Category: Covid19

16 Apr 2021

Curated GI articles Apr 15th, 2021: Capital Digestive Care Announces Transaction with Virginia group. Expands to 128 GI providers

Curated GI articles Apr 15th, 2021:
Capital Digestive Care Announces Transaction with Virginia group. Expands to 128 GI providers
Capital Digestive Care Announces Transaction with Gastrointestinal & Liver Specialists of Tidewater, PLLC (GlobeNewswire)
Transaction will add 8 locations in Southeastern Virginia, bringing the total number of specialized GI providers to 128 across the Mid-Atlantic Region.
Exact Sciences Completes Acquisition of Ashion Analytics, LLC  (PR Newswire)
The acquisition will incorporate Ashion’s team and help advance Exact Sciences’ precision oncology portfolio.
7 recent reports on interventional endoscopy (Healio)
These reports include new research in adenoma detection, the impact of COVID-19 on colonoscopy capacity and endoscopy-related injuries among GIs.
GI procedures and devices: 6 updates (Becker’s GI & Endoscopy)
Here are six recent updates on gastroenterology procedures and devices.
Breath Analysis Fairly Accurate For Detecting Gastric Cancer (Gastroenterology & Endoscopy News)
Breath testing has the potential to dramatically improve the efficiency of screening for gastric cancers, according to a recent assessment of the approach.
Machine Vision, Robots, and Endoscopes with Matt Schwartz (Out-Of-Pocket)
Interview with Matt Schwartz, the co-founder and CEO of Virgo. Virgo’s mission is to improve patient outcomes and clinical workflows in healthcare by developing automation and AI tools for endoscopy.
Low-dose aspirin suppresses colorectal polyp recurrence (Healio)
Low-dose aspirin suppressed the recurrence of colorectal polyps in patients with familial adenomatous polyposis, according to research in The Lancet.
OncXerna Therapeutics Provides New Results from its Xerna™ RNA-based Biomarker Platform 
(OncXerna Therapeutics)
Xerna™ TME Panel describes the tumor microenvironmnent based on dominant biology subtypes with prognostic capabilities in colorectal cancer.
Colorectal Cancer Survivors Ask: What Can I Do Now? (Gastroenterology & Endoscopy News)
Gastroenterologists can and should guide survivors of colorectal cancer toward lifestyle choices that will reduce their risk for recurrence and death from the disease. But how?
Ingestible Technologies for Diagnosis of Gastrointestinal Disorders (Technology Networks)
Progenity is applying a multi-omics approach to its development of a novel pipeline of precision medicine products designed to provide solutions for gastrointestinal disorders.
U.S. Vaccine Panel Delays Vote on J&J Covid-19 Shot’s Blood-Clotting Risk (The Wall Street Journal)
CDC advisory group says it wants more data and plans to meet again soon on the issue. The Advisory Committee on Immunization Practices expects to meet again in another week or two to revisit the issue.
Nvidia collaborates with AstraZeneca, University of Florida on AI-driven drug discovery (Fierce Healthcare)
The MegaMolBART drug discovery model being developed by Nvidia and AstraZeneca is slated for use in reaction prediction, molecular optimization and de novo molecular generation.
Fecal immunochemical testing increases CRC screening, diagnoses (Healio)
Increased use of fecal immunochemical testing correlated with more colorectal cancer screenings and early-stage diagnoses amid the COVID-19 pandemic, according to research in JAMA Network Open.
Mayo Clinic Launches Joint Ventures to Create and Commercialize AI Diagnostic Tools (BioSpace)
The two new tech companies designed to harness AI and medical algorithms and create “software as medical devices” that clinicians can use to improve treatment across different diseases.
Microsoft Makes Big Bet on Health-Care AI Technology With Nuance (Bloomberg)
The software giant is set to buy Nuance Communications Inc., to overhaul solutions that free doctors from note-taking & better predict a patient’s needs.
Colorectal cancer deaths estimated in 2021: A state-by-state breakdown (Becker’s GI & Endoscopy)
Colorectal cancer is the third leading cause of cancer-related deaths in the United States, and CRC screening procedures dropped more than 80% in the early stages of the pandemic.
Congress passes Medicare sequester fix, now heads to President Biden (Fierce Healthcare)
The House passed the legislation 384-38 on Tuesday that pauses a 2% cut on Medicare payments through the rest of the year.
The mystery of Michigan’s overwhelming Covid surge (CNN)
Michigan is now in the midst of an overwhelming surge that began about six weeks ago. Daily cases are nearing their highest highs; and has by far the highest rate of new infections of any state (510.5 per 100,000 population).

More Hot headlines in GI

Dr. Scott Ketover: “The future of GI remains bright. Because if it goes in your mouth, it’s in our domain” (Interview) (NextServices)

New ACG IBS Guidelines with Brian E. Lacy, MD, PhD (Healio)

A timeline of COVID-19 aid for ASCs (Becker’s ASC Review)

Effect of COVID-19 on the detection and management of colorectal cancer in England (The Lancet)

Bariatric Surgery May Cut Cancer in Obesity With Liver Disease (Medscape)

Food as Medicine in the Management of Common Upper Gastrointestinal Symptoms  (AJG)

11 states projected have the most new colon, rectum cancer cases in 2021
(Becker’s GI & Endoscopy)

COVID-19 infection manifesting as a severe gastroparesis flare: A case report (DocWire News)

Top Takeaways from the 2021 ONC Annual Meeting (Healthcare IT Answers)

Hospital sues gastroenterologists attempting to exit contracts: 5 details (Becker’s GI & Endoscopy)

Fitbit unveils health equity research initiative: 4 details (Becker’s Health IT)

VIDEO: Website provides up-to-date data from NASH cirrhosis study (Healio)

Does Public Policy Affect Alcohol-Related Liver Disease Deaths? (Michigan Health Lab)

Videos: Interviews with GI Leaders  (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.
11 Apr 2021

Curated GI articles Apr 10th, 2021: FDA approves first AI Device (GI Genius) to detect colon lesions

Curated GI articles Apr 10th, 2021:
FDA approves first AI Device (GI Genius) to detect colon lesions
Dr. Scott Ketover: “The future of GI remains bright. Because if it goes in your mouth, it’s in our domain” (Interview) (NextServices)
Dr. Scott Ketover is the President and CEO of MNGI Digestive Health (previously Minnesota Gastroenterology). Find out about MNGI’s growth strategy and more in this insightful interview.
About 1 in 5 Clinicians Considers Quitting Due to Pandemic: Survey  (Medscape)
The COVID-19 pandemic continues to take its toll on the well-being and work satisfaction of healthcare providers, a new survey of more than 5,000 clinicians at an academic medical center illustrates.
Linked color imaging may improve adenoma detection in endoscopy (Healio)
Endoscopy with linked color imaging may help improve adenoma detection, particularly among endoscopists who normally have lower adenoma detection rates, according to study results.
FDA Approves First AI Device to Detect Colon Lesions (Medscape)
The GI Genius (Cosmo Artificial Intelligence) identifies areas of the colon where a colorectal polyp or tumor might be located. Clinicians then follow up with a closer examination and possible treatment.
GI partnerships, acquisitions and openings: 9 industry updates (Becker’s GI & Endoscopy)
GI companies have been busy in the past month, from ASC acquisitions to partnerships. Here are nine updates from GI companies and physicians.
ACG Clinical Guidelines: Colorectal Cancer Screening 2021 (AJG)
The “ideal” screening test should be noninvasive, have high sensitivity and specificity, be safe, readily available, convenient, and inexpensive.
7 recent reports on COVID-19 in GI (Healio)
These reports include new research on the impact of COVID-19 in GI bleeding, GI neoplasia detection, transmission during endoscopy and its effect on fecal microbiota transmission.
Walgreens Not Following U.S. Guidance on Pfizer Vaccine Spacing (The New York Times)
After complaints from customers and the C.D.C., the pharmacy chain will start scheduling doses three weeks apart.
Will the pandemic spark more ASC sales? 4 observations (Becker’s ASC Review)
Independent surgery centers experienced revenue loss last year when elective surgeries were limited due to COVID-19, but many ramped cases back up and aim to stay independent if possible.
Doctors Accuse UnitedHealthcare of Stifling Competition (The New York Times)
A multistate group of anesthesiologists filed cases in Texas and Colorado, accusing the insurance giant of squeezing them like a “boa constrictor.”
NHS trials edible capsule cameras to detect colon cancer (Mobihealthnews)
The Pillcam Colon 2 technology, from US medical device firm Medtronic, takes images as it passes through the bowel which are transmitted to a recording device worn by the patient at their waist.
OptumCare scaled up its home colon cancer screenings due to COVID-19. Here’s how (Fierce Healthcare)
100,000 tests sent to patients’ homes last year under the pandemic said Daniel Frank, M.D., chief medical officer at OptumCare in an interview
GI leadership updates in Q1 (Becker’s GI & Endoscopy)
At least five gastroenterologists or GI innovators were appointed to leadership positions in the first quarter of 2021. Here are five GI leaders who have been named to leadership positions in the first quarter.
Verizon latest tech giant to elbow into telehealth space with provider platform (Healthcare Drive)
Verizon is joining the crowded virtual care market with the launch of its new telemedicine platform for providers, Verizon BlueJeans, on Monday, banking on continued demand for virtual care post-COVID-19.
Opinion: To stem the pandemic, the U.S. needs a national Covid-19 genomic sequencing effort (STAT)
More than a year into the pandemic, the United States is at yet another critical inflection point. The number of Covid-19 cases remains high and is on the rise in more than half of states.
At-Home Colon Cancer Tests: What Do Doctors Think? (The Healthy)
The pandemic has accelerated the interest in at-home tests and not just from patients. Some health care providers, like Kaiser Permanente, are mailing colon cancer testing kits to members.
CRH Medical acquires remaining interest in GI anesthesia practice  (Becker’s GI & Endoscopy)
CRH Medical acquired the remaining 25 percent interest in Gainesville, Ga.-based Lake Lanier Anesthesia Associates, which CRH obtained 75 percent of in June 2020.
Esophageal Cancer: An Updated Review (Medscape)
With the distinct subtypes of adenocarcinoma and squamous cell carcinoma comes specific risk factors, and as a result, people of certain regions of the world can be more prone to a subtype.
IBD Patients Should Be Screened for Anxiety, Depression (Medscape)
Up to one-third of patients with inflammatory bowel disease (IBD) experience anxiety and one-quarter have symptoms of depression, a systematic review and meta-analysis reveals.
Prior authorizations lead to serious patient adverse events, 30% of physicians say (Becker’s Hospital CFO Report)
Thirty percent of physicians said that prior authorizations have led to a serious adverse event for a patient in their care, according to research released April 7 by the American Medical Association.


More Hot headlines in GI

AGA Clinical Practice Guidelines on Intragastric Balloons in the Management of Obesity (AGA)

Clear need for sensitive diagnostic markers for pancreatic cancer surveillance (Healio)

Coffee Could Be the Secret Weapon Against NAFLD (Medscape)

Physician Perspectives: How the Merit-based Incentive Payment System Improves Value (AJMC)

Dr. Kalloo takes over as chair of medicine at Maimonides (Brooklyn Reporter)

Opioid prescriptions for GI diseases increased over 10 years in US, study says
(Becker’s GI & Endoscopy)

Remicade, Stelara have similar speed of onset in Crohn’s (Healio)

The Future Of Clinical Trials: How AI, Big Tech, & Covid-19 Could Make Drug Development Cheaper, Faster, & More Effective (CB Insights)

During the Pandemic, Remote Patient Monitoring Took on New Meaning for Doctors (Health TechZone)

Healthcare tops 100 most innovative AI companies: 8 digital health startups on the list (Becker’s Health IT)

Liver Transplant Emerges for Hepatic Mets in Colorectal Cancer (Medscape)

Ohio woman granted $10.3M verdict after botched colon surgery (Becker’s GI & Endoscopy)

Dare to be Different: Success Stories in Transforming Endoscopy (British Society of Gastroenterology)

Interview: Will AI replace GIs? President of Medtronic GI responds (NextServices)

Videos: Interviews with GI Leaders  (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.
09 Apr 2021

Dr. Scott Ketover: “The future of GI remains bright. Because if it goes in your mouth, it’s in our domain” (Interview)

Dr. Scott Ketover is the President and CEO of MNGI Digestive Health (previously Minnesota Gastroenterology). MNGI is one of the country’s largest independent GI practices.
In a world of private equity, MNGI has firmly decided to stay independent. Dr. Ketover shares why they don’t need to and what their growth strategy is. Our conversation explores many topics. Especially insightful are his views on how GIs must build programs for the entire GI tract and not just focus on endoscopies. He reflects on what he took away about the future during the pandemic.
Invest in your future by listening to this interview (29+min). Sometimes just one idea is enough to change our trajectory.
◘  “How COVID affected independent GI practices and employed physicians.”
◘  “Approximately 50% of DHPA members are under some form of PE umbrella.” 
◘  Is MNGI considering a private equity partner?
◘  “When practices look at private equity, they should really be thinking about what motivates them.”
◘  What does the growth strategy for MNGI look like?
◘  How has MNGI managed to negotiate or use leverage with insurances and health systems?
◘  Will the dependence on insurance systems reduce overtime, or stay the same, or increase going forward?
◘  “From a financial view point, the work of a gastroenterologist is compensated by the ancillaries that the professional services generate.”
◘  “The gastroenterologist must own the GI tract.”
◘  How and when will the shift from just doing endoscopic procedures to focusing on overall health of the patient happen?
◘  What are some digital health initiatives going on at MNGI?
◘  Will gastroenterology face a new, different kind of competition from digital health companies?
◘  How does the pandemic influence future of GI?
◘  What does the future of GI look like from this point on?
◘  What actions must gastroenterologists take today to create a future where GI care means much more than endoscopies?


