Category: Covid19

28 May 2020

Curated COVID-19 GI Resources: May 27th, 2020


Curated COVID-19 GI Resources: May 27th, 2020
Video: Interview with Dr. Spinnell: “Everyone knows someone who had the virus” (NextServices)
Watch this interview to gain insights on opening up from Dr. Mitchell Spinnell from Bergen County, NJ – a red zone.
Medscape Physician Compensation Report 2020 (Medscape)
Practices report 55% decrease in revenue and 60% decrease in patient volume during COVID. Remote patient engagement increased by 225%.
An interview with Robert K. Cleary, MD, FACS, FASCRS (American College of Surgeons)
Gastroenterologist Dr. Clearly offers an emotional account of his battle with COVID as a patient. A must watch.
Medicare and Commercial Insurances Telemedicine Billing Policies (NextServices)
Commercial insurances may have different rules than Medicare. Here’s an lookup excellent resource to get paid correctly.
GI Symptoms Should Not Prompt Routine Screening for SARS-CoV-2, Group Says (Medscape)
Gastrointestinal symptoms may be less common in COVID-19 than previously thought.
PE will return. The question is, ‘When?’ — Edgemont’s Luke Mitchell explores post-COVID-19 market (Becker’s ASC)
“Seller valuation expectations do not just adjust overnight, and somebody who thought they were sitting on a $100 million business three months ago isn’t going to sell their business for half of that.”
Uncommon Presentation Of Covid-19: Gastrointestinal Bleeding (ScienceDirect)
Every patient undergoing endoscopy should be considered potentially infected or can infect others.
What Hospitals Overwhelmed by Covid-19 Can Learn From Startups (Harvard Business Review)
It’s time to invent new ways. A central business concept — the S curve — can help.
How COVID-19 Has Impacted Top Clinical Service Lines at Hospitals (RevCycle Intelligence)
COVID-19 continues to damage inpatient and outpatient volumes, with certain clinical service lines being hit harder than others. GI saw a drop of 10%.
COVID-19 possibly delayed 28M elective procedures (Becker’s ASC)
The COVID-19 pandemic could’ve canceled or delayed around 28.4 million elective procedures during its peak 12-week disruption.
Changes in GI Bleeding Management During the COVID-19 Pandemic (NEJM Journal Watch)
Patients are likely trying to avoid going to the hospital to prevent exposure and are thus presenting at later stages.
How Private Equity Is Ruining American Health Care (Bloomberg)
To make PE right for GI, it’s important to understand how it’s gone bad in other specialties. This is a severely critical article on private equity in healthcare.
The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges (The Commonwealth Fund)
The rebound in provider visits is due to more in-person appointments rather than more telemedicine visits (see graphs).
‘We do not have much room for growth’: A GI center’s plans for the next 12 months amid the pandemic (Becker’s GI & Endoscopy)
Harbin Clinic Endoscopy Center in Rome, Ga., outlines how the center is resuming operations during the pandemic and what it expects in the next year.
COVID-19 in New York: Experiences of a Gastroenterologist  (AIG Hospitals)
Watch Dr. Amrita Sethi, Director of Pancreaticobiliary Endoscopy Services, Columbia University Medical Center New York, moderated by Dr. D Nageshwar Reddy, Chairman & Chief of Gastroenterology, AIG Hospitals.
Q&A: Addressing the explosive growth of telehealth use amid COVID-19 (Healio)
Dr. Kvedar: health system used telehealth for office visits less than 2,000 times in February 2020. Two months later, monthly telehealth office visits approached a quarter million.

Headlines for GI
AI stepping up against COVID-19 (NextServices)
What reopened endoscopy centers are doing & more: 4 GI industry key notes (Becker’s GI & Endoscopy)
COVID-19: Important Updates for GI Practices (ACG)
In final rule, CMS makes telehealth more widely available in Medicare Advantage plans (Healthcare Finance)
Covid-19 Will Accelerate the AI Health Care Revolution (Wired)
Is It Better to Be a Doctor Now Than It Was 50 Years Ago? (Physician Sense)
Digital health stocks are surging because ‘suddenly now we’re in the future’ (CNBC)
Covid-19: 3 Things we have to get right at re-entry (MedCity News)
The End of the Game (The Healthcare Blog)
ACG Magazine – The Discoverers: Development of the Colon Prep (ACG)
COVID-19 tests the value of artificial intelligence in medicine (Modern Healthcare)
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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 May 2020

Medicare and Commercial Insurances Telemedicine Billing Policies

CMS is frequently updating its policies to make telemedicine available to all its beneficiaries. However, these policies may or may not be followed by commercial insurances. As a practice, you might have several questions while providing care to patients with private insurances.
◘ Will this payor cover audio only services?
◘ Can I bill a consult code for this insurance?
◘ Do I need to use POS 02 or POS 11?
◘ Will this service get bundled as per the payor policy?
◘ What are the restrictions for billing this code?What are the modifiers to be used while billing this service?
We have been working with our clients to help them get the most out of the new telehealth rules. The following information is collated by working with insurances and closely referring to the latest updates on the insurance websites.

 


Note: These rules are as of May 05, 2020 and would be updated as and when changes are applicable.
► Telemedicine coverage insurance verification recommendations
To plan further and for better clarity, check online or call the insurance for the following information while checking eligibility:
◘ Is telemedicine covered for this patient plan?
◘ Are there any specific restrictions from your insurance for billing telemedicine?
Will patient have to share cost for this service (co-pay, coinsurance, deductible) – Specific guidelines for getting paid 100%
Does your insurance follow CMS guidelines for reimbursement?
What are the services included under telehealth?
Are telephonic codes reimbursed at televisit rates?
► Reimbursement parity telemedicine visit to face-to-face visit
As per the interim rule CMS announced to reimburse telehealth visit at the same rate as in person visits. Refer to the below table to check similar guidelines from commercial insurances.
► Reimbursement parity telephonic visits to real time televisit
CMS has announced payments for telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. These payments are retroactive to March 1, 2020. Refer to the below table for similar guidelines from commercial insurances.
►  Cost sharing telemedicine waiver updates
►  COVID-19 Testing-Related Telehealth Visits (MODIFIER CS)
The Families First Coronavirus Response Act from CMS waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services. These services are medical visits for the HCPCS evaluation and management categories described below when an outpatient provider, physician, or other providers and suppliers that bill Medicare for Part B services orders or administers COVID-19 lab test U0001, U0002, or 87635. This means that if a telemedicine service is provided which further results in a COVID-19 test than the cost sharing would be waived for televisit as well as COVID-19 testing.
Refer to the below table for updates from commercial insurances. We will update this list as and when updates are available from other insurances.
> Need help with telemedicine implementation at your practice?
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References:
Medicare Telemedicine Health Care Provider Fact Sheet
Aetna Better Health of New Jersey Guidance on Telehealth Services
Aetna Telemedicine billing FAQ
Horizon BCBS Telemedicine codes
United Healthcare Telehealth services
Emblem Health Telemedicine update
Amerihealth Telemedicine services
Amerihealth consult code FAQ
Cigna Interim Billing Guidelines
Humana Telemedicine updates
Oxford Telemedicine Reimbursement Policy

 

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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.
button_download
26 May 2020

Interview with Dr. Spinnell: “Everyone knows someone who had the virus”

This Memorial Day, I spoke to Dr. Mitchell Spinnell from The Gastroenterology Group of Northern New Jersey. Bergen County where Dr. Spinnell and his partners practice is a red zone. After prolonged closure, they are opening up their office and surgery center this week.
In this incredibly insightful interview, Dr. Spinnell shares his experience while working at a COVID unit to Cologuard to consolidation in New Jersey.
Dr. Spinnell’s experience working at a COVID unit
◘ Closing down the surgery center and opening it now (“Number of cases skyrocketed”)
◘ Exact steps they took to open up from staff training to PPEs (“cases every 45min to an hour”)
◘ What concerns did staff have? What were they fearful of?
◘ “Everyone knows someone who had the virus”
“I was concerned about my exposure [to my young family]”
◘ What if someone tests positive AFTER you start? Do you open or close?
◘ What’s confusing as a clinician and business owner?
◘ We furloughed our entire ASC staff (The financial piece is a struggle)
◘ Does Dr. Spinnell foresee patient behavior change?
◘ “We’ve seen a significant uptick in Cologuard”
◘ “Cologuard is a force. I would rather be a part of it than fight it.”
◘ Consolidation in New Jersey
◘ Would interest from doctors change if PE valuations change

 


