of a set of surgical instruments today is more than $3,000. This cost can reduce dramatically with 3D printing.
A multihospital organization can have more than 25,000 pieces of equipment. 3D printing has a big role to play here.
Emerging opportunities for business and impacting people’s lives are aplenty here. Add the power of customization and precision, you can see the power of this exponential technology.
If you are in healthcare and be a part of this transformation, the time to experiment is now.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices
Image Credit: Unsplash.com, Rob Wingate

 

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COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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