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.
02 Apr 2021

Curated GI articles Apr 1st, 2021: AI increases ADR detection in CRC screening (Healio)

Curated GI articles Apr 1st, 2021:
AI increases ADR detection in CRC screening (Healio)
Covid Has Traumatized America. A Doctor Explains What We Need to Heal  (NY Times)
The physical and emotional concerns, central to palliative care, have forced their way into so many of our lives during the pandemic, even as we edge toward some skewed version of normalcy.
Scope Forward podcast – AGA talk: What must you know when considering PE (8 factors, 4 risks) (Episode 22)
Listen to the interviews while on the move! Praveen Suthrum’s conversations with GI leaders are now available via the Scope Forward podcast on Apple PodcastsSpotify and elsewhere.
ASCs should ‘look beyond the financial’ when considering private equity  (Becker’s ASC Review)
ASCs can partner with private equity-backed platforms as a way to capitalize on future value and mitigate risks, but some ASC leaders warn that partnering with private equity firms requires consideration of costs outside the financial.
5 Key Diligence Considerations When Buying a GI Practice (JDSUPRA)
Private equity investors’ interest in gastroenterology (GI) practices continues to remain strong, despite some headwinds that GI practices have experienced as a result of the COVID-19 pandemic and further investment in this sector is likely to continue.
DiGI Capital Partners invests in stool AI company (AF21)
Over the course of five cycles, stool AI (stAI) was able to associate neural firing patterns with specific stool smells. It accurately detected eight of the smells 100% of the time, and remaining two with 90% accuracy.
Pandemic Strain on Physician Practices Drives More Consolidation (Bloomberg Law)
Physician services was one of the top five active sectors for health-care transactions in February and is on pace to reach well over 300 deals in 2021.
Partnership streamlines genetic counseling, testing to identify hereditary GI cancer (Healio)
The program automates the process for genetic screening by sending to patients that are being seen in GI practices an electronic family history assessment tool in order to risk stratify them for the need for genetic testing.
Artificial intelligence increases adenoma detection in CRC screening (Healio)
The addition of real-time computer-aided detection in colonoscopy significantly increased the adenoma detection rate and adenomas detected per colonoscopy in colorectal cancer screening.
Two GIs on the biggest threats to gastroenterology (Becker’s GI & Endoscopy)
Misunderstandings of Cologuard and shifts in reimbursement are some concerns gastroenterologists have for the field. Read to find out what the threats are.
CEO predicts Biden’s $1.9 trillion plan will help ASCs (Becker’s ASC Review)
Jason Richardson, CEO of Gastroenterology of the Rockies spoke about the influx of private equity in the ASC industry and how he thinks President Joe Biden’s $1.9 trillion COVID-19 relief law, dubbed the American Rescue Plan, could help ASC.
8 recent big tech partnerships in healthcare: Apple, Amazon, Google & more (Becker’s Health IT)
Here are eight recent partnerships between healthcare organizations and big tech companies including Amazon, Apple and Google.
NYU Langone’s new grant seeks to address CRC disparities (Becker’s GI & Endoscopy)
New York City-based NYU Langone received a $2.2 million grant to expand a program addressing disparities in colorectal cancer and gastrointestinal health.
Gastroenterologists Routinely Reverse DNR Orders, Survey Finds  (Gastroenterology & Endoscopy News)
Gastroenterologists reverse “do not resuscitate” orders to full code status more than 75% of the time prior to starting endoscopy, the results of a recent study show.
The smartest thing 7 ASC execs did last year (Becker’s ASC Review)
Last year the pandemic forced many ASCs to close or limit surgical volume, but enterprising administrators took the time as an opportunity to evaluate their growth strategy, improve culture, acquire new technology and become more efficient.
AI-powered imaging technique is pushing CRC risk management forward (Becker’s GI & Endoscopy)
A team at Washington University in St. Louis developed an imaging technique for rectal tissues to assess risk management of colorectal cancer. AR-PAM/US imaging was better at discerning residual cancer from scar tissue compared to other techniques.
GI pharmaceutical company launches website for advanced practice providers (Becker’s GI & Endoscopy)
Salix Pharmaceuticals, announced the launch of its website, GastroHub – that provides resources and educational materials for GI nurse practitioners and physician assistants.
Did the pandemic change ASC-hospital relationships? (Becker’s ASC Review)
ASCs and hospitals shared resources and collaborated on protocols for performing safe surgical procedures to ensure the continuity of care for patients who didn’t have COVID-19. But will the harmony last?
Reducing deaths from colorectal cancer (Kaiser Permanente)
Jeffrey K. Lee, MD, MAS, a research scientist at the Division of Research and a gastroenterologist with The Permanente Medical Group, spoke about colorectal cancer research and prevention.
Extending intervals may help accommodate COVID-19-related colonoscopy reductions (Healio)
In the wake of a COVID-19 wave, extending screening intervals may be the best way to accommodate the reduction in available colonoscopy capacity with the smallest impact on the incidence of colorectal cancer.
Video: A New Playing Field: ACG’s Latest Guidelines Move the Goalposts for CRC Screening  (Medscape)
The American College of Gastroenterology (ACG) just released their 2021 clinical guidelines for colorectal cancer screening. Insights by David A. Johnson, MD.

More Hot headlines in GI

ICYMI: Who’s interested in buying Gastro Health, at what valuation & what it could all mean (Becker’s GI & Endoscopy)

Video: Genomic Profiling in Early CRC (Cancer Network)

COVID-19: 1st wave significantly reduced GI neoplasia detection (Healio)

New computational models to understand colon cancer (EurekAlert)

Do top GI hospitals ranked by U.S. News have better outcomes? (Becker’s GI & Endoscopy)

Minimizing the Pesky Placebo Response in IBS Trials (MedPage Today)

Endoscopic Accessory Disposal: Too Conservative, Too Costly? (Gastroenterology & Endoscopy News)

VIDEO: Six ways clinicians can address rising anti-Asian sentiment (Healio)

What Covid-19 Taught Us About Telemedicine (The Wall Street Journal)

COVID-19 transmission during endoscopy unlikely in lockdown setting (Healio)

IBD Centers Urged to Become Vaccination Hubs (Medscape)

The future of gastroenterology and other excerpts on industry-changing trends (Becker’s GI & Endoscopy)

Videos: Interviews with GI Leaders (NextServices)

Busting Myths About Diverticulitis Management (Gastroenterology & Endoscopy News)

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.
26 Mar 2021

Curated GI articles Mar 25th, 2021: Backlog of a half million endoscopies and rising during the pandemic, report finds

Curated GI articles Mar 25th, 2021:
Backlog of a half million endoscopies and rising during the pandemic, report finds
Author of VRx Dr. Brennan Spiegel: We used VR on over 3,000 patients (Interview) (NextServices)
Dr. Brennan Spiegel is the Director of Health Services Research, Cedars-Sinai Health System. This is a historic, one-of-a-kind interview that lays out the digital future for GI from the lens of virtual reality (VR).
Scope Forward podcast – Rock Rockett: Yes, you can stay small and independent. But, it’s a qualified yes (Episode 21)
Listen to the interviews while on the move! Praveen Suthrum’s conversations with GI leaders are now available via the Scope Forward podcast on Apple PodcastsSpotify and elsewhere.
Capital Digestive Care Partners with Temple Hills Gastroenterology  (GlobeNewsWire)
This partnership will expand Capital Digestive Care’s reach in southern Maryland and will help meet the needs of patients and physician groups in the under-served Temple Hills community.
How 5 states are using Google Cloud for COVID-19 vaccination efforts (Becker’s Health IT)
Google Cloud launched its Intelligent Vaccine Impact solution in February to help get vaccines to communities quickly and efficiently.
FDA gives IDE approval for pivotal study of prep-free colorectal screening capsule (Medical Plastics News)
Check-Cap, a clinical stage medical diagnostics company advancing the development of C-Scan, the first and only preparation-free screening test to detect polyps before they may transform into CRC.
PE-backed One GI acquires 26-physician Ohio practice (Becker’s GI & Endoscopy)
One GI has acquired Dayton Gastroenterology, the second- largest independent GI practice in the state. One GI is expected to acquire the largest gastroenterology group in Louisville, Ky., by the end of March, bringing its number of physicians to about 96 across four states.
PE GI, New Jersey endoscopy center acquire new ASC (Becker’s GI & Endoscopy)
PE GI Solutions, formerly named Physicians Endoscopy, first partnered with ACE in 2012. PE GI partners with 60 gastroenterology centers and more than 600 gastroenterologists nationwide.
CMS allows MIPS reporting relief for 2020 performance period (AGA)
CMS also reopened the period to apply for an EUC exception and extended the deadline to March 31 to allow participants to request MIPS performance category reweighting.
Precision Medicine Takes Center Stage in GI Cancer (Cancer Network)
To best utilize these therapies, oncologists must be able to recognize specific biomarkers and oncologic drivers associated with an individual patient’s cancer diagnosis. This is true, in particular, for oncologists specializing in the care of gastrointestinal (GI) cancers.
Nationwide clinical research study involves blood test to potentially detect colorectal cancer (WGRZ)
The Colorectal Cancer Alliance is partnering with biotech company Freenome to recruit participants who are of average risk and plan to undergo a routine colonoscopy.
Backlog of a half-million endoscopies and rising during the pandemic, report finds (Medical Xpress)
By January 2021 researchers estimated the backlog was 476,000, and this figure could potentially rise to more than 870,000, should there be a further full or partial lockdown and/or a slow return to normality.
Ophthalmology, GI among 5 largest CMS spending drops during early days of pandemic (Becker’s ASC Review)
The report found that in the first six months of 2020, the total estimated reduction in Medicare physician spending associated with the pandemic was $9.4 billion, a 19 percent drop.
Sepsis, Colorectal Surgery Linked With Increased C. diff Recurrences  (Gastroenterology & Endoscopy News)
Their review of a national database showed 43% of individuals with three or more CDI recurrences experienced sepsis and more than 10% required colorectal surgery.
Novel marker bests traditional measures in understanding gut function (Healio)
A novel blue dye marker was a more informative marker of gut microbiome function compared with traditional measures, according to a study published in Gut.
Postpandemic Vision: Half of Cancer Visits via Telemedicine (Medscape)
After the pandemic, an estimated 33% of patients could be seen using video visits, and 13% could be seen using phone visits; thus, 46% of patient visits could be performed remotely.
GI drugmaker partners with diagnostics company (Becker’s GI & Endoscopy)
Sebela Pharmaceuticals and CellMax Life have entered a strategic development and commercial collaboration partnership to accelerate the development of CellMax’s multimodal liquid biopsy blood test.
GI Cancer Expert Is Searching for Big Leaps in Care (OncLive)
John L. Marshall, MD has concentrated on early-phase trials, particularly genomic and biomarker studies, looking for giant leaps in GI cancer care rather than small steps.
From disruption to innovation: Lasting changes to care delivery (Becker’s Health IT)
If there’s a silver lining to the coronavirus pandemic, it’s that we’ve finally opened the door to new care paradigms — and opened minds to new possibilities.
Podcast: COVID-19 Vaccines and the GI Practitioner (Gastroenterology & Endoscopy News)
In this episode, Adam Marcus talks with Freddy Caldera, DO, of the University of Wisconsin-Madison, on the arrival of the COVID-19 vaccines and what questions gastroenterologists might field from their patients about the injections.
Q&A with Dr. Eric Topol: Remote care and the future of care delivery (Fierce Healthcare)
Virtual care must become more advanced and it will need to be tailored to meet the patient’s needs before it becomes a mainstream and permanent fixture in the care delivery model, Dr. Eric Topol said.