The Transcribed Interview:
Praveen Suthrum: Dr. Spinnell, welcome and it’s really nice to see you. I would want to start by asking you about your practice. If you could tell us a little bit about your practice.
Dr. Mitchell Spinnell: Great. Well, I appreciate the invitation Praveen. This was a really welcomed way to start my Memorial Day celebrations. So, I am a gastroenterologist practicing in Englewood, New Jersey. Englewood is in Bergen County in Northern New Jersey right across the bridge from New York City. And we were you know, sort of in the hotbed of the COVID pandemic.
We’re a 11 physician GI specialty group with some roots in internal medicine. We have one nurse practitioner. We work out of an ASC that is partly hospital-owned. Middle of March, things had really exploded at an exponential level and Bergen county has remained a red zone after that.
Praveen Suthrum: And you worked at the COVID unit in the Englewood Hospital. How was that experience?
Dr. Mitchell Spinnell: Yeah. It was incredible. The hospital was sponsoring weekly or bi-weekly meetings and was sort of updating what was happening at the institution. And as the number of cases was mounting, there really was an effort to convert the hospital, increase its ICU capacity, and turn the majority of the units into COVID units.
There still was an incredible shortage of manpower. So, there was an outreach to some of the specialty physicians to assist. I devoted a little over two weeks to the COVID unit specifically. I wanted to carve out a block of time and you know; over that period, I was involved in the care of over 40 COVID patients.
Praveen Suthrum: How long has your practice or your surgery center been closed?
Dr. Mitchell Spinnell: Our last day of full operation was on March 16th and it was the weekend before that Monday that we really began to see the number of cases in New Jersey skyrocket. And I believe on the 13th, the Governor declared a state of emergency. I was doing endoscopy on that Monday, the 16th, and there was great concern because the unit didn’t have appropriate PPE.
Many of our cases either dropped off because of patient concerns and we had to cancel quite a few because we were concerned about upper endoscopy and not having proper protective gear for the staff, the physicians, and the anesthesiologists. The unit officially closed on the 16th of March. I’m happy to report though that we are scheduled to open up this coming week on Thursday, May 28th.
Praveen Suthrum: And how are you transitioning, you know from this phase to the phase of opening up back again? Do you have enough PPEs? What kind of staff training and physician training did you have to undergo in preparation of this opening?
Dr. Mitchell Spinnell: Yeah. So, that question really encapsulates my last two weeks because it has really been a challenge. You know, we have three rooms in our facility and what we’ve opted, at least to start is that we’re going to have one provider toggling between two rooms. We are going to schedule cases every 45 minutes to an hour. And for the first weeks, we plan on scheduling no more than 12 cases on a given day. Part of that is because of our lack of PPE. Part of that is to gain comfort for the staff and the physicians, many of the physicians have not been on the hospital environment during the pandemic and they are not familiar with protocol and we have done extensive training.
We have been able to secure some PPE. The biggest variable are the N-95 masks. As a result, we have actually purchased some respirators, a number of them for the entire staff. And those are hopefully going to arrive this week. We do have enough N-95 masks to maybe last for 10 working days. So, those are the limiting factors. We’re going to really start at a snail’s pace. We spent three days training the staff last week. And we have really put in a protocol that I think is going to be quite effective.
The detail on that is because we’re in a red zone. As per our hospital protocol, which we will be following and now it’s mandated throughout the state of New Jersey, all patients receiving elective procedures and we wouldn’t consider our initial patients to be elective, they’re more semi-urgent cases, all patients will require a COVID nasopharyngeal swab 72 to 48 hours prior to their procedure. We’ll have documented a negative swab upon the patient and the patients are then asked to self-isolate from the time of their swab till the time of the procedure. They’ll arrive at our unit where they will be questioned by a nurse. They’ll get a temperature check and we will also be evaluating them with the pulse oximetry and then, assuming that their COVID is negative, and they haven’t answered affirmative to any of the questions, they will be admitted and the procedure will take place.
We’ve also asked our staff if they were interested in getting swabbed and antibody tested prior to restarting and all of the staff were interested. I’m happy to report that everyone was negative. But this is the protocol that we set up and I think it is the best way we can maintain safety for our staff and our patients.
Praveen Suthrum: Yeah. I’m glad to hear that everybody tested negative. When you were going through this training with staff, what kind of concerns did they have? What were they fearful about?
Dr. Mitchell Spinnell: You know, I think it’s the fear of the unknown. There is not a single employee in our unit that has not been affected by this pandemic. Everyone knows someone who has had the virus, knows someone who was hospitalized, and we have had several family members who have lost relatives.
So, there still is great concern about exposure. I think that we’ve really tried to reassure the staff that with proper PPE, they can remain safe. You know, when I was working on the unit, I was very concerned about my exposure, I have a young family I was away from my family during my time of work and I was concerned that when I did reunite with them, that I would be bringing the virus back. And I think this is a big concern that the family had that you know, after a workday when they return home, what will they be bringing with them?
I was able to reassure them that, after my stint in the COVID unit where I was seeing 10 or 12 COVID patients a day, at the end of my term, I nasal tested negative and my antibody was negative. So, the PPE clearly works, if it’s used properly and you’re absolutely fastidious about the details of donning and doffing, I think you can remain safe.
Praveen Suthrum: So, if after you start, someone tests positive. As in you end up discovering that the patient was infected maybe after you do the procedure or after you’ve seen the patient. Then, do you remain open or do you close? What is part of your protocol? How have you thought about that?
Dr. Mitchell Spinnell: Yeah. I mean that’s a great question. You know, the big concern is that we don’t want our unit to be associated with any infection. Because clearly as things open up, everyone is going to be hyper-vigilant about new clusters of cases that emerge.
Our plan is that obviously we are not going to admit anyone into our unit that either test positive or answers affirmative to any of the approving questions and their cases can be deferred. But after their procedure, typically we would do a follow-up call on their first post-procedure day. Our plan is to extend that. So, we will follow-up the day after the procedure, a week after the procedure, and 14 days later.
And this is our way of contact tracing, making sure that nothing has happened to the patient after an exposure. And this will all be tied-in with the local health department. If we do find a positive, obviously we’re going to need to restore. We’ve also offered to our staff, you know, they will be tested daily on arrival at the unit with temperature checks. We’re going to be logging all of that data and if they do want to get periodic swabs or periodic antibody testing, that is available. Our hospital network has really ramped up its capacity to provide necessary testing, particularly for healthcare workers.
Praveen Suthrum: I want to ask you about what must be confusing for you right now, both as a clinician and as a physician partner or business owner?
Dr. Mitchell Spinnell: The financial pieces is clearly a struggle. We furloughed our entire ASC staff and more than 50% of our office staff during the height of the pandemic. We’re bringing back 50% of our staff in the ASC and about 75% in the office as we ramp up and start to see patients.
We were lucky that we were very aggressive in applying for the PPP (Paycheck Protection Program) loans that were available and we did receive all aspects of the loan. And that has carried us through. We are now obligated to try to utilize that money during a certain time period. So, having our staff back and paying our staff is very satisfying. Most people want to come back.
Clearly there were some people affected by the pandemic in a variety of ways. Some are still at home mourning others have childcare responsibilities given the fact that schools are still out. Summers programs will probably not be available. So, these will all be challenges moving forward.
You know, the financial piece of it will remain a challenge. I don’t think we can expect things to get back to normal for quite some time. I think it’s going to be a matter of just surviving and working our way through this. The financial piece will hopefully come maybe towards the end of the year but that’s all contingent on whether or not we see a second wave. But at this point it’s just a matter of staying positive and trying to forge forward. You know, I don’t have a better response to that. It’s scary.
Praveen Suthrum: Do you foresee patient behavior change during this period? Do you think, that patients would think, ‘If I can avoid screening colonoscopy, maybe I should. Why get into a healthcare facility if at all it can be avoided’?
Dr. Mitchell Spinnell: I think that many patients are going to feel that way. And I think that the internists that we work with are quite sophisticated and are aware of all the screening tools. You know, we have seen a significant uptick in Exact Sciences’ Cologuard use. Over the last year, year and a half. I mean, it’s there. We utilize it ourselves for patients that are higher risk or endoscopic procedures that do require a screening test. I think to bury your head in the sand, and think it’s not going to have a major impact, I think is false.
It’s here to stay and it will continue to grow. I think we’ll have to be creative in terms of how we structure our practice moving forward. There are many services that we provide, and we continue to expand the services and patient offerings. And I think we need to be innovators. I think Cologuard is a force and I would rather be a part of that force than to fight against it.
Praveen Suthrum: Talking about consolidation in your region. So, you’ve had small practices talk to you? Smaller practices call you, share their concerns? What is the vibe about consolidation in your area?
Dr. Mitchell Spinnell: So, you know consolidation has been in and out of New Jersey for the last four years now. There have been multiple attempts at trying to form a large super-group and private equity has had its hand in New Jersey for quite some time. I know that there were quite a few deals that were being explored. Our group has certainly considered the possibility of syndication either with a private equity group or with a large hospital network. We have been in talks and we’re trying to decide on which direction we want to go.
I’m amazed that some of the groups that have been exploring, investing in gastroenterology groups in New Jersey have fallen off and have not been expressing the same kind of interest as they were months ago. But there still are some very dominant, large private equity groups that are still showing interests. So, the talks are ongoing. There has not been a major transaction in New Jersey, but I anticipate that in the months to come something may finally come to market.
Praveen Suthrum: If the valuations change, would the interest from doctors also change?
Dr. Mitchell Spinnell: I think so. I think a lot of it is going to depend on whether or not it makes financial sense. But more importantly, depending on what your horizon is I think we know that consolidation is really the only way forward. In order to mount some strength against the payors, groups of two or three physicians won’t be able to survive. Larger groups have a better chance.
But I think the weight of a private equity partner or a hospital partner is really what’s needed in order to see some light. Clearly as a result of the pandemic, our expenses are going to increase significantly. And the only way we can whether those added costs is if we are part of a larger entity and have the ability to negotiate. So, I think consolidation remains the way in the future.
Praveen Suthrum: What kind of advice do you have for GI practices or endoscopy units that are outside of the red zone and looking to you. You know, you’re in the thick of things and you’re opening up now.
Dr. Mitchell Spinnell: You know, I don’t think you can underestimate the variety of ways that this virus presents. We have all been blown away by the variety of clinical manifestations and presentations. I remember a patient of mine who was in the emergency room with what sounded like peptic ulcer symptoms. They did a chest X-ray on him and they saw bilateral ground glass infiltrates. He had absolutely no respiratory symptoms at all and was diagnosed with COVID. So, my point is that we have to take this virus incredibly seriously. I think that PPE is critical. We have to be sensitive to our staff and make sure that they feel protected. And I think appropriate questioning and screening of our patients remains essential.
I mean, even in people that are outside of red zones, I think we need to change our approach to donning and doffing the PPE and I think we need to remain absolutely fastidious about the details of putting on the equipment and taking off the equipment, using shields, things that we very often took for granted in that past really need to be adopted and we need to be absolutely strict and we need to call each other out. When people are not doing things properly, whether it’s a physician or a nurse or a technician, we really need to be on top of each other because that’s the only way we’re going to be protected.
Praveen Suthrum: Dr. Spinnell, thank you very much for sharing all these insights. Incredibly useful. I wish you all the best in opening up this week. I wish you well, I wish your staff well. Take care. Thank you!
Dr. Mitchell Spinnell: Okay Praveen. Thank you very much, I really enjoyed it. We’ll talk soon.
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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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25 May 2020

