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