More Hot headlines in GI

ICYMI: Who’s interested in buying Gastro Health, at what valuation & what it could all mean (Becker’s GI & Endoscopy)

Cancer screenings bounced back after steep pandemic declines (Healthcare Dive)

9 studies that have GIs talking so far in 2021 (Becker’s GI & Endoscopy)

Podcast: Do Teams Work Better Than Solo Providers? Spoiler Alert: Yes (Health Affairs)

The next frontier for Physicians Endoscopy: Expanded services and a new name (Becker’s GI & Endoscopy)

Bowel Preparation Quality: How to Get Perfect Bowel Preparation For Every Patient (Gastroenterology & Endoscopy News)

ZIP code vs. genetic code: Understanding CRC disparities in Black Americans (Healio)

TNF Inhibitors for IBD May Open Door to SARS-CoV-2 (MedPage Today)

Colonoscopy Records Often Missing for Patient Self-Reports (Gastroenterology & Endoscopy News)

What Motus GI CEO Tim Moran hopes to achieve in 2021 (Becker’s GI & Endoscopy)

Hospital case volume linked with better GI cancer surgery outcomes (Healio)

The 5 Levels Of Automation In Medicine (The Medical Futurist)

Olympus files patent infringement related to colonoscopy devices (Becker’s GI & Endoscopy)

US preventive services task force update and computed tomography for colorectal cancer screening among privately insured population (MDLinx)

Adherence to Antireflux Lifestyle Factors Shows Benefit in Women (Medscape)

What ASC companies did in Q1: 11 notes (Becker’s GI & Endoscopy)

The future of gastroenterology and other excerpts on industry-changing trends (Becker’s GI & Endoscopy)

Videos: Interviews with GI Leaders  (NextServices)

Helio Health Announces China NMPA Acceptance of Registration Application for Helio Liver Test (PRNewswire)

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.
22 Mar 2021

Author of VRx Dr. Brennan Spiegel: Virtual Reality in Gastroenterology (Interview)

Dr. Brennan Spiegel is the author of VRx: How Virtual Therapeutics Will Revolutionize Medicine. He’s the Director of Health Services Research, Cedars-Sinai Health System
This is a historic, one-of-a-kind interview. It lays out the digital future for GI from the lens of virtual reality (VR). Dr. Spiegel and his team have seen 3,000 patients via VR. The technology is no more new. FDA is approving solutions. Medicare is due to pay for VR. 
The challenge of private practice GI is to diversify from colonoscopy. Could VR be a new ancillary stream? Find out.
Do not miss this one (35+ mins).
◘  Dr. Spiegel shares the story of the time he and his team first used VR
◘  “Non-pharmacological therapies can be used to support people with IBS”
◘  “We’ve used VR on over 3,000 patients now at Cedars-Sinai”
◘  What has inattentional blindness got to do with pain management? 
◘  “The whole idea of cognitive behavioral therapy is to allow patients to rethink their relationship between pain and their body”
◘  What happens to patients who use VR one year down the line?
◘  A powerful story about one of Dr. Spiegel’s GI patients that you should listen to
◘  “It was almost as if we gave her a micro dose of psychedelics, so we call it a cyber-delic instead of psychedelic”
◘  “I think it’s important for those of us in digital health to recognize that we’re held by the same scientific standards as any other traditional treatment” 
◘  Dr. Spiegel’s advice for private practice gastroenterologists
◘  “Soon Medicare may have to cover VR”
◘  How is VR being applied to treat obesity?
◘  What is the future of VR – especially in GI?