AI stepping up against COVID-19

The technology landscape for Healthcare is flooded with tools, experiments and innovations that are poised to re-shape the domain in a way unimaginable, prior to COVID-19.
In my previous post, I touched upon Tele-medicine as the new key to providing continuity in medical care to patients. This week, the focus is AI and its role in the fight against COVID-19. Patient screening, monitoring and drug repurposing have seen some interesting AI experiments recently.

 


Screening and Social Control
► Providence St. Joseph Health system in Seattle collaborated with Microsoft to build an online screening and triage tool to help differentiate between Covid-19 patients and those suffering from other ailments.
Partners Health-care Covid19 screener is an online web tool that throws up questions, based on content from the U.S. Centers for Disease Control and Prevention (CDC) and Partners HealthCare experts, on its chat interface. Basis its assessment, the tool will direct patients to the next steps to be taken.
► Clearstep, Babylon Health’s Covid-19 Care Assistant are other chatbot based online screening and triage tools available.
► AI systems built into cameras equipped with thermal sensors are getting widely deployed to scan for fevers. Chinese company Baidu uses AI and no contact infra red sensors to predict fevers. Currently deployed in Beijing’s Qinghe Railway Station, it can detect forehead temperatures of 200 people a minute.
► A group of scientists at Swiss University have developed an AI based application called “Coughvid” that listens to people cough and determine if they sound like a COVID patient.
Tampa General Hospital has deployed an AI based facial recognition scanner at the entrances . This performs facial scans to screen visitors to the hospital who may have fever.
There are also AI software solutions that help interpret lung CT scans. They quickly detect the visual signs of pneumonia linked to Covid patients. Zhongnan Hospital of Wuhan University in Wuhan, China, is experimenting with this software. This will help staff screen patients and prioritise those most likely to have Covid for further testing.
While AI based solutions are being used to facilitate the triage of patients with Covid symptoms, there are also intelligent robotic solutions that help with monitoring the symptoms and automating hospital operations.

 


Monitoring and Operations
China’s Wuhan Wuchang Hospital used robots to staff a smart field hospital. They were used to monitor vital signs of patients, deliver medicine and food, reducing physician exposure to the virus and easing the workload of exhausted health care workers.
► At both Brigham and Women’s Hospital and at Massachusetts General Hospital, experiments are underway to use intelligent robots, developed at Boston Dynamics and MIT, to interview Covid patients, to obtain vital signs or deliver medication that would otherwise require human contact.
► MIT’s Computer Science and Artificial Intelligence Laboratory (CSAIL) has developed Emerald , a WiFI like box, that helps to remotely monitor a COVID-19 patient’s breathing, movement, and sleep patterns using wireless signals .
► British Health-Tech startup, Medopad, is also providing clinicians with a specialized Covid-19 version of its Remote Patient Monitoring platform. The patients have a smart phone version of this app to securely share health data such as their heart rate, respiration rate and body temperature.
The use of AI is not just limited to patient monitoring or robotics, there is a fascinating movement that is using AI to discover drugs. With the global pressure on the discovery of an effective drug against COVID-19 mounting by the day, the use of AI in drug repurposing is the new hope.

 


Drug Repurposing 
What does drug repurposing mean?
It simply means using a drug meant for one disease on another.
This could be based on the expertise and educated guesses of scientists. Using Hydoxychloroquine, an anti-malarial drug, for some advanced Covid-19 patients was one such attempt.
Developing a new drug from scratch to combat Covid-19 is an effort that will take at least a decade. Instead, if you scan existing drugs, that have already been approved by regulatory bodies, to shortlist potential candidates that could work, the time taken to develop a viable could be greatly diminished.
pre-print paper has recently outlined the use of AI based drug repurposing in the fight against Covid. Deep neural networks could be used to not just scan existing drugs but also scan a list of approved compounds, that have been developed for other ailments, that could work for corona virus symptoms. The pre-print paper is based on a hypothesis using SARS, a virus similar to the Covid-19. Since both these viruses have an 86% similarity in their genome, a drug that works for SARS could be effective in battling Covid-19.
There have been some other interesting experiments on the horizon:
► BenevolentAI, has identified Baricitinib, a drug approved for the treatment of rheumatoid arthritis, as a potential treatment to prevent the virus infecting lung cells
Exscientia, first to put an AI-discovered drug into human trial, is trawling through 15,000 drugs held by the Scripps research institute, in California. Their idea is to screen every known approved and investigational drug against key Covid-19 drug targets to shortlist compounds that could possibly become viable drugs to treat the coronavirus.
There are many more companies using AI to find a treatment for Covid-19; HealxInnoplexusDeargenCyclicaGero, VantAI to name a few.
Some caution may be advised. AI based discoveries need the right data set and mining tools and any solutions thereof need to be backed with controlled trials. The objective intervention of the scientific community is a must.

 


AI AI everywhere
So there you have it. AI based solutions rising up to the challenge in prevention, diagnosis, prognosis, operations, drug discovery and development, not to rule out its effective use in vaccine deployment too. While experiments are still at an early phase, the tools already in use look very promising to ease the load on the healthcare system. The challenges of unifying data from various resources, scrubbing out the noise and outlying data, getting the right dataset ( CORD-19) to train AI systems, continue. The role of AI in tracking and predicting the spread of this disease is still not accurate and will need exhaustive work. However, joint initiatives involving the government, healthcare, science and tech communities look to produce promising results as one works the learning curve.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices

 

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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.
button_download
20 May 2020

Curated COVID-19 GI Resources: May 19th, 2020


Curated COVID-19 GI Resources: May 19th, 2020
Video: Interview with Dr. Gagneja (ACG Governor for S. Texas): “Telemedicine is not a panacea!” (NextServices)
Practical wisdom from Dr. Harish Gagneja from Austin Gastroenterology, the largest single-specialty group in Austin.
Amid the Coronavirus Crisis, a Regimen for Reëntry (The New Yorker)
Atul Gawande writes this insightful article regarding a cocktail approach to stay safe: hygiene measures, screening, distancing, and masks. Then he added culture as an afterthought.
There Are Tough Financial Days Ahead For U.S. Healthcare In The Wake Of The Coronavirus Pandemic (Forbes)
Dr. Stephen Thomas, Chief of Infectious Diseases at SUNY Upstate Medical University, discusses the financial toll that the Covid-19 pandemic is taking on U.S. healthcare systems, and what the road ahead looks like.
20 Takeaways from Exact Sciences call: “Cologuard fits seamlessly into a permanently changed healthcare environment” (NextServices)
These takeaways are based on the Q1 2020 Earnings Call. Screening revenue was $219.5 million, an increase of 35%.
How 4 centers across the U.S. reopened & the new standards they set (Becker’s ASC Review)
In this article, four administrators share what they’ve done to reopen their centers and prevent the spread of COVID-19.
Gastrointestinal symptoms affected one in four patients hospitalized with COVID-19 (MDedge)
Gastrointestinal symptoms affected 26% of patients and most commonly included diarrhea (18%), nausea (8%), vomiting (6%), and abdominal pain (2%), the researchers reported.
New ebook – COVID-19: The Way Forward for GI Practices (NextServices)
COVID-19 is a double whammy of both clinical and business disruption. Download this free eBook. Part 2 to launch this week. “This is so good” “Terrific insights.”
COVID-19: What Will Happen to Physician Income This Year?  (Medscape)
“Private practices are reaching the point where prior A/R will start to dwindle and they will start feeling the decline in new claims submissions.”
Industry Voices—7 things to consider before reopening your operating room (FierceHealthcare)
‘A local hospital we’ve worked with recently began contacting patients to reschedule their canceled elective surgeries and found that nearly 40% were unwilling to’.
COVID-19: Endoscopy Centers Try to Expect The Unexpected (GI & Endoscopy News)
Obviously, sticking with single-use scopes and other disposable equipment is “going to be ideal.”
N.J. reveals multi-stage coronavirus reopening plan. We’re in ‘Stage 1,’ Murphy says. (NJ.com)
This article from New Jersey (a red one) has useful infographics that describe Stage 1 to Stage 3 to a New normal. It’s one way to think about opening up.
IBD may require more intense care approach due to higher cost volatility (Healio)
Dr. Kosinski: “Payers and gastroenterologists need to work together to engage patients with high beta conditions, track symptoms, catch deterioration early, and intervene before it becomes a bigger problem.”
Treating Liver Disease During COVID-19: New Recommendations (Medscape)
New Recommendations by AASLD. Early reports suggest a 14%-53% incidence of liver injury in patients with COVID-19.
The ‘new normal’ for ASCs: 16 admins on how the pandemic will change the field forever (Becker’s ASC Review)
ASC administrators project what the “new normal” will be at their centers as a result of the pandemic.
Code Green: Telehealth Gone Viral, the Alternative e-Universe  (Gastroenterology & Endoscopy News)
FAQs on reimbursable services from ASGE’s coding advisor Dr. Littenberg.
Implications of gastrointestinal manifestations of COVID-19 (The Lancet)
Ren Mao and colleagues report findings of a systematic review and meta-analysis of data from 35 studies, including 6,686 patients with COVID-19.
How COVID-19 affected procedure volume for 25+ specialties  (Becker’s ASC Review)
Researchers analyzed 2 million patient visits from 228 hospitals in 40 states over a two-week period in March and April in both 2019 and 2020.
Simple Strategies Can Lessen GI Burnout (Gastroenterology & Endoscopy News)
Even before the COVID-19 pandemic hit the United States, physicians in this country were confronting a different kind of epidemic: burnout.

Headlines for GI
Hospitals Knew How to Make Money. Then Coronavirus Happened (The New York Times)
Thoughts on COVID-19 Care (Gastroenterology & Endoscopy News)
Telemedicine – The Emerging Face of Healthcare Amidst COVID-19 (NextServices)
HHS grants $15M to 150+ providers for telehealth training, support (Becker’s Hospital Review)
CMS issues more rule changes to cope with COVID-19 — are they enough? (Healio)
AMSURG Develops Toolkit to Guide Ambulatory Surgery Centers in Providing Safe, Quality Patient Care (Yahoo Finance)
Colonoscopy prep is changing — here’s how (Becker’s GI & Endoscopy)
Amazon extends telemedicine pilot to warehouse employees in Seattle area (CNBC)
_

 

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 May 2020

Interview with Dr. Gagneja (ACG Governor for S. Texas): “Telemedicine is not a panacea!”

I recently spoke to Dr. Harish Gagneja from Austin Gastroenterology, the largest single specialty group in Austin, Texas. Dr. Gagneja serves as the American College of Gastroenterology (ACG) Governor for Southern Texas. He is also the former President of Texas Society of Gastroenterology and Endoscopy.
During the interview, we debated on how much digital technologies will impact healthcare during and after COVID. Dr. Gagneja had contrarian but very practical views on telemedicine, which he feels is overhyped.
Also, if you are opening up your endoscopy center this month, you’ll find plenty of on-the-ground insights in this interview.
Impact on their practice – “We moved very fast”
“No more an on/off switch. We’ve replaced that with a dial”
“Testing [before endoscopy] is an overkill”
Are patients scheduling for screening colonoscopy?
“We will be at 70%-80% this year”
◘ Our debate: “What do you mean healthcare will be permanently changed?”
“Digital revolution so far hasn’t really helped”
Practical challenges with telemedicine: payment, video freezes, patients don’t know how to turn on the microphone, distracted patients, more work than office visit, back and forth
“Yesterday, my colleague’s patient was ordering a fish sandwich!”
“Telemedicine is overhyped”
“Screening [colonoscopy] I’m divided on”
Advice on opening up for GI practices

 