The Transcribed Interview:
Praveen Suthrum:  Dr. Brennan Spiegel, author of “VRx: How Virtual Therapeutics Will Revolutionize Medicine” thank you so much for coming on The Scope Forward Show. I want to first warmly welcome you.
Dr. Brennan Spiegel: Thanks for having me.
Praveen Suthrum:  Brennan, I want first start by asking you about your author photoWhenI see your author picture on the book it’s the same as the one that shows up on the website of the Cedar Sinai website for VR and I’msure something happened that day you know, with that patient and that must mean something to you so I wanted to ask you about that.
Dr. Brennan Spiegel: Well, no one has ever asked that question before! Yeah, so, that was taken several years ago when we were first starting to test virtual reality and with patients. You know, for listeners here they may first of all wonder what we’re even talking about? And you know most people think about VR for gaming or entertainment but about six years ago we were beginning to test virtual reality with our patients in the hospital mainly to see if it could help them with their pain management. And that particular day we were using virtual reality with a young woman who had severe recurrent abdominal pain, and had been in the hospital many times actually six times in one year. And had been on a number of medications – opioidsketamines, and she was pretty frustrated and so we tried virtual reality. And the moment that that photograph was taken of me was me responding to her responding to the VR. And she went from being understandably frustrated, upset, and disappointed that the therapies she had been receiving were not working to being kind of swept away into this virtual world reaching out to blue whales that were swimming across her visual field in the middle of a hospital room and laughing and enjoying herself and just seemingly having fun. So, I couldn’t help but smile in response. And it just so happens that moment we had a photographer who was a part of this this event and yeah I’ve used that as my headshot sort of ever since because I think it’s just a genuine reaction to a patient responding to VR. 
Praveen Suthrum: Yeah, and that actually comes through you know in that photograph. I want to ask you Brennan, why did you choose to use VR that day? You know this is the first patient… I’m sure around that time you must have come across many people with abdominal pain. Why that day? Why her? What prompted it? 
Dr. Brennan Spiegel: Well, we all learn in gastroenterology about the braingut axis. We know that the brain and the gut are connected and why wouldn’t they be? That’s just for starters. There’s this old notion that really comes from René Descartes from the mid 1600s – a very old idea of dualism that the brain and the body are separate and distinct and they operate independently. But we know that’s completely false. That the brain is tied in and completely with the gut and the rest of the body and vice versa and they’re connected through all sorts of neurohormonal avenues. So, with that background we’ve always known that cognitive behavioral therapy,  psychotherapy,  hypnotherapy,  talk therapy, and other nonpharmacological treatments that go back thousands of years from the earliest transcendental meditative traditions, can help people with IBS. Not that it’s always the cure. Not that it is in place of traditional medical therapies. But it can support people with IBS.
So, with that background when I learned about virtual reality and recognized the ability it has to nudge the human mind in different directions including positive directions, I thought why don’t we try this with people with IBS specially those who are in the hospital where you know the most severe patients have been admitted and our treatments are so lacking, so wanting. And when I started to see responses that’s when I realized I think we’re on to something here and this is something we need tstudy and learn more. About and six years later we’ve used VR in over 3000 people at Cedars Sinai and we’ve learned an awful lot. We could talk more about that today.  
Praveen Suthrum: Let’s go there then. You know from these 3000 people on whom you’ve used VR what would be you know, three or five takeaways? 
Dr. Brennan Spiegel: I’ll start with what is VR doing and how is it working – as you know clinicians want to understand what is sort of the mechanism of action whenever we’re recommending a new treatment. Whether it’s a drug or non-pharmacological therapy. The first takeaway, I spent quite a bit of time and in the book, I talk about this in VRx – what we think is the mechanism particularly for pain. So, I’ll just address pain for the moment. So, listeners know virtual reality has been used for many conditions not just for pain. It’s been used for eating disorders, for anorexia, for obesity, it has been used for managing dementia, schizophrenia, anxiety, depression, stroke rehabilitation, autism, cerebral palsy, multiple sclerosis, I mean the list is about 50 or 60 conditions at this point where there’s evidence with over 5000 studies! So, that’s one takeaway unto itself. But for pain one question is – how would it help somebody with pain? And so, there’s different mechanisms and one is purely just distraction for starters neuroscientists called that inattentional blindness.’ And the idea is it’s difficult we’re not able as humans to concentrate on many things at once although we might think we multitask But there’s just no way that person is listening to these words, and counting their heartbeats, and thinking about the pressure of the floor on their feet or the pressure of the seat on their bottom. It’s just not something you can do without getting distracted. That’s because we have a spotlight of attention sort of psychologically speaking and neuroscientifically. And so, what virtual reality does is it can draw attention away from neurosusceptive experiences like pain. So, that’s one but it also seems that it might be able to help the brain fight back.
One reason why people seek calm, and go on a vacation, and meditate is that the brain when it’s in a calm condition can inhibit pain signals through your descending inhibitory pathways. And we think virtual reality probably works by putting the brain in a state of mind, so to speak that rejects pain. In other words, it will inhibit pain using this old ‘gate control’ theory with along the spinal cord. The brain can sort of send inhibitory signals down to close these gates along the spinal cord to disallow the arising pain. And we think that’s how VR is working. And then finally there’s cognitive restructuring – giving people ways to think about their pain in a different way. And this is important not just for acute pain but for chronic pain especially visceral pain like irritable bowel syndrome, functional abdominal pain, functional dyspepsia, where you know our pills fall short. And often we need to allow patients to rethink and re understand their pain and the relationship between their pain, and their body, and their minds and that’s the whole point of cognitive behavioral therapy. So, VR could do all those things.
Praveen Suthrum: Great! I want to ask you what happens to the story of these patients after the first few visits? Like someone has IBS, there is a new sensory experience that going through with dolphins swimming or surreal trip you know from the app Tripp or in any of these experiences. Now, that’s new for the first time but then the mind might get used to that. And I wonder does their reliance on drugs reduce overtime? What happens to this story in three months, six months, one year, two or three years down the line?
Dr. Brennan Spiegel: Yes, so, we’re just now starting to see studies with longer term follow-ups. Not yet in GI, although we intend to begin doing those studies. But outside of GI for example there was a recent study for people with chronic lower back painIn that study randomized controlled trial of virtual reality using an 8week skillsbased CBT treatment in VR was compared to what they called sham VR where the other group did wear a VR headset but they only watched sort of neutral two-dimensional scenes that do not have any apparent benefit. And they followed those patients for eight weeks. So, you know we don’t have 12 week or one year data for pain but we do have at least 8-week data. And they showed not only a separation pain initially but the separation grew over the course of the eight weeks treatment. So that, by the end the patients in the VR group had considerably, statistically, and clinically meaningful reductions in pain over 8 weeks. It did not show evidence of them getting used to it or sort of a tachyphylaxis, where the therapy starts to wear off like you can see with certain medicines. That was not seen in that study. 
And the whole point is of these studies is not to ask people to use VR more and more but actually just using VR less and less. If people learn something about their mind, about their body, learn new skills in VR that they can then take with them outside of VR an enjoy real reality RR even more than they might have otherwise without relying upon virtual reality. So, when we use VR it’s not as an addictive substance like a video game, it is to teach people skills that they can use in their real life and so that’s the really the goal. But we do need more data in in GI and so we’re creating a comprehensive IBS VR program right now and we certainly intend to test it over longer periods to see if this bears out with our patients in GI.  
Praveen Suthrum: Excellent. So, in in the book VRx Brennan, I remember the story where you went to see this patient with abdominal pain and she experienced VR and they had tried everything else but nothing worked and then in that moment she realizes that her abdominal pain is linked to her brother’s death due to stomach cancer. Can you talk about some of these examples? I’m sure the GI community keeps seeing similar patients but somehow you know we may not be making these connections like you did in that story. 
Dr. Brennan Spiegel: Yes…that is a powerful story and I often tell itIndeed, there was a patient with recurrent severe abdominal pain of unknown origin. She was in the hospital and had been fully worked up. She had an upper endoscopy, colonoscopy, abdominal imaging, CT scan, laboratory tests for everything, for inflammatory bowel disease, celiac disease, etc. And we’ve all seen patients like this, we were scratching our headwe were perplexed. What are we missing? You know, is this porphyria? Is this Familial Mediterranean fever? Or you know what could this possibly be? Well, this woman was in the hospital with this pain and I really was starting to scratch my head. And they asked us to come in and I decided to use virtual reality. So, I used the headset and put her in a scene where she was swimming with Dolphins. And it’s a scene that we often use because it turns out to be very pleasant. People enjoy Dolphins and they like watching them, listening to their squeaks, and all this sort of thing.
And so, she found herself all of a sudden underwater swimming with Dolphins all around her, and there was some music playing, then she became silent and after about four minutes she started to cry and we’ve seen this a lot with VR and you have to imagine if you’re patient who is just in one moment in a hospital room feeling vulnerable and the next moment your brain accepts that you’re swimming with dolphins, the contrast is so striking that it can lead to sort of emotional responses. And she started crying, I said, “Are you okay?” and she said, “Yeah I am. I think I know why I have this pain.” I said, “Really? Why? Tell me more she said, I think it’s my brother” I said, “Your brotherWhat about your brother?” and she said, “Well my brother died of stomach cancer and I think I’m going to also and I said, “You know we’ve been in your stomach though and we haven’t seen cancer. There was no sign of cancer she said, I know that, you guys keep telling me that, but I haven’t been willing to accept it. But these dolphins  they’re telling me I need to accept this explanation. I need to move on with my life and I’ve got to tell you, my stomach pain is better too! I just don’t have any pain right now and she said, “I could have been on the couch for a year and I wouldn’t have figured this out but I‘m ready to go home. 
And so, it was just like an incredible experience because I thought to myself, man I’m a gastroenterologist not a psychiatrist! But somehow, she had had this you know incredible turn around. And it’s not like it works like this every single time. So, I don’t want to overstate that this is some kind of miracle but for her it was just the right thing to kind of reboot her brain. And if I had a brain scanner we actually know a little bit about what’s going on in the brain when people use virtual reality because we’ve had MRI studies, it would have seen that the part of the brain the default mode network that kind of controls our inner voice will power down in the setting of virtual reality allowing the rest of the brain to have lateral thinking. It’s the same thing that meditation does, it’s the same thing that psychedelics do. They all work in the same way. It’s not like the brain has many different functions or it does but it’s not like it has brand new ways of dealing with this. It‘s the same function in all three cases. So, it’s almost like we gave her a micro dose of psychedelics and then she was ready to go. So, we call this a cyberdelicinstead of a psychedelic. I didn’t make that term up by the way, somebody else did.  
Praveen Suthrum: few years back I was in Peru you know with the native shaman, and I went through this whole ayahuasca ceremony and it was semi psychedelic first-hand experience. And then when I look at some of these apps like… there’s something called Tripp, there’s one called ayahuasca, if I remember correctly or a video that I came across. They are trying to replicate some of these experiences and it’s very interesting. So, to me on the outside it appears that because we’re calling VR as a tech tool or a technology tool and we’re doing all these clinical studies it almost seems to give credibility to all these ancient healing modalities which we have maybe before poo-pooed on and said you know that’s BS and that’s not medicine or that’s not healing and so on. But now we seem to or the health care system seems to be more open to this. I’m curious you know about your comments on this.
Dr. Brennan Spiegel: Oh yeah, I have so much to say I’ll try not to spend the rest of the podcast on just this topic. You’re absolutely right. Particularly in western medicine historically there’s no doubt that there was a bias against behavioral medicine, historically. And this I think still stems from that Descartian notion of dualism. That there’s sort of the mind and that’s what we call super territorial you knowwhich in medicine is referring to the everything above basically the brain. And that’s sort of for the psychiatrist. Then there’s the rest of the body that’s where the real scientists work you know, like where we have enzymes, and we have you know physiologic processes, and we have targets for pharmacotherapiesBut you know that’s nonsense. The brain and  the body have always been connected and I talked about that at the top. And so, these traditional approaches of meditation, and socalled mind body interventions undoubtedly have effects on the body is just no question about it. Neurohormonal effects of longterm and shortterm benefits.  So, this is not a new idea whatsoever I think all virtual reality is doing which is which you point out is leveraging those innate abilities we have whether it’s to deploy our own endocannabinoid system,  our own endorphins, and intrinsic opioid system whether it’s to trigger changes in cortisol, all the mechanisms that have been identified in that literature. 
VR is just making it a little easier to do that. If you think about what it takes to become an expert at meditation you know Buddhist monks average 30 to 40,000 hours meditating to get to the point where they can basically turn off their default mode network in their brain and that’s what’s happening neurologically. So, what VR is doing is it’s leveling the playing field a little bit so that you know people like me who have not lived in a cave practicing meditation for 30,000 hours can suddenly get that ability. Especially, if you start adding biosensors to this. So, we can add an EEG and for example is one company called Healium – where you it’s monitoring your brain waves and it’s looking for particular pattern of asymmetric beta waves over the prefrontal cortex that’s associated with the flow state. And when you achieve that, you’re rewarded in the VR headset.  
So, for example use your mind to fly out of the Yosemite Valley, and you can use your brainpower to move yourself around space and just imagine all the other things that you could do when you start connecting brain computer interfaces to wearables and then connect that to the virtual reality headset. So, VR is a way to leverage all of those known benefits. And medicine finally is slowly coming back to recognizing all of that after being in low desert for most of the 1900s from around 1950 to 2000. I have looked historically and actually traced this history in the book and I talk about  the sort of pendulum – how it’s gone back and forth. And we’re now at a point where this type of therapy is considered to be reasonable as a mainstream therapy whereas 20 years ago when I was training or 30 years ago, it wouldn’t have been accepted as it is now. So, things have changed now. 
Praveen Suthrum: Yeah, I think it’s also got to do with societal shifts in this direction. There are apps for medication. So, I think the market or people or consumers are primed to adapt to something like this and there much more open and because consumers are open, I think the physicians follow. So that’s something that I took away. 
Dr. Brennan Spiegel: I would add to that because there’s so much consumer interest it’s very easy to create non-evidencebased kind of stitch in a snake oil and sell it. And I think it’s very important for those of us in digital health to recognize that we’re held by the same scientific standards as any other traditional treatment. And so, that’s why you know we’re funded by the NIH right now to do clinical trials using virtual reality. That‘s why we’ve published randomized controlled trials. And that’s why in the book VRx I’ve cited… Oh God, I don’t even know… well over 300 studies in that book. I know because it took me months just to write the reference section. Because I felt it was very important when I wrote this book that it should not feel like sort of like a snake oil thing but rather it should feel like a real evidence based scientific endeavor. And I’m really pleased that the FDA on the basis of the work that we’re doing and many other people are doing has now recognized this field and is now calling it MXR which stands for medical extended reality. And so, we’re going to see more and more treatments coming through FDA through the regulatory pathway. that’s already happening right now and we’ve started to really truly see this this field expand as a legitimate treatment approach. 
Praveen Suthrum: I want to get back to GI and ask you what advice do you have for the private practice gastroenterology that’s largely busy maybe in the procedure room so to take time away from colonoscopy and focusing on something like this If you could tell them how they could use it and if you can connect it to business benefit
Dr. Brennan Spiegel: Yeah, absolutely I think this is actually a perfect solution for the busy endoscopist because let’s face it like most of us went into GI because we really liked surgery but maybe we didn’t want to get up in the morning quite that early or wear scrubs all day but we liked using our hands, we like doing procedures, we like stopping a bleeding peptic ulcer, we like  clipping a vessel, and screening for colon cancer but yet we found out that the most common condition we manage – irritable bowel syndrome – it’s like we have to sort of be honorary psychologists for part of the day and that’s not what we signed up for. So, I think for some GI doctors there’s this almost like tension between this handsonmanual, mechanical approach to handling patients and is very cognitive nonprocedural approach to managing these very common patients.  And then you throw in the fact that the treatments that we have for IBS although many are very effective it’s hard to predict when they’re going to work. 
Giving an antibiotic to a patient with IBS is not like giving an antibiotic to somebody within the mode. You know, the relationship you had with your patient and their understanding of the treatment you’re giving, will modify the effectiveness of an antibiotic or any medicine that we give. We know this. So, patients like to go to doctors who feel like they’re giving them something more than just pills, they’re giving them their time but also giving them insights that they may not have had. And so, that’s why we’re creating this IBS VR program right now which takes all the science that goes back years about CBT, the mindful meditation, that packages it all up into a program that patients can use at home. So, they have this ability to build skills and the GI doctor may not even know how to do that, but we’re packaging it up in a VR headset. So, it’s like you have a CBT psychologist with you at home – you can do hypnotherapy, you could do CBT therapy, and you can do mindful meditation around gut health. And all the GI doctor really needs to do is tell the patient about it and send them on their way rather than learn how to do CBT or always send them to another person who may or may not be all that helpful. So, I think that there’s a lot of benefits to private practitioners to learn about this. I think patients are increasingly… I wouldn’t say demanding yet, but are very receptive to it and seeing really positive benefits so it’s something we’re thinking about.  
Praveen Suthrum: So, the obvious question is who pays for all this? 
Dr. Brennan Spiegel: Yeah so, that’s a great question and it’s one that insurance companies are actively exploring right now. For the most part, insurance companies are not covering VR as a procedure or as a treatment but there are some models emerging. So, at Cedar Sinai where I work, we are soon going to announce and this is I guess like a little teaser a clinical VR program that is going to be run by clinical team for both inpatients and out-patients. So, not just a research program like we have right now but a full-fledged consulting service. I mentioned that because the person running that is a psychiatrist who’s trained in virtual reality. And so, he gets paid just like he would in any other day of the week. He’s getting paid to use VR. Because he’s getting paid for delivering psychological treatments it just so happens that it is VR, he doesn’t get paid separately.  But sompsychiatrists are billing for VR for exposure therapy for example for phobias that’s a very effective use of virtual reality and one in which many doctors are getting paid.
There are some codes being developed for VR for physical therapy. But we’re now at the point with FDA starting to look at these treatments that soon Medicare may actually have to cover VR. This is really interesting. There is a company in LA called Applied VR and Applied VR by the way, came through Cedars Sinai’s accelerator program many years ago and they they’ve been working towards FDA clearance for their chronic pain treatment program and it received what’s called “breakthrough”  designation by the FDA. And that’s sort of a rare designation that once approved, requires some level of coverage from CMS. So, CMS may actually have to cover breakthrough VR therapies just from a statutory standpoint. But other insurance companies like – travelers insurance has funded our research. Blue Cross Blue Shield have been looking at this with other groups and are seriously considering supporting it. But in the meantime, patients can also download the stuff. They could just buy a headset for $200 or $300 and download programs for free or for $15 to $20 and off they go. So, we don’t necessarily need insurance to cover this right now. But certainly, for people who can’t afford these headsets it would be great if we had other ways to cover it.  
Praveen Suthrum: How have you seen VR being applied in obesity? I’ve read what you wrote in your book but I’m sure things have evolved nowJust your take on weight loss and virtual reality.
Dr. Brennan Spiegel: Right and this idea as you mentioned we have discussed in the book. We haven’t yet seen this go mainstream, but I’ll tell you I before the pandemic I was at one of these VR centers in a local mall here in Los Angeles called Dreamscape. And it’s really amazing if you haven’t been in one of these things. You get in a body pack, and you wear headset, and you look down and you see that you become a different person and, in this case, we were like some Navy seals or something underwater and it was really amazing and immersive. So, I mention it because one of the people in our group was obese, she was overweight and she herself said this, as we were getting on our outfits for this VR experience. But what was amazing to me is when she looked down and she said, Oh my God, I’m thin! It was sort of a tongue in cheek joke, I guess, she said it sort of facetiously. But when you look down you see this really fit avatar and you’re embodying that avatar.
So, what she was experiencing at that moment has actually been studied and I talk about that in the book. There’s a guy in northern Italy who’s worked on this program and he’s shown in a randomized control trial over a one year follow up so we talked about long term follow-up not over a day or a week or month – a year later people who use VR compared to cognitive behavioral therapy without VR had durable and significant weight loss that was sustained. So, I think there’s an opportunity here probably for private practitioners, for weight loss centers, to actually learn this paradigm to figure out how it works and start applying it as part of a multi component CBT approach. We think about patients with non-alcoholic fatty liver disease and NASH, you know that’s an obvious case. I know you’re interested in gastroenterology where the VR treatments may be affective to help change cognitions about the body.   
Praveen Suthrum: How far are we from a timeline standpoint on when all this goes mainstream? You might say it already is but maybe you know it’s not mainstream. I want your outlook on you know the future of VR three to five years from now.
Dr. Brennan Spiegel: Yeah, it’s going to depend upon certain things. As you say VR is not quite mainstream yet but it’s certainly VR in general has become pretty mainstream. You know not in healthcare but in general. You know, two years ago if I said VR most people would know what that means. Now we just say VR, we don’t say virtual reality. So, it’s just… there’s a familiarity with the technology. And you know it’s becoming more mainstream for gaming and entertainment. The question is in healthcare in the next five years, what will be the catalysts? One of them will be insurance coverage, and payment models which we’ve discussed. The other will be more evidence around novel therapeutics and acceptance amongst clinicians that these are worthwhile, I believe that that’s already happening. And it’s going to be you know a bit by bit progressive realization and up some point will hit this sort of threshold of dissemination where enough people know about it and see the benefits that they’re willing to use it as a matter of routine.
In GI I think we’re going to start seeing more effective therapies and there will be a demand from patients to have access to those therapies when they will start to talk about it on social media and talk to one another and I think that’s going to happen. I think we’re going to really see a particularly in IBS and disorders of brain-gut interactions in particular. So, you know, we’ll see. I don’t have a magic ball… just seeing what’s happened over the last two years it’s really been moving quickly and I think if we continue this trajectory, we’re going to see it really penetrating.  
Praveen Suthrum: You know this has been fantastic I’ve been greatly inspired by your book. So, Dr. Brennan Spiegel, thank you so much for coming on The Scope Forward Show. Any final words before we go? 
Dr. Brennan Spiegel: No, I appreciate the time. If anyone’s left interested the book is called the VRx: How virtual therapy will revolutionize medicine and just happen to have a copy sitting here on my desk. 
Praveen Suthrum: I have one too and I highly recommend it. 
Dr. Brennan Spiegel: For those that are listening the book is about VR but it’s really about what is VR teach us about our consciousness about our connection between mind and body what does it teach us about the boundaries of neuroscience and the intersection between neuroscience and psychology, technology, and clinical medicine so it was a blast to write it and to explore all these fields in a way that would be accessible to non-scientists also who are just interested in science in general so hope you take a look and enjoy the book. 
Praveen Suthrum: Thank you so much. 
Dr. Brennan Spiegel: 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.
19 Mar 2021

Curated GI articles Mar 18th, 2021: When burn-out reaches a pandemic level in gastroenterology (BMJ)

Curated GI articles Mar 18th, 2021:
When burn-out reaches a pandemic level in gastroenterology (BMJ)
Rock Rockett: Yes, you can stay small and independent. But it’s a qualified yes (Interview)  (NextServices)
Rock Rockett is the Founder and Principal of Rockett Healthcare Strategies. In this interview, we explore the big question on many people’s minds: is it still possible to stay small and independent if you choose to?
Scope Forward podcast – Dr. Baig and Dr. Gialanella: “Shift will occur when there’s financial hardship. And it’ll occur pretty quickly as we see screening colonoscopy going down‪” (Episode 20)
Listen to the interviews while on the move! Praveen Suthrum’s conversations with GI leaders are now available via the Scope Forward podcast on Apple PodcastsSpotify and elsewhere.
The rise of GI Alliance (Becker’s GI & Endoscopy)
GI Alliance, led by President Jim Weber, MD, has aggressively expanded since first closing its deal with Waud Capital Partners in November 2018.
When burn-out reaches a pandemic level in gastroenterology (BMJ)
Up to one-half of gastroenterologists report burn-out, with increased rates among trainees, early career physicians and interventional endoscopists.
Provation and Iterative Scopes Announce Exclusive AI Partnership  (Globe Newswire)
One of the first initiatives under the partnership will be an AI-based patient recruiting solution for inflammatory bowel disease (IBD) patients.
An escalating trend in private equity healthcare transactions (Becker’s ASC Review)
We have begun to notice a shift from the formation of platform GI businesses to tuck-in, also referred to as add-on, acquisition activity by these platform companies.
CRH Medical Corporation Announces Startup Joint Venture (PRNewswire)
Dr. Tushar Ramani said, “We now provide services to 71 ambulatory surgery centers across 14 states, and we see ample opportunity for additional business development execution over the remainder of 2021.”
CMS increases payment for administering COVID-19 vaccine  (Healio)
CMS has announced that it is increasing the Medicare payment rate for administering COVID-19 vaccine doses, in some instances by more than 75%.
Colonoscopies, New-Patient GI Visits Walloped by COVID-19  (Gastroenterology & Endoscopy News)
The COVID-19 pandemic has had a broad impact on virtually all health care delivery, but one of the hardest hit areas is screening for colorectal cancer and subsequent follow-up for the disease.
FDA Clears Olympus’ Narrow Band Imaging® (NBI) for Use in Assessing Colonic Lesions (Daily American)
The data show experienced endoscopists employing a validated classification system, such as the NICE classification.
Amazon to soon launch telehealth offering in all 50 states, report says  (Healthcare IT News)
Sources told Insider that the company plans to make its app-based Amazon Care services available to employees throughout the country.
Study finds blood-based CRC tests most cost-effective CRC screening test alternative (Becker’s GI & Endoscopy)
A blood-based colorectal cancer test was found to be the most cost-effective alternative colorectal cancer test for people who didn’t want a colonoscopy or fecal immunochemical test.
Swallowable Capsule-Camera Instead of Endoscopy for Use at Home (Medscape)
The Pillcam technology is manufactured by US medical device firm Medtronic. A national NHS trial will see patients in England given edible miniature cameras to check for signs of colon cancer.
cliexa scoops up GI surgical scheduling platform ProSkedge (mobi health news)
The acquisition allows cliexa to meet GI customers with an end-to-end automated scheduling, reporting and communications platform.
Apps Offer Digital Option To Track Stool Habits (Gastroenterology & Endoscopy News)
Phone apps that track stool habits are as accurate and effective as traditional paper diaries and could help improve the management of these conditions.
GI OnDEMAND Announces Partnership with Ambry Genetics (PRNewswire)
This partnership addresses a critical clinical need for identifying hereditary GI cancer syndromes to help guide potentially life-altering health care decisions.
FDA grants Check-Cap investigational device exemption for its prep-free CRC screening test (Becker’s GI & Endoscopy)
The test requires no bowel preparation and is noninvasive. The test, however, is not a colonoscopy replacement and all positive C-Scan tests should be followed by a colonoscopy.
Endoscopic bariatric treatments improve fibrosis in NAFLD (Healio)
Patients with non-alcoholic fatty liver disease who underwent endoscopic bariatric and metabolic therapies saw improvements in liver fibrosis and other outcomes.
Video: How to Become an ‘Ink Master’: Endoscopic Colonic Tattooing Tips (Medscape)
“To date, we’ve lacked expert guidelines or recommendations on the endoscopic tattooing technique.” Commentary by Dr. David A. Johnson.
Medicine and Health Technology Are Advancing Exponentially (Journal of Clinical Pathways)
Machine learning, artificial intelligence, immunotherapy, genomics, robotic limbs, wearable health-monitoring tech, mRNA vaccines—it is an exciting time in medical research and technology.


More Hot headlines in GI

ICYMI: Who’s interested in buying Gastro Health, at what valuation & what it could all mean (Becker’s GI & Endoscopy)

One Year Later: How Has COVID-19 Affected You? (Medscape)

CRH Medical sees Q4 gains, overall dip in revenue in 2020: 5 details (Becker’s GI & Endoscopy)

Opinion: Google My Business (Gastroenterology & Endoscopy News)

Patients with NASH cirrhosis have poorer prognosis than those with HBV (Healio)

10 GI leaders to know (Healio)

GEN Board Responds to NY Times Article on FIT Testing (Gastroenterology & Endoscopy News)

Doctor on Demand, Grand Rounds merge to form multibillion-dollar virtual care company (Becker’s Hospital Review)

Top in GI: New CRC screening guidance, GI symptoms in COVID-19 (Healio)

Cologuard vs colonoscopy: A question of convenience, money (

Health systems partner to open pediatric outpatient center with GI, cardiology care (Becker’s GI & Endoscopy)

Olamkicept May Induce Response in IBD Patients (Medscape)

Crossing to Safety (Gastroenterology & Endoscopy News)

Game Changer for Ulcerative Colitis Patients Failing Anti-TNF? (MedPage Today)

Breaking down the top GI hospitals in the world: Newsweek (Becker’s GI & Endoscopy)

The future of gastroenterology and other excerpts on industry-changing trends (Becker’s GI & Endoscopy)

Videos: Interviews with GI Leaders  (NextServices)

2021 is Prime for Private Investment in Healthcare: What that Means for the Health System (The Keckley Report)

Top GI articles: The best gastroenterology hospitals, ASCs; what GIs make in 5 big cities and more (Becker’s GI & Endoscopy)

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.
15 Mar 2021

Rock Rockett: Yes, you can stay small and independent. But it’s a qualified yes (Interview)

Rock Rockett is the Founder and Principal of Rockett Healthcare Strategies. Rock has been in the GI space for almost two decades now. As a business person, he saw GI physicians evolve.
In this interview, we explore the big question on many people’s minds: is it still possible to stay small and independent if you choose to?
Do not miss this one (15+ mins).
◘  Rock’s background in GI
◘  How has GI landscape changed over the last couple of decades? 
◘  “Consolidation is going on. There’s also the downward pressure on their charges and reimbursement”
◘  “I guess ultimately I’m not a big fan of consolidation”
◘  “Consolidation will sweep up the large segments of the healthcare industry but not the whole thing”
◘  Keeping the external environment in mind – Is it possible to stay small and independent? – “Yes, but it’s a qualified yes”
◘  What are the strategies that small groups can deploy?
◘  “You’ve got to have money to make money, right?”
◘  A positive trend – “Payors reimburse more if the procedure is done in the office”
◘  “Payors want to do something to counter the efforts of consolidation because they’re losing leverage”
◘  Since insurances are getting bigger and bigger will the smaller groups even make it to the negotiating table?
◘  Rock reflects on the relationship between small groups and regional health systems
◘  “There are arrangements where everybody can share in a piece of the pie”
◘  “Maybe it’s the more affluent who will be able to preserve their independent physician practice. It’s unequal, but it’s a reality”