The Transcribed Interview:
Praveen Suthrum: Dr. Gagneja, thank you very much for joining me today. You are from Austin Gastroenterology. I want to get started first by asking you to share a little bit about your practice in Austin.
Dr. Harish Gagneja: Praveen, thank you for having me today for this interview. I can tell you that we are the largest single specialty group in Austin, Texas. We are about 35 physicians and 25 mid-level or 60 plus providers. We have a three endoscopy centers. We are vertically integrated which means we have all the ancillary services available through us and we have presence in all major hospitals in Austin.
When the pandemic hit it was mid-March, I think 17th or 18th of March when all the guidance came out, so we had to really move very fast. We stopped elective procedures, all of them. Within a week we furloughed about 35% of our staff. We temporarily shut down our satellite offices. You know, I have to tell you something that we are very blessed to have a very talented C-suite. Our CEO, CFO and COO we are together for more than a decade, 12 – 13 years and we have learned together from the 2008-2009 crisis as well. We moved really fast and then we were talking about the process of getting telemedicine onboard and this really accelerated it, COVID-19 accelerated it and now we are opening up again we’ll be opening up slowly.
What I say is that there is no more on and off switch, now we have replaced that with a dial. We will be dialing up and dialing down depending upon how the city is doing. At this time, the city prevalence is about three percent. We are watching it every day. Our cases are a flattened. There is no decrease yet. Our hospitalizations are about the same number, about 40 to 45 hospitalizations so, we have opened them slowly. We have three endoscopy centers, we started opening with the first. We had six rooms in that we have opened three rooms only doing all the social distancing, we’re keeping all the patients… everybody who comes down in the morning, they get checked with temperature, with all the symptoms. Patients are called three days and one day before. All the patient’s relatives stay in the car outside in the parking lot. So, we’re taking all the precautions. We also have increased our block times as well.
Praveen Suthrum: And you have enough PPEs available and enough testing going on?
Dr. Harish Gagneja: Yes. We have enough PPEs available. We are not doing testing at this time are we doing only PPE but there’s a talk of doing testing, upper endoscopy cases only. But we are not doing testing at this time. I can tell you, in my humble opinion testing is overkill. If you have a PPE, then there’s no need for testing if you don’t have PPE at all then testing is done.
Praveen Suthrum: Okay. I’ve observed that you know this view on testing differs from state to state. 
Dr. Harish Gagneja: That should be used for somewhere else… we’re wasting testing if… I was listening to a podcast from University Minnesota, Infectious disease. So, within next one month there will be a need for one billion, not million, billion tests all over the world. Where is all those tests going to come from? Tests are one thing, then there are swabs, reagents, when you start adding all that up, it really adds up. If you have PPE as I said, I think testing is not really necessary because N-95 masks are really 95% effective. You look at the refugees’ article that was published, which was recently, two weeks ago. That article clearly shows that… and that was done in the Lombardy area all the high-risk areas in Italy. 85% of their endoscopies were done before even they started taking significant universal precautions and PPE. The risk of transmission was 4.2% in health care workers and 0.6% were hospitalized which is as good as community. So, I think there is a lot of knee jerk going on. I really think that if you have a PPE, testing is not necessary.
Praveen Suthrum: What kind of patients are you seeing in the endoscopy center? 
Dr. Harish Gagneja: So, right now what we’re doing is that we are triaging our patients. We are seeing all the symptomatic patients. So, there are three buckets: one bucket is a kind of a semi urgent bucket, so we’ve been through that very quickly with all those patients. Second bucket is all the patient with diagnostic codes, so we are going through that right now and we’re making sure that patients who need the endoscopy are get done first because we’re right now operating at about 30% of our capacity. So, then after this we’ll be getting back to our doing screenings as well, which would be probably next week.
Praveen Suthrum: And patients are scheduling themselves for screening? Is that happening?
Dr. Harish Gagneja: Personally, I have a backlog of about 200 patients who are calling to get scheduled. If we open it up, I think we’ll fill it up. It’s just the matter of getting them done safely.  
Praveen Suthrum: What kind of changes do you see happening after this COVID period?
Dr. Harish Gagneja: We’ve all utilized telemedicine more than before but not to a degree which is being projected in the media as well as a lot of people are talking about it… we will do that. I personally believe and that’s only me, I’m not talking about the group, talking for me personally I believe that we will not get to 100% this year, I believe that we will probably hit 70 to 80% this year and that also depends on what happens with the second wave for U.S. If everything goes well, no guarantees for anybody, we think that vaccine will be available by first quarter of 2021 and I think after the vaccine will be available, then normalization starts and that doesn’t mean that it is going to be normal, but normalization starts. I again, personally believe that by end of 2021 everything is going to be normal again.
Praveen Suthrum: End of 2021? And by then, health care might permanently change itself right or do you believe it… you know things will be a little bit of the same or different? I’m just curious… your views on how things will be different?
Dr. Harish Gagneja: What do you mean by that… permanently change. Everything will not be telemedicine.
Praveen Suthrum: Everything will not be telemedicine, but what this whole period is prompting us to try new things and different things that we have not tried before. Telemedicine is definitely one example, but there are several aspects of digital technology that is coming very actively into healthcare. My view is that, it might expand because you know, now that we have gotten the taste of it, it just might expand and after this whole period is over it might become part of the new norm. But I know you think differently about telemedicine and that’s what prompted this interview, but I’d like to hear what you have to say.
Dr. Harish Gagneja: Yeah. As we know, crisis is mother of innovation and it really gets accelerated during the crisis times. So, some of the business stuff that I said will be normal in the end of 2021, I didn’t mean that we won’t be doing anything, right? We’ll still be at 60 to 70 or 80 to 90% of what we are doing, and it won’t be 100% like we were doing, right? So, all of that stuff will still be happening, and I can tell you… we just opened up face to face as well. There’s no double booking, we’re still booking instead of 15 – 17 patients we’re booking 10. Then, we’re adding telemedicine in between and still getting to 15 – 17 patients and have something like that, right? Stuff is still happening.
But digital revolution is going to happen. Whether that happens in these two years, five years or ten years, I don’t know. Whatever so far has happened in this digital revolution such as Electronic Medical Record (EMR) that really has not helped. I think it is being projected as telemedicine is the savior, it is the panacea. If they’re seeing 20 patients in half-day and with telemedicine, they’re seeing six or seven or eight patients a day and not seeing 20 patients. Yes, they started telemedicine, but they are not fully blown with telemedicine, that’s number one. Number two question is, right now we are under the emergency act. Basically, an emergency from CMS. So, what’s happening with that is, telemedicine is being paid at same level that office visit. Whether that will ever continue I don’t know that.
Even though I know you’re talking about… Seema Verma said that the genie’s out the bottle. Yes, but what happens after COVID-19 is over? Or are they going to continue with that. Having said that, I would also tell you that telemedicine is more work than office visit for our staff and our physicians and paying at the same level even doesn’t cut it. I think it should be paid more. Let’s set up. Let’s talk about them. Steps with telemedicine: number one is set up. You’ve got to have all the setup of telemedicine takes, then you have a pre-visit where you prep the patients for pre-visit. Then you have during the visit. So, setup, pre-visit prep and during the visit.
Visit is very easy it’s not hard, but two things can happen during the visit, i.e. challenges which happens quite frequently actually… technology challenges, videos freezing up, voice is not going in and patients don’t know how to turn the microphone on or have staff walk them through all that but it happens all the time. I can tell you it happens about 30 to 40% of the time. Sometimes you can see, the ‘seeing of their own on their face’ but they don’t know how to look at the (camera)… a lot of things happen like that, right?
Then, the other thing I tell you is distractions during the visit. I have had a patient, I had to stop televisit because they were driving and doing televisit. People are abusing it not even using it but abusing it. I also had one of my colleagues tell me yesterday that one of his televisit patient was ordering a fish sandwich and he said he had to stop the delivering the televisit. So, people are not using the televisit like your office visit.
They think… It’s just something else. They’re walking around, walking in the speed and then they tell that doesn’t work. So, that’s the ‘during the visit’ telehealth challenges. Then post-visits, check-outs. So, any procedures that needs to be scheduled, that’s multiple phone calls multiple back and forth. When patient is in the office visit, the procedure is 10 minutes everything is done – prep, insurance, and scheduling. Here, now you have multiple phone calls for prep, for insurance issues, they will keep on calling you back for insurance and then scheduling they have a back and forth multiple times. If you look at all this, like I outlined, telemedicine is not that straightforward as it sounds to me.
Praveen Suthrum: Those are all really very good points and a lot of practical challenges there, right? But could that be part of the learning curve? But I want to also read out Seema Verma’s quote like since you brought it up. She is the CMS administrator and she said, “I think it’s fair to say that the advent of telehealth has been just completely accelerated that it’s taken this crisis to push us to a new frontier but there’s absolutely no going back”.
So, it looks like you know, Medicare will continue to pay for it, at whatever level like you know there will be the reimbursement part associated with it. But I’m also thinking for chronic GI patients, right? Like so they’ve now… yeah there’s always a negative side to a coin and you know there are these patients who are taking or misusing this whole benefit but there are also patients who would otherwise have driven a long way to meet the physician and it may be a follow up visit but now they have this whole benefit of seeing you remotely. Don’t you think that will stay?
Dr. Harish Gagneja: So, you are mistaking my point. My point was that telemedicine is being overhyped. It means that ‘Oh my god everything will be done with telemedicine’. Telemedicine has a definite role in future. I really think that… I’m very happy that this happened with telemedicine not at all with COVID-19. But telemedicine… it definitely has a role. I can give you examples. I personally feel that in my practice I will be doing about 20 to 25% telemedicine not 50 to 60% what a lot of people are putting out. I don’t say that it’s going to go over completely. No, telemedicine is here to stay and it’s going to happen.
Screening I’m divided on. I think that if a patient is insisting on telemedicine to screening sure no problem. But I said outlined previously that there’s a lot of challenges. Challenges are best for one reason; I know that I’m against the grain here regarding open access endoscopy. I just do not like it because same thing, telemedicine for screening – prep issues, insurance issues, issues with scheduling. There’s so much time taken. If you’re in the office, it takes 10 minutes to get all that done and one time and you’re done it doesn’t take three or four or five phone calls and back and forth, “let me call you back”, “let me do this”, it doesn’t happen (in office visits). So, screening if my patient is insisting, sure I’ll do it. But I prefer that I see them, talk to them.
Praveen Suthrum: I have one final question. You know given where you are you’ve already started your surgery center, you’re seeing patients, you know you’ve restarted. What advice do you have for GI practices you know that might be watching this?
Dr. Harish Gagneja: The first and foremost thing I would say is that make sure that you are in regulatory compliance. That everything was okay. So, that’s very important. Your state, the city, the county, and of course CMS, CDC, look at all the guidance papers. I would point them towards the paper we just published, white paper from American College of Gastroenterology with 12 people task force, look at that. That’s a very comprehensive document to look at. Safety of your patients, your staff, is the paramount importance. So, do all the necessary things.
I was reading an article from Atul Gawande this morning. It was about a recipe… he was talking about… a cocktail. The cocktail is hand hygiene, social distancing, masks. That’s the cocktail. One each by itself doesn’t work very well. When you put them all three together, then it is very good. So, make sure that you do all the rules in your practices. And then fourth part of the cocktail was screening which needs to be done.
So, that’s the starting. And I said before in our interview that to me that it is not a on and off switch anymore. It’s going to be the replaced by a dial. You go dialing up to dialing down depending upon what happened in your city, county and state. So, that’s important thing. If you think that you are going back to 100% like what you’re doing before that’s a mirage. The way things are, the way the regulations are going to be, with the government… what is your real estate needs? Do you really need all the real estate anymore? I think we will diverse some of that. So, I think those long-term future or questions you start asking yourself, what do you have, what do you need? So, that all needs are to be thought about.
Praveen Suthrum: Well, thank you so much Dr. Gagneja, this was very helpful and insightful and people who are watching this would feel the same. I wish you all the best in opening your center in more, as the months go by and all the best in keeping safe to you and your staff as well. Thank you so much for your time today.
Dr. Harish Gagneja: Thank You Praveen. Thank you very much. Thank you for having me. Have a great day. And you know what I say, in these interviews these days I say, “stay positive test negative”.
Praveen Suthrum: Thank you.
_

 

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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14 May 2020

20 Takeaways from Exact Sciences call: “Cologuard fits seamlessly into a permanently changed healthcare environment”

Last week, Exact Sciences, the maker of Cologuard announced their first quarter results. Here are 23 takeaways from their earnings call.
The 2020 Q1 earnings call was based on three key topics:
◘ Near-term challenges presented by the coronavirus and steps the Exact Sciences team is taking to respond
◘ The company’s positioning to provide smarter solutions to patients and providers across the cancer continuum 
◘ Delivering value over the long term

 

Let’s start with some numbers:
◘ Total revenue was $347.8 million (compare that to $162 million in Q1 2019 and $296 million in Q4 2019)
◘ Screening revenue was $219.5 million with an increase of 35% 
◘ Precision Oncology revenue was $128.4 million
These takeaways are based on the Q1 2020 Earnings Call. Kevin Conroy, Chairman and CEO, Exact Sciences and Jeff Elliott, Chief Financial Officer, Exact Sciences made these remarks.

 


 Takeaways: 
1. The company plans to play an even greater role in cancer screening and guiding therapy decisions after the coronavirus abates.
2. Approximately 9,000 new healthcare providers ordered Cologuard during the first quarter, and nearly 206,000 providers ordered Cologuard since launch. 
3. Cologuard test orders have shown a 63% year-over-year decline during the first 20 days of April.
4. The Exact Sciences team rewrote 2020 priorities in response to the coronavirus pandemic. New priorities are: getting people tested, taking care of customers, preserving financial strength.    
5. The company is using its marketing and inside sales tools to reach healthcare providers virtually.
6. Exact Sciences has accelerated the launch of their telehealth site with patient education resources. People can now request a telehealth consult specific to Cologuard from home. The company feels that telehealth has opened a new way for people to access Cologuard from the safety of their own home.
7. The company introduced new advertisements to raise awareness of the importance of staying up-to-date with screening and the opportunity to order Cologuard online as they believe that in a COVID world, TV viewership rates are a lot higher now than they were pre-COVID.
8. The company reckons that because of the pandemic there is a significant backlog of those who need to be screened. And that this backlog will continue to grow as focus remains on more urgent diagnostic colonoscopies. They believe that Cologuard can play an important role in alleviating this backlog and getting more people screened. 
9. Exact Sciences recently closed the acquisition of Paradigm, a company specialized in advanced cancer therapy selection. They plan to expand the tissue-based Paradigm test. They also plan to make an enhanced tissue-based and a blood-based version of the Paradigm test that’s currently available.
10. Exact Sciences has decided to develop and roll out testing for the SARS CoV-2 virus. They have the capacity to test more than 60,000 people per week. 
11. The company has secured FDA emergency use authorization and scaled up their Madison lab sites to handle significant volumes. 
12. The company remarked that cancer doesn’t stop for anything and COVID-19 highlights the value of Cologuard and Oncotype DX. 
13. Exact Sciences has estimated that roughly 300,000 to 350,000 screening colonoscopies per month are not happening right now due to COVID-19.
14. According to the company the volume of Cologuard did not fall anywhere near and as fast as screening colonoscopies.
15. The company is having conversations with the GI societies and are foreseeing to partner with GIs to get people screened. 
16. According to the company, through their partnership with Epic, around 40% and 50% of all primary care providers in the U.S. are on the Epic platform. Later this year, Epic will release new functionality that will enable the providers to order electronically. 
17. The company has high coverage in Medicare and increasing coverage in Medicaid. They believe that the broad coverage will help them lessen the impact of rising unemployment. Medicare mix from a volume standpoint in Q1 was about 44%. 
18. Some of the major trials that the company had under way are temporarily paused. For example, BLUE-C (prospective trial) is temporarily paused. 
19. Some of the trials like Cologuard 2.0, colon blood product and the liver cancer test will continue.
20. The company expects to be more profitable as it comes out of COVID-19 than they would have been otherwise. 
_
References:
Exact Sciences Corp (EXAS) Q1 2020 Earnings Call Transcript (The Motley Fool)  
Exact Sciences Announces First Quarter 2020 Results (Exact Sciences)  
_

 

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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13 May 2020

Curated COVID-19 GI Resources: May 12th, 2020


Curated COVID-19 GI Resources: May 12th, 2020
New ebook – COVID-19: The Way Forward for GI Practices (NextServices)
COVID-19 is a double whammy of both clinical and business disruption. Download this free eBook. Part 2 to launch this week. “This is so good” “Terrific insights”
Exact Sciences pivots to telemedicine in a COVID-19 world — 4 quotes on the company’s Q1 performance (Becker’s GI & Endoscopy)
“Post-COVID outlook: Cologuard fits into that market very well.”
Doctors Without Patients: ‘Our Waiting Rooms Are Like Ghost Towns’ (The New York Times)
As many as 60,000 physicians in family medicine may no longer be working in their practices by June because of the pandemic.
Coding and coverage for telehealth and eVisits during the COVID-19 crisis (AGA)
Updated coding and coverage for telehealth and eVisits during the COVID-19 crisis.
Walmart Health expands as physician practices face cash crunch (Becker’s CFO Report)
With more than 5,000 stores and clubs nationwide, Walmart has the potential to upend the way many Americans receive medical care.
COVID-19: 8 Steps for Getting Ready to See Patients Again (Medscape)
“Reopening the economy or loosening physical distancing restrictions will be difficult when 20% of primary care practices predict closure within four weeks”.
GI nurse practitioner delivering telemedicine at home (Killeen Daily Herald)
‘Point at your stomach and show me where you are having this pain’ is what a GI nurse practitioner says to her patients.
Paying private insurers Medicare rates would tank hospital revenue by 35%, study finds (HealthcareDive)
The gap between Medicare and commercial rates is growing due to forces like rampant provider consolidation, making it difficult for private payers to negotiate rates.
Guide to COVID-19 financial assistance programs for physicians (AGA)
AGA’s guide to COVID-19 financial assistance programs for physicians [updated].
5 Reasons Why Telehealth Is Here To Stay (COVID-19 And Beyond) (Forbes)
33% of consumer respondents would leave their current physician for a provider who offered telehealth access.
The Regueiro Report: IBD Live (Gastroenterology & Endoscopy News)
The SECURE-IBD registry includes data on nearly 600 patients with IBD and COVID-19 from 30 countries.
Colorado GI practice’s surgical schedules begin to ‘fill up’ (Becker’s GI & Endoscopy)
The GI practice is not alone in seeing an uptick. Advanced Medical Imaging Consultants in Fort Collins lost 55% of its imaging cases but is also seeing elective procedure volume return.
AGA issues guideline on COVID-19 case management (Becker’s GI & Endoscopy)
Gastrointestinal symptoms were associated with COVID-19 patients in less than 10% of cases. Seven best practices to implement for the consultative management of COVID-19.
Video: Interview with Abe M’Bodj: Impact of COVID-19 on private equity in gastroenterology (NextServices)
Don’t miss this super insightful interview with Abe M’Bodj from Provident Healthcare Partners, an investment bank that’s been active in gastroenterology.
Video: Healthcare Has Left the Building (a16z)
The healthcare system is getting unbundled—and everything from where we get our care to what our medicines will look like to even how we experience symptoms will look very different in the future.
The Scope: the Financial Fallout of the Covid-19 Pandemic (Gastroenterology & Endoscopy News)
Joseph Losurdo, MD, a member of the American Gastroenterological Association, discusses the financial resources available to GI practices in the Covid-19 pandemic, and more.

Transforming healthcare with AI: The impact on workforce and organisations (McKinsey & Company)
Download this 134-page white paper and invest the time to understand the role of AI in healthcare.

 


More Hot Headlines for GI
The ‘beginning of the end’ of the health-care recession is ‘finally arising,’ Jim Cramer says (CNBC)
COVID-19 Conversations: ASGE President Dr. Mergener’s conversation with Professor of Vaccinology Florian Krammer (ASGE)
Survey: U.S. payers feel well-positioned to survive COVID-19 (FierceHealthcare)
97% of practices feel COVID-19 financial sting: Where to get help (AMA)
Introducing the GI COVID-19 Connection (AGA)
Top 3 financial challenges young doctors face (Physicians Practice)
New protection barrier for endoscopic procedures in the era of pandemic COVID-19 (Elsevier Health)
New Risk Grid Aims to Protect IBD Patients During COVID-19 Pandemic (Medscape)
GI and IBD in COVID Times: The new “Normal” by Prof. Siew NG (AIG Hospitals)
Perspective: Helping Our Hospitals so They Can Continue to Care for Us (American Hospital Association)
_

 

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
07 May 2020

Interview with Abe M’Bodj: Impact of COVID-19 on private equity in gastroenterology

Yesterday, I spoke to Abe M’Bodj from Provident Healthcare Partners, an investment bank that’s been very active in the gastroenterology space. Abe has always had a pulse on where private equity is headed in healthcare.
During our chat, I was pleasantly surprised to learn that Abe’s parents are gastroenterologists. This super insightful interview would help you understand what private equity is thinking while COVID-19 is on.
You must watch it in full to get to the depth of these insights. Here are some key highlights:
Provident Healthcare Partners is a healthcare focused investment bank
◘ What’s PE thinking? How has COVID affected private equity?
◘ There are transactions that are getting done but with creative transactions
Number of transactions that would be underway even during COVID-19
◘ Will valuation remain the same if you choose to wait until the other end of COVID-19?
This is going to accelerate M&A activity
Will multiples (valuation) drop? (cash in closing changing)
◘ In any transaction, there are 3 parties: seller, buyer and the lender
◘ What would happen to highly leveraged transactions?
◘ It’s a possibility that companies can end up in bankruptcy (may be not GI)
◘ If this uncertainty plays out longterm, what will investors do?
◘ Use the capital to help GI go digital?
◘ If we sit here 24 months from now (similar situation), if they’ll invest in GI anymore
Advice for mid-size or small GI groups considering PE (pros and cons) – his parents are gastroenterologists in Maryland