The Transcribed Interview:
Praveen Suthrum: Rock Rockett thank you so much for coming on The Scope Forward Show. It’s not every day that I get to talk to somebody who has founded a company on his own name. So, you are the principal of Rockett Healthcare Strategies and you have worked for a long time with gastroenterologists and in the GI space. So, I’m really looking forward to our conversation today.
Rock Rockett: Great! It’s a pleasure to be here Praveen. I’ve admired your company and the growth of your organization over the last few years and have listened to your talks from time to time but it’s been great getting acquainted with you.
Praveen Suthrum: Rock you’ve been in the GI space for a long time. How did you get involved with gastroenterology?
Rock Rockett: I’ve been involved with a gastroenterologist for about 15 or 20 years. I initially became involved through a small company that I was running that was doing accreditation consulting. We had a relationship with the accreditation agencies with the joint commission. So, I was approached by the joint commission and they said Blue Cross has some concerns about office-based procedures and they asked me – would you be able to talk to them? And so, I started talking with Blue Cross and out of that developed a negotiated arrangement so that the gastroenterologists could be reimbursed at a higher rate for doing procedures in their offices provided that they became accredited. So, I provided the accreditation consulting, Blue Cross provided the incentive. It was a nice little package deal, a win-win for the members, for Rockett Healthcare, and for the gastroenterologists. So, that was really what kicked things off for me.
Praveen Suthrum: How has GI changed over these last couple of decades from your lens?
Rock Rockett: What I’ve seen over the last 15 to 20 years is… you know number one is consolidation. I see that they’re also being able to look at different revenue sources because you know while the consolidation is going on there’s also the downward pressure on their charges and on their reimbursement. And so, with that downward pressure then they have to come up with more creative solutions. And so developing additional revenue strategies is something I’ve been very much involved with and I’ve helped the gastroenterologists in that regard.
Praveen Suthrum: What do you think of this wave of consolidation that has swept gastroenterology as a space?
Rock Rockett: You know, I guess ultimately I’m not a big fan of it. But the consolidation obviously leads to bigger and bigger organizations. And bigger organizations are tougher to deal with, more difficult for patients to navigate, and so you start losing some of that age-old you know physician-patient relationship. You know it’s a fact of life, it’s here to stay, it’s not going away, and it will sweep up large segments and large chunks of the entire healthcare industry but not the whole thing. So, that’s my view.
Praveen Suthrum: So, when you say not the whole thing… let’s talk about the segment that does not want to consolidate and wants to stay small and independent. So, I want to start by asking you – is that even possible? You know given this massive pressure coming in from the health system side because the health systems are consolidating and they’re locking in referral networks and then the other practices may be in a region they’ve taken PE or joining a PE platform or plan to… they might be consolidating or hospitals are acquiring physician practices… that trend is happening. And again like you said the insurance reimbursement is on the decline. So, given all these changes is it still possible? And I’m sure many in the audience are interested in this question – Is it possible to stay small and independent in this environment and if the answer is yes, I already have a follow-up of… how?
Rock Rockett: For sure! Well, definitely the answer is yes. But it’s a qualified yes, okay? So, it’s a qualified yes. You can stay small, you can stay independent, you can be in control of not only your own destiny but be in control of your own practice patterns, and your own approach to patients and patient care, and so forth. And in some situations with these consolidated and larger groups, they get very focused on production and productivity and so forth. They kind of get obsessed with that.
I’ve had clients of mine who just rebelled against that and say, ‘I want to practice the way I want to practice’, ‘I want to do as many procedures as I want to do’, ‘I want to have that control that a physician should have.’ And it depends upon your market, depends upon where your group is, and it depends upon your relationships within that market, your referral network, and so forth. Some others have come to me and said, ‘well, if I go off and do this and set up office endoscopy suite the hospital is going to crush me!’ and I say, ‘well, that’s certainly possible and maybe this is not for you!’ So, it’s not for everybody but it definitely is a strong and viable solution.
Praveen Suthrum: So, who is it for? In what kind of environments is such a model possible? And when you say that… again, I’m saying this in my own words but helping physicians or gastroenterologists diversify and add revenue streams, how can they do that? What are those strategies that they can deploy?
Rock Rockett: Well, so the strategies are the strategies that the consolidated groups employ as well. So, there are arrangements where the gastroenterologists can share in the pathology revenue that are you know totally legal totally within the constraints of the regulations. And there’s one model is called the TCPC model there are other kinds of arrangements where a group can work with a local path lab or a path lab anywhere in the country for that matter. And they can you know participate in the pathology revenue likewise on the anesthesia piece. The anesthesia piece can be part of the revenue solution because you know you hire your own MD anesthesiologist, hire your own CRNAs, bill and collect for them. There are other models where the mobile anesthesia group will come into your office and you will do the work with them and then they will provide the nursing services, they’ll provide the recovery room nurse or say if a recovery room nurse charges 80,000 a year for instance that’s a pretty significant chunk. So, I would say to anybody interested in being on their own or going out on their own or having a small group and on an independent basis – you look at the professional fees that’s coming to you for your practice, you look at other revenue sources and principally those are anesthesia and pathology. There are some other smaller items like colon prep and so forth. But yeah, kind of in a nutshell that’s how it can work.
Praveen Suthrum: Doesn’t some of this require investments or money? And some doctors may ask where would that come from?
Rock Rockett: Exactly! You’ve got to have money to make money, right? So, it does require an investment. So, what I would do with a gastroenterology group, they can come to me or they can go to an accountant or someone to say, ‘hey how much is this going to cost and how much am I going to get from it?’ So you kind of develop a Performa much like the surgery center management companies would develop. And so, you look at those costs of the build-out, the design of the build-out, the equipment, the staff, the cost of getting it accredited and put all of that together and that’s the cost and over how many years can we amortize those costs? Can we lease equipment to do certain things? The first component is the expense side the second side is – what is the reimbursement going to be? Are the payors going to reimburse me more for doing the procedure in the office?
And there is a certain trend in that regard that’s a very positive trend. I had a conversation just yesterday afternoon with the Vice President of a leading Blue Cross organization just as of this past January, two months ago, increased the reimbursement for office-based procedures by 15%. Well, if you’re a gastroenterologist and you’re already getting seven or eight hundred dollars for an office-based procedure then that’s another 15% on top of that… you could be a podiatrist, you can be a urologist, there are several different specialties that it applies to. The payor organizations and principally Blue Cross are seeing that they have to do something to counter the consolidation efforts because they’re losing leverage. When the payor is still the same size the payor is but the providers get larger and larger then the payors are losing leverage. So, they have to do something to strengthen their position. There are regulations, right? The certificate of need regulations which dampen or prohibit the development of surgery centers in roughly half of the states of the US – Illinois is one, Massachusetts, North Carolina, lots of east coast states, and a couple of west coast states. So, the payors are looking at different strategies. In some cases, the payor will pay the gastroenterologist equivalent to a facility fee. They will say, ‘We’ll pay you as if you’re a licensed surgery center. We know you can’t be because of the regulations in our state.’
Praveen Suthrum: What I keep learning is that the insurances are getting so big that even some of the largest physician groups are finding it difficult to negotiate with them and improve contracts. So, if that is the case for these large groups then if somebody decides to stay small could they ever expect to get better reimbursements or negotiate with these insurances? Will they even come to the negotiating table?
Rock Rockett: Yeah a very good point Praveen. A small group negotiating with a Blue Cross? Yeah! Forget it! That’s not really going to be too effective. I think what you have to be aware of is – what are the reimbursement trends being invoked by the payors and it’s literally on a state-by-state basis. The Blue Cross of Illinois pays for roughly 200,000 endoscopy procedures per year and then you know if they’re paying a surgery center or a hospital outpatient department an average of 1500 to 2,000 dollars then it’s hundreds of millions… it’s like 300 million dollars a year. And so it’s not heart surgery, and it’s not knee replacement. It’s not big-ticket items but it’s the high volume of a relatively low-cost procedure and so Blue Cross is incentivized now.
They are motivated to address that issue and how they can impact it. And I think the pandemic is probably inspiring that as well or contributing to that. So, you know nobody wants to go to a hospital now unless they absolutely have to. So, to have a colonoscopy done in a hospital this doesn’t make much sense it needs to be done in a surgery center… ‘Oh our state is a certificate of need state. We don’t have many surgery centers!’ Okay… you got to come up with another solution… And that’s where this office-based solution is effective. So, there are favorable market conditions for office-based procedures and for independent practices to maintain and grow and sustain themselves, and then there are certainly unfavorable market conditions that people have to be aware of. And that’s something that I try to keep my finger on the pulse of so that’s part of the value that I bring to the table.
Praveen Suthrum: You know the gastroenterologists who are deciding to stay small and independent, how are they working out their relationships with the regional or local hospital or health system? Do they have any control at all? If so how?
Rock Rockett: You know let’s take Chicago for an example. Let’s take the Advocate Health system for example. So, you know within a very large organization like Advocate, 14 or more hospitals, thousands of physicians, many of those physicians are employees, right? They’re employees of that organization, kind of an equal number… a couple of thousand physicians are what they call Advocate physician partners. So, they are contracted through their arrangements with the carriers. They are contracted through the Advocate system and the Advocate umbrella but they’re not constrained by that. They’re not employees of that so they still have this independence and that can work.
And there are age-old examples from I don’t know 20 or more years ago in Virginia with Dr. Irving Pike negotiating an arrangement with the system there to say, look this is what we’re going to do – our group is going to do office-based procedures that doesn’t mean we’re going to cut out the hospital entirely because we’re still going to you know do make referrals to the hospital there are still the higher-level cases the cancer cases that are going to get referred to the hospital so you know it’s not a total sum game. There are arrangements where everybody can share in a piece of the pie. Maybe it’s not as big a piece of the pie as they used to have but they still get a piece of the pie.
Praveen Suthrum: What’s your view on gastroenterology for the next five years, 10 years maybe even longer? How do you see the space from a business standpoint evolve?
Rock Rockett: So, I think technology is going to erode the position of gastroenterologists. I said something to a prominent gastroenterologist in Chicago a couple of years ago about doing a colonoscopy and he looked at me and he said, “A monkey can do a colonoscopy. So, just don’t get worried about the difficulty involved in doing a colonoscopy.” So, that may be somewhat of an exaggeration but nevertheless that there are those issues. So, technology is a big driver, and then there is consolidation. It’s interesting to me because I see the pros and cons of consolidation and once consolidated, do the doctors stay in those groups? And there are some indications that there definitely is a segment of people who once they’ve gone through that whole consolidation process, say, ‘you know what? This is not what I thought it was going to be and I’m out, I’m going to exit!’ And maybe it’s the more affluent who will be able to preserve their independent physician practice. You know, they’ll still have that relationship with their independent, small physician practices and you know it’s unequal but it’s a reality.
Praveen Suthrum: Rock, thank you so much for this conversation. Any final words before we close?
Rock Rockett: I very much appreciate your time today and spending this time with you Praveen. It has been a good experience and I hope I can contribute something to help the gastroenterology specialty and the individual physicians who are looking for what’s the right career fit for them within their specialty.
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.
11 Mar 2021

Curated GI articles Mar 10th, 2021: GI Alliance partners with Austin Gastroenterology

Curated GI articles Mar 10th, 2021:
GI Alliance partners with Austin Gastroenterology
Dr. Baig and Dr. Gialanella: “Shift will occur when there’s financial hardship. And it’ll occur pretty quickly as we see screening colonoscopy going down”  (NextServices)
Watch this direct and lucid interview with Dr. Robert Gialanella, CEO/President and Dr. Nadeem Baig, Vice President of Allied Digestive Health to understand the evolving landscape of GI.
Scope Forward podcast – Gastrologix: “We create companies that physicians can have ownership in” (Episode 19)
Listen to the interviews while on the move! Praveen Suthrum’s conversations with GI leaders are now available via the Scope Forward podcast on Apple PodcastsSpotify and elsewhere.
GI Alliance Partners with Austin Gastroenterology  (PRNewswire)
GI Alliance, one of the nation’s largest independent gastroenterology services organizations, announced further expansion in Texas through a partnership with Austin Gastroenterology.
CRC Screening to Start at Age 45: ACG Update (Medscape)
Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s (ACG’s) updated guidelines.
The fastest-growing PE-backed GI platforms are among the newest  (Becker’s GI & Endoscopy)
Memphis, Tenn.-based One GI and Michigan-based Pinnacle GI Partners are among the fastest-growing platforms in GI with a combined six deals between them since their formation.
Checklists Pare Procedure Delays  (Gastroenterology & Endoscopy News)
A preprocedure checklist written collaboratively by charge nurses at Mayo Clinic significantly reduced the number of canceled and rescheduled procedures and enhanced staff communication and satisfaction.
NAFLD linked with increased risk for extrahepatic cancers  (Healio)
Patients with non-alcoholic fatty liver disease had a moderately increased risk for extrahepatic cancers, such as gastrointestinal, breast and gynecological cancers, according to a meta-analysis.
Confirmed: Diet Influences Colorectal Cancer Risk  (Medscape)
Convincing evidence was found for three inverse associations: a decrease in the risk for CRC was associated with higher vs lower intake of total dietary fiber, calcium, and yogurt.
After Retirement, Master Endoscopist Not Ready to Hang Up His Scopes  (Gastroenterology & Endoscopy News)
What does retirement look like after a long career as one of the country’s leading endoscopists? Insights from Jerome D. Waye, MD.
High prevalence of dysplasia among women with SSc warrants screening for BE (Healio)
The prevalence of Barrett’s esophagus was 12.8% among women with scleroderma, according to a study published in the American Journal of Gastroenterology.
Optum has 5.4% of US physicians & 5 more notes (Becker’s GI & Endoscopy)
OptumHealth, the division of Optum including physician practices and ASCs, nearly tripled its revenue in the last five years to $40 billion in 2020.
10 factors that can make or break an ASC in the next 2 years (Becker’s ASC Review)
The pandemic affected ASC case volume and operations in several ways in the last year, with some centers adapting while others are struggling to stay afloat.
Ergonomic consultation spares endoscopists a pain in the necks (GI & Hepatology News)
Assessment of position and posture by a physical therapist can help reduce and prevent injury in endoscopists, based on data from a pilot study of eight individuals.
An AI Solution to Volume Status in Cirrhotic Patients  (Gastroenterology & Endoscopy News)
A new machine learning algorithm seems to be able to use pulse oximeter waveforms to estimate volume status in patients with cirrhosis.
Physician pay under Stark Law’s final rule: 4 takeaways on fair market value (Becker’s ASC Review)
CMS unveiled three definitions for fair market value in the new rule, focused on general services, equipment rental and office space.
The (robotic) doctor will see you now (Science Daily)
A large majority of patients interacting with a health care provider via a video screen mounted on a robot said it was similar to an in-person interaction with a health care worker.
Video: New AASLD Guidelines Ask Us to Reconsider How We View Bleeding Risk in Cirrhosis (Medscape)
A commentary by David A. Johnson, MD. He covers the section dealing with coagulation management in patients with cirrhosis.
Podcast: Disparities in GI health care: 8 key questions and answers (AGA)
In this episode, Drs. Sandra Quezada and Carlos Diaz, provide actionable tips to improve your care of vulnerable patients and ultimately become a better doctor.