 


The Transcribed Interview:
Praveen Suthrum: Abe M’Bodj firstly thank you so much for joining me today. You have been very involved in private equity transactions throughout 2019 and even before that and PE in gastroenterology has been a hot topic for 12 months to 18 months now and then COVID hit. A lot of physicians are actually wondering how it’s going to pan out from this point on. And I’m so glad that you could join me today and I look forward to chatting with you about this.  
Abe M’Bodj: Absolutely Praveen. Thank you for having me. I have watched the interviews you have done previously and thought they were well done. So, very happy to participate. Again, I’m Abe M’Bodj with Provident Healthcare Partners and we are a healthcare focused investment bank that has large focus on physician transactions. So, lot of work in the GI space, lot of work in the physician space in general. So, we have been on the frontlines of seeing private equity and the change that COVID has brought to the market. So, happy to talk about that.    
Praveen Suthrum: Thank you. Let me start by asking you a broader question. During this COVID period, what is private equity thinking and how has it affected private equity as an industry in general?  
Abe M’Bodj: Yeah. Well, I think it has forced everyone just like society at large. It has forced everyone into two buckets. There are people who are pressing forward and are trying to figure things out from adeal standpoint and then there people who have taken a step back and are evaluating ‘is it the right time to deploy capital?’ ‘should we be investing right now?’. A lot of them have been forced to focus on their portfolio companies or the businesses that they have already made investments into.
I think now we are starting to see the dust settle not entirely in regard to COVID or what’s going on but in regard to getting a hand on what’s going on within our businesses. We are starting to see some private equity firms return to at least talking about the timeline to either completing the older deals that were put on hold as a result of COVID or looking at new opportunities. You did an interview with the president of OneGI, there have been couple of transactions that have closed as well. With OneGI and Webster in the GI space. In April we closed a women’s health transaction, in another space obviously but there are transactions getting done albeit I think all transactions are getting done at this point of time. They have creative structures that are involved that are different than what everyone thought they were going to be.  
Praveen Suthrum: (Now before COVID hit), we used to talk about the number of transactions that were underway in GI and you would come up with a number of 16-20 and we went with that for a while and that was my estimate as well. So, If I ask you the same question now, so, how many transactions are underway in GI, what does that number look like right now?
Abe M’Bodj: Yeah. I think the number of transactions underway hasn’t changed significantly, right. So, some of them have closed, some of them have stopped. So, I’d say they are still in around the 15 range. That being said, those transactions I’m certain are all figuring out what are they going to do and just because they are not going doesn’t mean they immediately want to close, right? They are figuring out and it doesn’t make sense for us to wait for things to turn around. What impact could that have on our transactions and at the time when we went to the market? Will our valuation remain the same if we chose to wait till the other end of COVID-19?  Some people are going to wait. Others are trying to figure out are there structures that can make sense for them to close the deal in short-term, is there an opportunity to structure the cash pay-outs because really everyone is concerned about cash right now. Or private equity firms with platform transactions it is difficult to get third party lenders or outside financing to close those transactions.  
So, they need to put more cash out there out of their investment pools. If you’re an established platform, you know, their lenders are skeptical to give them more money or let them draw too much of their credit facilities or revolvers that they use to finance transactions and frankly, they have a business to run as well, right? So, they want to conserve as much as cash as they can also. It is our firms expectation that this is going to accelerate the M&A activity, when that’s going to happen we don’t really know but on the other side of this, it is painting a picture that absolutely shows the benefit of being involved with a large organization of this scale that can navigate an environment like this as opposed to having to navigate this as an independent practice. And, I have seen the mindset change from physicians and practices that were skeptical about ideas like this. They are seeing the value in some of it now. 
Praveen Suthrum: So, pre-COVID, the multiples were pretty good for private practices in general and even in gastroenterology. How have these multiples changed after COVID? Or how do you expect this to change now? Are the valuations going to drop? From the point of view of private equity, how will they compute valuation at this time? 
Abe M’Bodj: Well, most deals that are currently underway and when I say underway, they have moved all the way to the point of identifying the actual party they want to get a transaction done with and are in which is called due diligence, right? Those transactions we are actually seeing valuations remain the same in terms of the total purchase value or the enterprise value of the transactions are remaining to what was agreed to at the letter of intent stage when they identified the buyer and chose to move with that party. Now, that been said, what’s changing is really the cash at closing. So, you may not get as much cash at the closing of the transaction as that you originally signed the letter of intent for. But cash deferrals or seller notes or different source of financing you’re getting back to the same place over, you know called 12-24-month period.  
From a multiple standpoint going forward, we are expecting multiples to come down a little bit, without questions there are transactions in the market maybe not necessarily specific to GI but healthcare services and physician investment in general. Just valuations have been absurd for the last few years. Valuation routines, double-digit multiples were at normalcy at non-normalcy if you look at the history of healthcare services investing. So, we do expect those to come down. 
I think also, the other impact, this is again in any transaction where there are three parties, there’s the seller, the buyer and there are lenders who finance a lot of these transactions. Lenders’ perspectives on the economy and COVID and the deal environment are going to impact valuations as well. They are going to be more skittish to lend money for new platforms that have recently gone through a new traumatic business event thinking about this from the other side now, they’ve got to have a very strong certainty on what the future cash flows of this business is going to be, what are the profits going to be, because they need to get paid back whatever capital they are lending to this company.
So, if the lending markets or the debt markets are frozen as well then you can’t raise as much debt or finance a transaction which also has an impact on valuation. People used to quote ‘dental practice management never had a down year’ the only year the industry didn’t grow was in the midst of the financial crisis no way to know they did not. That was probably one of the hardest hit industries in terms of the electives procedures dropped with COVID and a lot of businesses are in serious trouble. So, people are finding these areas of investment that they thought were originally untouchable are not so untouchable and as a result it’s going to change their risk evaluation of practices and valuations will come down.   
Praveen Suthrum: So, you brought up the third player in a transaction, the lenders and these are typically for deals that are leveraged. Meaning you take debt on behalf of the company that you’re investing in and that’s how the transaction happens, correct? 
Abe M’Bodj: Yep. That’s correct.
Praveen Suthrum: So, now I would assume that a lot of private equity transactions that have happened not just in GI but in the medical practice industry in general would be leveraged. Which means that it is like taking mortgage to understand very simply, right? Now, it is imperative that I generate the amount of cash that is required to pay my mortgage every month, every quarter, every year, whatever that is. now, in a pandemic situation like this, like you know when there is uncertainty about cash flows in general for all businesses, what happens to lender behavior? I’m not talking about new transactions now but I’m talking about transactions that are already in existence now. How would lenders behave with companies that might be struggling with cash flows in the future, who knows? Just wanted your views on that. 
Abe M’Bodj: I mean you have seen large companies out there enter chapter 11, I mean that’s the worst-case scenario, right? If these companies get to busting, they call it in the industry, busting their covenants. There are certain covenants, think of it like a house, you need to maintain a certain amount of value ratio, or just to stay up on the payments but the companies generally need to maintain some sort of EBITDA to debt ratio and that’s there in their loan covenant for agreement. You obviously have COVID which is causing EBITDA to drop, and they have a certain amount of debt in the books or the ratios are coming up. Some lenders who are willing to stand by their portfolio companies and actually will lend them more money that will get them through this short-term fall-out because of COVID. 
Look it is certainly a possibility that there are companies that end up in bankruptcy. I don’t think that’s the case specifically with GI and healthcare services in general. You know there are companies out there that have taken on the outside debt financing and they are not going to be able to pay those obligations so, that does happen. Now, how that plays out practically, if we think about it like a house, the last thing the bank wants to do is foreclosing the house, that’s a headache for everyone, the bankers don’t enjoy doing that. They haven’t got paid back and they are trying to recoup their investment through the foreclosure of the house, I mean, physician practices or private equity portfolio companies it’s the same thing, the last thing they want to do is foreclose or force these businesses into bankruptcy. What happens a lot of times is they end up taking the equity of the company because that’s all that the company has as they’re not paying back their debt. But everyone in the market at least from a lending perspective from what we’ve heard has been pretty rational about this stuff. In a sense that the expectation is that things will get back and return to normalcy.  
Praveen Suthrum: Okay. So, let’s say the uncertainty plays out for a longer period and then you have investors on one side who have capital, its not like private equity players don’t have capital, they are sitting on a lot of capital but then they want to look for the perfect deal or the right kind of deal they’re conservative, they’re gun shy right now and they want to wait and watch for the economy to turn around and let’s say the economy takes it time to turn around what happens in that scenario? As far as these private equity transactions are concerned. Are they going to continue to sit on the money or are they going to begin to take more risk than they usually would in such a scenario? 
Abe M’Bodj: Yeah. There’s just so much of capital that has been raised and there is so much dry powder and you are absolutely right there is… they have pools of capital. Frankly that capital has to be deployed. If they don’t deploy that capital, they don’t get paid for managing that money and that’s what they are in business to do, right? So, they need to find a way to deploy that capital
Albeit they certainly don’t get paid if they deploy that capital and then lose it because they made a terrible investment. If we are in the current state where we are in quarantine, we are 24 months from now then I don’t see transactions happening at that point because now we’re past the narrative that is keeping transactions and M&A work alive then things are going to recover and return to a sense of normalcy at least to a point where these physicians can sustain themselves.  
Praveen Suthrum: Yeah. I would think Abe, that if there is capital and if this is a long-term situation, then you’ll use the capital to figure a way out. Like you now, if private equity can wear that hat and help businesses get digital like you know, GI groups or physician practices, that’ll be interesting. While it’s not what they might have signed up for, but it will be an interesting way to deploy capital and see practices and the healthcare industry out of this situation.
Abe M’Bodj: I agree, I think there is… I think it’s actually a great point to meet. Its going to shift what they are making investments into. There are areas of healthcare that haven’t been as impacted. So, I was more so speaking about the current private equity initiatives that… where investments have been made in things like that. They will stick with their portfolio companies as long as possible but we’re still seeing valuations for businesses that haven’t been impacted by this and you have a financial track record to show that you haven’t been impacted by COVID. You know, actually private equity firms have shown a lot of interest in those types of models
Hospices is an example of industries that haven’t been as impacted, interventional pain management is another space where we have certainly seen a reduction in volume but they haven’t seen the same reduction in volume as say the GI industry has so, that has found a lot of private equity interest. People think that on the other side of this, women’s health is going to see a lot of activity as well in the short-term, coming out of this. So, certainly there are spaces going to see investments and you’ll see private equity firms transition towards that.  
Another interesting space would be the healthcare IT space as you referenced, in terms of moving a lot of the stuff to the digital realm and helping practices or helping businesses do that you are certainly going to see private equity and venture capitals chasing those investments because those are going to be big businesses. So, private equity firms are smart people, smart individuals, they are in-charge of billions of dollars for a reason and have been good stewards of that money. They are going to find creative ways to invest their capital but if we are sitting here 24 months from now, I just don’t think it will necessarily be in the GI practice space, but they’ll find ways to invest those dollars.   
Praveen Suthrum: From the lens of a mid-size GI practice, or a small GI practice and if you were to see it from their lens, not the super large groups and so on that have already created the platforms. But the mid-sized and the smaller groups, when you see it from their lens, what the pros and cons of considering private equity at this point of time, what advice would you have for them?   
Abe M’Bodj: I don’t think I’ve ever told you this Praveen, my parents are gastroenterologists, a small GI practice with about five doctors. So, this is the type of conversation I’m having with them on a regular basis. And they have certainly been impacted in a big way by this whole thing. For them...Just speaking specifically for them, I think they will be benefited, they feel like they would benefit by partnering to a large organization that can help them navigate something like this, right? As everyone would, instead they’re like a lot of these other practices that are scrambling to figure out where they can get some funding from, some government programs to meet payroll, they are having to furlough their employees and lay people off which a lot of practices are doing, big or small, and it’s a challenging environment. 
So, certainly one of the benefits could be that it wouldn’t be all on their shoulders, handling those decisions, and figuring out what to do so that they can keep their livelihood same as it is today. Now, the cons of that obviously, specifically related to COVID, you know, one of the things that came out with some of the government funding acts was that private equity owned companies were actually not able to participate in some of those, in some of the funding. So, certainly that is an angle on the other side of the spectrum of medicine where the government is kind of taking the stance , ‘hey you have millions of dollars of capital, it shouldn’t necessarily be on the taxpayers to help you get through a crisis like that’ and whether you like it or not is for another conversation.  
Similar cons that you have pre-transaction, there’s a certain level of autonomy that you’re giving up in joining a large organization and assimilating with a larger group. Like I said, there’s benefit to that in terms of… you’re not bearing the whole risk you’re not having to face the consequences of making the decisions at that point in time but on the flip side you’ve given up a lot of autonomy to be in that position. So, for physicians I know it’s always the biggest concern with any of these transactions. So, same cons really still exist.   
Praveen Suthrum: Okay. Well Abe, thank you so much for your extremely insightful comments, I learnt a lot and I’m sure people who watch this interview would also be learning a lot. Do stay safe and I will talk to you soon. Thank you so much. 
Abe M’Bodj: Absolutely. You too stay safe Praveen. Thank you for having me. I appreciate it. 
_