More Hot headlines in GI
ICYMI: Who’s interested in buying Gastro Health, at what valuation & what it could all mean (Becker’s GI & Endoscopy)

Does the Microbiome Affect COVID-19 Infection? (Gastroenterology & Endoscopy News)

Colorectal cancer, private equity & more: 7 recent GI trends (Becker’s GI & Endoscopy)

H. pylori infection high among Hispanic/Latino individuals (Healio)

Six Hopeful Healthcare Trends For 2021 (Forbes)

Clubhouse: Engaging with others outside your ‘normal sphere’ (Healio)

7 industry notes: One GI’s latest acquisitions, the new at-home CRC test making waves and more (Becker’s GI & Endoscopy)

Battle of the Sexes: Who Gives Better Medical Care? (Medscape)

The best GI ASCs in the US: Newsweek (Becker’s GI & Endoscopy)

March Special Issue of The American Journal of Gastroenterology Focuses on Women’s Health in Gastroenterology and Hepatology (News Wise)

Gastrointestinal sequelae 90 days after discharge for COVID-19 (The Lancet)

Measures to combat COVID-19 cause sharp decline in norovirus (Healio)

We Must Recognize Women For Their Valuable Contributions To Medicine And Science (Forbes)

The future of gastroenterology and other excerpts on industry-changing trends (Becker’s GI & Endoscopy)

Videos: Interviews with GI Leaders  (NextServices)

7 recent reports in HCV (Healio)

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.
05 Mar 2021

Dr. Baig and Dr. Gialanella: “Shift will occur when there’s financial hardship. And it’ll occur pretty quickly as we see screening colonoscopy going down” (Interview)

New Jersey-based Allied Digestive Health recently became the 8th private equity platform in gastroenterology. In this interview, Dr. Robert Gialanella, CEO/President and Dr. Nadeem Baig, Vice President of Allied Digestive Health talk about their journey – from being competitors to partners to choosing private equity and more. 
Learn about how they consolidated without private equity first, building the largest GI group in New Jersey. They talk about the “generational divide” between the senior and junior partners and reflected on how they tackled this situation at Allied. They also shared their views on consolidations, disruptions, and EBITDA assumptions. Finally, they laid out four trends as gastroenterology moves to the future.
Watch this direct and lucid interview in full to understand the evolving landscape of GI.
◘  How did Allied Health get started?
◘  Even before PE, Allied had consolidated its back offices. What are they doing differently with the PE-backed MSO?
◘  “A good company really invests in itself – human capital, new technologies”
◘  How did they close the generational divide between the senior and junior partners?
◘  The valuation process at Allied
◘  “I felt like I was on a witness stand, but at the end of the day we were happy to know that our practice was perfect in that sense “
◘  What is the effect of disruptions on the EBITDA assumptions? 
◘   “If screening colonoscopies go down because of some disruptive technology, then we concentrate more on treating chronic illnesses”
◘  “Over 70% of our revenue was being derived through four CPT codes”
◘   How long before we see changes in GI?
◘  “Shift will occur when there is financial hardship. And it will occur pretty quickly as we see screening colonoscopy going down”
◘  How do  they keep business and clinical interests separate?
◘  Where’s GI consolidation going?
◘  “I was tired of remaining or staying a pawn on the healthcare chessboard”
◘  Don’t get bigger to get bigger. Get bigger to get better”
◘  Four trends beyond consolidation highlighted by Dr. Nadeem Baig

The Transcribed Interview:
Praveen Suthrum: Dr. Nadeem Baig and Dr. Robert Gialanella welcome to The Scope Forward Show. Thank you so much for being here and again I’m excited to have this conversation with you.
Dr. Robert Gialanella: Thank you Praveen, much appreciated.
Dr. Nadeem Baig: Praveen it’s an honor and pleasure to be on this podcast with you today with my partner in arms, Bob Gialanella. We’re really thrilled and honored you know to be part of this great service you’re providing to the GI community beyond. I just wish I had something like this in my training days where someone was actually collating and curating all the best and emerging practices in the business and practice side of GI and medicine. It’s just a wonderful resource for physicians like us in the community.
Praveen Suthrum: Thank you so much for saying so. I want to first start right from the beginning and ask you how did Allied get started way before the PE days?
Dr. Robert Gialanella: Sure. We formed Allied Digestive…it was a sort of a brainchild of I and Nadeems’ in 2014 or so. We were five competing groups in the same geographic area and we had multiple meetings and explored other possibilities with large multi-specialty integrated groups and decided that we really wanted to be single-specialty and in early 2015 we all took the leap of faith and merged five groups that had previously competed with each other and we decided that we would be much better together than apart. And at that point our cultures were very similar, our quality also very similar which was very important. And then we took on the task of integrating operations tracking quality metrics, creating a central business office to handle all the operational needs of the practices. And that’s how we basically did it.
It wasn’t easy in the beginning you know, loans, a few stumbling blocks in the first year or so but we pulled it together and you know we all kept rowing in the right direction. You know when we look back on it people say to us we can’t believe what you’ve done in such a short period of time but it wasn’t for people like Nadeem and our other board members and the overwhelming need for this type of consolidation looking to the future and the present market in GI, we wouldn’t have done it but here we are and very happy to be here and talk to you about our journey.
Praveen Suthrum: So, Bob what is the difference between this MSO and the MSO that is now forming together with your private equity partner because based on what you’re saying you pretty much did what different platforms have done in partnership with a private equity company… you were doing it already. How does this change the game?
Dr. Robert Gialanella: Three years ago again it was a board initiative to create an MSO this was in anticipation of either a private equity partnership or maybe becoming multi-specialty and you need an MSO to handle multiple specialties. So, we were a bit ahead of the game and that’s what made us so attractive to our private equity partners… is that we already had an MSO in place and it was licensed, and it was operating. So, it was very easy for them to partner with us because we didn’t have to create a new company. The MSO is basically our previous CBO sort of on steroids. It just works more efficiently, we become much more attractive to very high-level executives because now not only do they get paid well they have equity in our company and that to me that’s alignment and retention when you’re all basically partners in the same organization.
Dr. Nadeem Baig: Praveen may I just add also that you know partnering with our private equity company now I think as Bob alluded to, allows us to invest more in the company. Traditionally as you know Praveen, medical practices and physicians who are part of medical practices tend to want to take every dollar out of profits… for themselves, they feel it as the income they’ve hard-earned, we’ve seen patients, we’re doing procedures… so, they want to take that home. And you know they invest some in the company but you know especially with these emerging changes that are currently going on in the healthcare climate place, a good company really invests in itself. And it’s not just investing in new technologies or new modalities but it’s investing probably the best resource of all – human capital. We learned that a couple of years ago when we went out and hired a healthcare executive with expertise and hospital management and also from Kaiser Permanente in the value-based care world, in a sense, it was enormous value and benefits for the organization and be able to grow and get to where we are now but it cost money to pay for that high-level executive employee and before we formed Allied I don’t think anyone else would have even thought or considered it the possibility of hiring someone of that caliber and scale and you know the cost that comes with that service.
Dr. Robert Gialanella: Yeah, you know Nadeem is absolutely right. We all worked on sort of this flow-through type of economics, right? As opposed to capital investment. In our particular case, the important thing was we were looking at a strategic financial partnership that allowed care center autonomy and clinical autonomy you may not find that with a large multi-specialty group or a healthcare system and we looked at all three models and by far this one allowed us the clinical autonomy and operational autonomy and did not disrupt our care center culture at all. So, our care centers operate just as they did prior to ADH. Their compensation agreements stay the same, their clinical staff stays the same all clinical decision-making is unchanged that was very important to find a partner that would invest in us but allow us those freedoms and we did.
You know the process that we went through… I always thought and Nadeem felt the same way you know we always talk to our board like “we’re going have to spend capital to get the best” so we looked around and Nadeem through DHPA, our national advocacy pack, he has been in contact with other three thousand gastroenterologists like-minded independent practitioners around the country and that’s how we found Nexus Healthcare Capital, Canton our law firm who had been involved with the largest GI platforms in the country really knew how to do this. So, we immediately partnered with them as well and that was sort of the process that started us. They were just phenomenal I mean they educated our membership especially our younger membership you know there’s always the… I call it generational divide and when you go through something like this, the younger people see things a little bit differently than the older partners so we had to close that gap, and really we did it. Our investment bankers… I thank them again they spent day and night educating our junior membership and after it was all said and done they realized that this direction was the best one for them as well as us.
Praveen Suthrum: So, I wanted to touch upon that whole aspect of junior partners versus senior partners because a lot of people struggle with it. How did you make the case to the junior partners who think that all the senior partners want is an early retirement fund or an exit quickly from private equity? How did you make that case?
Dr. Nadeem Baig: When Bob and I first formed Allied, I think I told Bob and my other board members as well that… you know I helped to drive and form this company not so much for the senior partners but really for the junior partners and the junior associates. It was to provide financial stability and practice quality, practice management, and care for the long term not just the next five to ten years. And we achieved in that in great measure over the last five years with Allied. That strategic goal and the objective did not change when we partnered with private equity. I felt the same way now as I did six years ago when we formed Allied that this is just as much a means to provide financial stability and security and quality of practice management for the junior partners as it was back then. It’s just meeting and arriving at a strategic goal which was set out… we formed Allied to grow the company from day one to lockstep and pace with the other major stakeholders whether it’s you know healthcare systems, payors, biotech companies, pharmaceutical companies, pharmacy, etc. We just want to keep lock and pace with them and this helps to ensure that. And that was a driving message we made to the junior partners you know in forming this new partnership.
Dr. Robert Gialanella: Also if you look at the economics of it…in a model like this the longer you’re in it the better off you are. I think if our junior partners got… as you said before Praveen, two or three bites of the apple they would see the benefit in this type of corporation. So, we were you know very mindful of taking care of them with equity in the MSO, with you know changing partnership tracks within their care centers we decided it was important that the care centers sort of do away with their legacy buy-sell agreements and we standardized all that. So, no one care center looked more attractive than another to a new recruit.
Praveen Suthrum: How was valuation done in your transaction?
Dr. Robert Gialanella: Valuation as you know is all based on EBITDA. You go through an extensive due diligence process – legal and economic. It took months and then there was back and forth with Nexus Healthcare Capital to get us some extra share. But it was a very laborious process, especially from the legal standpoint. I think Nadeem and I were on a couple of calls with regulatory lawyers, I felt like I was on the witness stand but we were happy to know that at the end of the day our company was perfect in that sense. You know we were always mindful of those type of things as we put Allied together of you know abiding by all the stark laws and local laws as well we’re very fortunate in New Jersey to have an excellent corporate practice of medicine laws too which really defined our relationship with our private equity partners and gave us a lot of comfort in the fact that you know there was a clear separation between the practice and the MSO. And our and our partners were very happy about that too because there was no gray zone. So, we all knew what our roles were we all knew how our care centers would operate and it gave a lot of comfort to us as well so.
Praveen Suthrum: I want to get into this valuation and EBITDA a little bit more and as we know the way currently evaluations are done it’s based on future physician productivity and that future physician productivity is based on the number of procedures that are done and for GI a good part of those procedures pertain to colonoscopies and screening colonoscopies and each of those is connected to other ancillaries like you know pathology is connected, anesthesia is connected and so on. So, if something disruptive happens to that primary revenue stream then it is possible that everything else gets affected so I’m curious to know what happens in that case to EBITDA assumptions and what is like a plan B when you know in your discussions with your PE partner.
Dr. Robert Gialanella: So, I look at it as two different types of EBITDA right there are mergers and acquisition EBITDA groups that you add okay and then internal EBITDA it’s how the existing physicians and Allied increase their revenue stream. Now when you talk about disruptive technologies that may drive down the necessity for screening colonoscopies I think we have to look at it in terms of income diversity. You know if screening colonoscopies go down because of some disruptive technology then we concentrate more on treating chronic illness like – liver diseases, like inflammatory bowel disease and irritable bowel syndrome. There are many diseases that are not procedurally oriented so we expand those service lines.
Dr. Nadeem Baig: When you know Allied first formed, I was a bit of a data nerd and you know my second life I thought I should have become a mathematician or an accountant because you know math was second nature to me. So, early on I would through our EHR and I was able to like to dig into financial data of the organization it came across came across a pretty startling fact which Praveen you have highlighted both in your books and in other conversations with other thought leaders in this area… Over 70% of our revenue in the organization was being derived through four  CPT codes you know it was either one EGD code and three colonoscopy codes and you know I said to Bob and myself that we’re way over-leveraged you know in these few lines of service. So, you know we felt that we had to start diversifying and you know it takes time to work that out and you know part of it of course is… you know the limitations are our you know previous working cultures and environments and just the mindset of physicians who are just attuned to practicing medicine a certain way because that’s the way they’ve seen it happen for 20, 30, or 40 years. You know, once we’re done with the COVID pandemic, we have to go back and start focusing upon the original pandemic of the 21st century which is obesity. You know and that’s still an area that’s not being adequately met by physicians and practices and other healthcare providers across the country. As you see Praveen there’s a lot of already a lot of good innovative solutions out there from Michigan like Modify Health and other new platforms out there. I think it’s the right time for us to get more engaged.
Praveen Suthrum: How long do you think before you know all this happens for GI as an industry? The shift from reliance on procedures, those four CPT codes… because it’s true and it’s true for every almost every practice out there you know before that shift happens from that reliance on those codes to these newer diversified revenue streams?
Dr. Robert Gialanella: Shift will occur when there’s financial hardship and I think it will happen pretty quickly as we see maybe the need for screening colonoscopy going down. But I also look at it another way you know if you have a non-invasive test we may be picking out more higher-risk individuals and they will be coming our way
Dr. Nadeem Baig: I think we have to have a sense of honesty humorous about this. You know every so often there have been threats to colonoscopy. 10 to 15 years ago we were dealing with the CT colonography program. In fact, one of our member practices, before they joined us they invested heavily in a CT scan machine expecting that this is the future, colonoscopy is going to go down, CT is going to take over. Guess what happened? Medicare never covered it, private payors never really covered it and that practice literally went under because of that bad investment. So, you know it’s one thing I think to appreciate the future trends and in some way do we do expect colonoscopy decline we also must recognize that colonoscopy for screening has been extremely effective and there’s a high bar for other technologies to meet that threshold. I mean we’ve seen a 50% reduction in colon cancer incidence and death in the past 20 years with the use of colonoscopy screening and they’re going to be still a lot of patients I think they are going to still choose colonoscopy over other modalities whether it’s Cologuard or other types of stool-based DNA testing or liquid biopsy.
So, the most important thing we can recognize that there’s still patient choice that will play a factor. Nonetheless, we do expect it to go down and as Bob said one of the ways to be reactive just to see our decline revenue and then try to adjust but that’s not the job of good leadership and the leadership that I think we have in our organization and our partners you know with our private equity side you know we recognize that we do have to look ahead and look forward at finding new other areas to be involved with that with the goal of number one you know providing good quality care for our patients. I think I’ve heard some other thought leaders say it, we want to say it here again – you always want to put patients before profits. And if you focus your goal and objective on that you will succeed in healthcare and practice. And the one thing in Jersey is that we have a great advantage of payors that recognize and want to engage in alternative payment models one to engage with you know patient-centered medical homes you know new ways of managing chronic diseases that reduce the overall cost to care while improving that site through the triple aim scores. So, you know that’s where I think we see an opportunity to start to work with our payors in a new role where we’re their partners, not their adversaries.
Praveen Suthrum: If you read any of the news articles that are scathing about the whole private equity space you know there was one in Bloomberg, I mean you pick some of the new magazines and there are some articles talking about it. The issue happens when PE seems to dictate the clinical aspects like of maybe pushing not physicians but maybe APPs instead of physicians for certain procedures or pushing certain procedures which are not needed and especially you know you would read this in the case of dermatology. Now my question is given that… that background does exist, how are you ensuring as a platform that you’re keeping the business interests and the clinical interests separate?
Dr. Robert Gialanella: Yeah, as I said we have separated it pretty well. You know all of our licensed practitioners are employees of Allied Digestive Health the practice and others are employed by the MSO so there is a sort of a firewall there between the people that operate the company and the clinicians. I think in our situation, we figured that out. Now, you could say as the platforms get larger and they get multi-state and you can lose that local control and I think that’s what happened to dermatology out in California. They lost that local control and maybe you can make an argument for that… it also happened to emergency room doctors where they had no idea where the MSO was and who the executives were. And it became such a foreign entity to them that they became just labor and were treated like labor. So, COVID happens there are layoffs you know which is really devastating to a physician. So, I think you know a majority of the states in this country don’t have good corporate practice and medicine laws. We’re very fortunate in New York and New Jersey.
So, you know and I think also our second partner has to be chosen very carefully and our partners at Assured have also let us know that will be a very long conversation with all the clinical practitioners and the clinical side of Allied Digestive as well as the MSO side so, I think the next partner we choose will be like-minded probably another large GI platform that is structured just as we are and I think that helps a lot. You know the problem is I think when private equity gets too big and these companies are bought out by people not in the medical space whether it be insurance companies or other corporations that’s where you start to lose that control because they just look at you know they just look at your P&L. You know and we are a patient-centered practice, a compassionate patient-centered practice and we’re going to keep it that way.
Dr. Nadeem Baig: You know it’s our job as clinicians to make sure that we’re always focused upon the patients. Currently, our private equity partners appreciate the need of providing good quality care. One of the reasons why they really liked us over other potential GI groups that they were looking at was because we provide high-quality care. They said, “You have the highest ADR rates we’ve seen in any GI group and we really like that” so I think they also acutely recognize, especially in this emerging value-based care world which they embrace and any good private equity platform that works with any medical practice should also embrace that quality is a key element of value-based care… if you don’t provide good quality you will not be a valued partner you know with the other key stakeholders whether it’s healthcare systems and most importantly patients, payors, and employers because ultimately that’s what they care about.
Praveen Suthrum: Thank you. So, I want to comment back on one of your points Bob which was you know… and again I’m saying it in my own words that as of now yes it’s restricted to private practice medicine and perhaps in your case very regional very local but as you go to the future and that actually takes us to my final question which is you know where is all this consolidation going in your view? And what do you see happen over the next five years? But connecting the dots a little bit… it is going to take us in some ways in the direction of going beyond private practice too, right? So, there are limited partners, who own private equity players, there are insurance companies that are also interested in the provider side, there are large health systems that are also connected to private equity and beyond and they’re investing in physician practices. So, it is going beyond the hands of physicians so how much control will physicians have it’s a multi-pronged question so I’ll leave it up to you to answer.
Dr. Robert Gialanella: You know that’s a great question. I think there surely will be a lot of consolidation in the next five years. There are nine GI platforms in our country so I would like those platforms to get together and hopefully not sell out to a health care system and you know grow this autonomous sort of model that we have that that may be a little far-reaching. But I agree with you, I think the next partner that we have, the second bite of the apple more to say is the most crucial move we will make as far as what our company looks like in 10 years from now. And I wouldn’t be surprised if in five to ten years from now they’re probably either one big GI platform across the country or two it may get to that. But you know I think that’s where we have to have a real discussion with our private equity partners about who our next partner is. It’s extremely important and you know for the longevity of Allied Digestive Health and the happiness of his of its physicians right now we’re young… I mean GI is young in this space. We really don’t know what’s going to happen.
Dr. Nadeem Baig: Yeah, you know Praveen, let me just add my two cents on this. First, when Bob and I started this company along with others several years ago one thing we’re focused upon is trying to maintain our autonomy. And keep physicians in the driver’s seat in managing the care of our patients. You know I was tired of remaining and staying a pawn in the healthcare chessboard and clearly as we consolidate with other stakeholders doing the same thing… we have no intentions of remaining or ever going back to being a pawn on that chessboard. You know I don’t think we’re a queen but maybe we’re a knight, or a bishop, or a rook, I’m hoping in that board. But beyond the consolidation part you know… which was what everyone’s been out gaming for it’s the challenge for really the successful groups is to what do you make of that consolidation? What do you do when you finally merge all these you know hospitals or pharmacies systems?… I think is Jim Weber said it really well in a conference you know… Jim from GI Alliance… he’s the president/CEO there, he said, “You don’t get bigger to get bigger, but you get bigger to get better” and that’s where we’re going to focus on an in Allied.
You know those four trends they look at beyond consolidation – one is you know is adapting to payment reform from you know both the government and the private payors who are definitely pushing us to fee for service to value-based care and also using the new tools that the government just provided us with the stark, anti-kickback reforms that CMS just enacted a couple of months ago. You know another big trend would be you’re very attuned to this… it is digitization. You know healthcare is the last group of people to ever adapt to newly evolving trends in the digital space. I mean you know people can like you know book appointments online for their airline, their car, lodging, but it’s so hard to book an appointment online to see a doctor. But we’re getting there and it’s not just like you know that customer relations tools through our EHRs, or through telemedicine, it’s you know finding better ways of connecting with the patient in their space at a way they feel comfortable and they feel they have still maintained their privacy. The third big trying to look at as a utility to us is like adapting to an innovation you know not just in like new ways of testing diagnostic modalities but also new service lines and being prepared for those disruptive technologies of innovation.
The last one I want to focus upon is you know is going from a reactive posture to a proactive posture in care management. You know medicine has really progressed through the ages from reactive healthcare, from when the patient comes in the office so they’re sick, waiting to come to the hospital ER to like meet us to be more proactive and you know various people come to see us across. And of course not moving to even preventive care with the whole idea of cancer screening and prevention of cancer which obviously colonoscopy has been a vanguard in that space but it’s now in that the same line of thought is taking a proactive stance in managing chronic diseases in the GI space which we’re not really attuned to. And alongside with that is also the idea of improving quality not just from what you learn in your training and applying that and learning it from like your practice management conferences or practice management courses you would go annually with the AGA or ACG but it’s applying quality improvement at a systemic level. This is something that obviously industries like Toyota and other companies like that have really obviously adapted well – six sigma protocols and lean models and other methodologies like that. But how to take those methodologies and apply them in large-scale groups like ours so we can improve quality performance and outcomes across the board not just you know based upon what you learn at the latest AGA conference, ACG conference.
Dr. Robert Gialanella: And to add to that you know the patient experience… it’s very important from a compliance standpoint to track patient satisfaction very carefully and as Nadeem said, be proactive. If patients view their experience as not the best there are tools that we can use as Nadeem said to engage them early in chronic illness but also to get some feedback from them as to what their experience has been so that we can then improve on it.
Praveen Suthrum: Yeah, fantastic I love the direction that our conversation took. I want to thank both of you, Dr. Nadeem Baig and Dr. Bob Gialanella for sharing your insights and being open to going with the flow of our conversation today. Were there any final thoughts that you would like to leave us with?
Dr. Robert Gialanella: Well again Praveen I want to thank you very much for allowing us the opportunity today to talk about our very exciting journey through Allied Digestive Health and more importantly our goals for quality, compassionate patient care and you know this is a forum for all gastroenterologists across the country, not just platforms I’m sure we can reach many more practitioners than we could have without you. So, we really much appreciate it.
Praveen Suthrum: Thank you.
Dr. Nadeem Baig: Yeah the same for me it’s been a great opportunity for us to have a nice, pleasant, warm, conversation to share ideas, thoughts, both of our experiences, and what we think going forward but also really learning from you. I mean I’ve been getting through that book Scope Forward and I’m looking forward to finishing it in the coming weeks.
Praveen Suthrum: Thank you so much this has been a real pleasure and thank you once again.


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

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