 

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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06 May 2020

Curated COVID-19 GI Resources: May 5th, 2020


Curated COVID-19 GI Resources: May 5th, 2020
New ebook – COVID-19: The Way Forward for GI Practices (NextServices)
COVID-19 is a double whammy of both clinical and business disruption. Download this free eBook.
“This is so good” “Terrific insights” “fascinating read”.
21% of Physicians Furloughed, Had Pay Cut During COVID-19 Crisis (RevCycle Intelligence)
About a third of physicians also plan to change practice settings or stop providing patient care as a result of the COVID-19 crisis.
New COVID-19 guidance for gastroenterologists (AGA)
AGA has published new evidence-based recommendations citing that GI symptoms are not as common in COVID-19 as previously estimated.
Telemedicine – The Emerging Face of Healthcare Amidst COVID-19 (NextServices)
Bookmark this page to keep yourself updated on telemedicine including the new guidelines, tools, best practices.
Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic (CMS.gov)
New rules to support and expand COVID-19 diagnostic testing for Medicare and Medicaid beneficiaries.
This Doctor’s Bringing Free COVID-19 Testing And Telehealth Services To Underserved Communities (Forbes)
Read about pop-up drive-thru testing centers, where anyone can stop by for a COVID-19 tests.
What hospitals and health systems can do to recover financially from COVID-19 (Healthcare Finance)
Setting targets, focusing communication and getting buy-in from the entire organization will be necessary to succeed.
Some IBD Patients Require Endoscopy Despite COVID-19 Pandemic (Medscape)
Four urgent scenarios that might necessitate endoscopy and suggested algorithms for addressing these situations.
‘We’re in This Together’: COVID-19 and Gastroenterology (Healio Gastroenterology)
While infectious disease specialists have been on the front lines, as more information comes out, the world is beginning to understand the role the gastrointestinal tract plays in the disease.
COVID-19 polymerase chain reaction testing before endoscopy: an economic analysis (ScienceDirect)
Strategy 1: endoscopy for urgent indications only; Strategy 2: testing for semi-urgent indications; and Strategy 3: testing all patients.
Gastroenterology Groups Map a Return to Elective Endoscopy (Medscape)
Paul Berggreen, MD, secretary of the DHPA: “Gastroenterologists are looking for some framework, however fluid it might be, to guide them in the next 2 to 4 weeks.”
Disruption in The Payer Landscape (Managed Healthcare)
Medical groups are preparing for these “compelling events” by having a strategy in place that allows them to retain their patients through marketplace upheavals.
Medical practices reel financially from COVID-19 losses (Medical Economics)
Physician practices are experiencing 30% to 75% decreases in patient volume, says Halee Fischer-Wright, M.D., president and CEO of the MGMA.
The post-pandemic ASC landscape: 10 observations (Becker’s ASC Review)
10 observations on where surgery centers stand today and how the pandemic will affect operations going forward.
Looking to the Future to Prepare for Covid-19’s Second Wave (NEJM Catalyst)
A physician and researcher calls for a big data collection and analysis effort to address the many unanswered questions about the virus.
COVID-19 Crisis: Assesing Providers’ Opportunities to return after COVID-19 (McKinsey & Company)
An insightful slide deck. This notion of “COVID-19 as catalyst” can help providers emerge stronger as they achieve their next normal.

SI: Artificial Intelligence in Gastroenterology (TIGE Journal)
“It is unlikely that AI will replace endoscopists, but perhaps endoscopists who use AI will replace those who do not” (Read editorial by Dr. Michael Byrne)

 


More Hot Headlines for GI
Medical Groups Slam CMS For Suspending Advance Payment Program (RevCycle Intelligence)
Drive-Thru Health, In and After the Pandemic (HealthPopuli)
Management of a COVID-19 patient in the endoscopy suite (Elsevier Health)
New Guidelines on Use and Reuse of PPE for COVID-19 (Medscape)
Gastroenterology group expects 30% of normal volumes in May — 3 details (Becker’s GI & Endoscopy)
AGA Guideline: Management of eosinophilic esophagitis (MDedge)
What should you expect from AI in health care in 2020? Here are 4 themes to watch (Advisory Board)
24 states considering resuming or resuming elective surgeries (Becker’s ASC Review)
GIE Podcast: Cornonavirus Pandemic (GIE)
Diarrhea in Patients With COVID-19 Suggests Possible Oral-Fecal Transmission Route (Clinical Advisor)
43 million Americans could lose health insurance through their employer, study finds (Becker’s Payer Issues)
A Tipping Point for Healthcare? (Medpage Today)
Healthcare Has Left the Building (Andreessen Horowitz)
_

 

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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