Q&A: Transforming Gastroenterology

Today, RamaOnHealthcare talks with Dr. Spencer Dorn, Vice Chair and Professor of Medicine at the University of North Carolina and Praveen Suthrum, Entrepreneur and Healthcare futurist regarding profound changes happening within Gastroenterology.

Dr. Spencer Dorn, Vice Chair and Professor of Medicine, UNC

Praveen Suthrum, Healthcare Futurist Author and Entrepreneur

RamaOnHealthcare: Within the realities of healthcare practice today, what are the most challenging demands within a Gastroenterology practice?

Spencer Dorn: Today’s most immediate challenges are not unique to gastroenterology, per se.

For one, clinical care is becoming increasingly complex. For example, when I started medical school in 1998, there were less than 500,000 Medline-indexed publications each year. In 2020 there were almost one million. Similarly, when I completed my gastroenterology fellowship in 2009, we had one class of biologic medications and two classes of small molecule medications for inflammatory bowel disease. Today there are four classes of each, along with 10-plus biosimilars. Of course, more advanced knowledge and additional therapies are great! But it is challenging for gastroenterologists to keep up. And it often means we are treating patients with more complex and advanced conditions.

Running a gastroenterology practice is also increasingly difficult. Beyond the many administrative, regulatory, and technological requirements, there are severe workforce challenges. In addition to the projected gastroenterologist shortage, many practices cannot hire enough clinical and administrative support staff. And inflation has pushed wages, usually without commensurate increases in reimbursement. At the same time, due to the pandemic, there is tremendous pent-up demand for GI services. Combined, this worsens care access and strains patients, gastroenterologists, and their teams.

Praveen Suthrum: Key challenges for gastroenterology are across four disruptors: exponential technologies, consolidation, Big Brothers, and changes in patient behavior (as discussed in my 2020 book Scope Forward).

We are at a fork in the road right now as far as the industry is concerned. Gastroenterologists have dedicated crucial years of their lives to practice in a certain way. Now, these four disruptors are changing the norm. Let’s review each of them.

First, exponential technologies are advanced technologies that double in efficiency and reduce in cost every few years. For example, the field of digital biology has the potential to disrupt screening colonoscopy as we know. A stool DNA test offers a convenient method for patients to get screened. Not just DNA testing but companies such as Geneoscopy are developing RNA-based tests to detect cancer before it manifests beyond control, thereby reducing the risks for patients. Another example is Guardant’s liquid biopsy test engineered to detect not just one but 11 different types of cancers using a simple blood draw. This shift is a challenge for a specialty that depends on diagnostic procedures.

Second, consolidation amongst health systems, insurance companies, and private practices is creating enormous uncertainty in the industry. Even PE-funded platforms that have pegged valuations based on past physician productivity are at risk of digital disruption. As GI gets more consolidated, success or failure impacts a wider population of physicians.

Third, big health systems, big insurance companies, big technology companies, and big retailers all want a piece of the healthcare pie for different reasons. The fastest growing division within UnitedHealth Group isn’t insurance but their medical provider division. Health systems are aiming to lock-up regional markets. Technology companies are hungry for data generated by gastroenterologists. Retailers such as Walmart are busy converting their walk-in consumers into dedicated patients of its health clinics.

Fourth, changes in patient behavior are largely going unnoticed by gastroenterologists because they are too close to the fire. Patients are finding solutions outside of the mainstream healthcare system.

Digital health companies like FoodMarble provide a smart breath analyzing device that can measure subtle changes in abdominal gases and diagnose digestive disorders. Another start-up, Alimetry, provides a smart wearable belt with electrodes that measure subtle electric activity within the gut to diagnose GI conditions. Coprata plans to install smart toilets in patient homes. People will be drawn towards the convenience and affordability of such innovations.

Patients are also thinking of holistic health. For example, Headspace a meditation app merged with Ginger.io in a $3 billion plus deal to create Headspace Health. Surely, patients with inflammatory conditions are using apps such as Headspace.

While these challenges are causing a fundamental shift in gastroenterology, the doctors are too busy living between the endoscopy room and consultation room. They think the challenges are managed care, insurance reimbursements, patient volume, staffing shortages. Physician practices are busy competing with each other without realizing that the bigger threat to their livelihood is coming in from the outside.

In summary, the biggest challenge the industry faces is that of mindset that’s hinged on the past but needs to accelerate to an exponential future.

ROH: What GI trends or changes have you seen or expect to see within the near future? What advice do you have for those getting into this specialty?

SD: Gastroenterologists trained to deliver care through discrete, in-person encounters. Their practices are paid almost exclusively fee-for-service and are optimized around procedures – especially screening and surveillance colonoscopy — which typically account for at least 70% of total revenue. This orientation runs counter to broad societal trends to more distributed and remote services and the ongoing push to reign in health spending growth through new payment models. So, at some point, gastroenterology practices will need to reorient their clinical, operational, and business models to deliver more value-oriented, consumer-focused care. I believe there are key opportunities to better align with new advanced, retail, and virtual-first primary care organizations.

PS: We’ve covered the trends. Now, start with the basics. Zoom out and change the lens through which you are viewing GI care – the future will become apparent. Educate yourself by immersing yourself into future trends of not just medicine but also other industries. Clinicians must not shy away from business and technological aspects of medicine. Understand the continuum of GI care for top digestive conditions and ask what needs to ultimately happen for end patients. Plot various solutions that already exist for this continuum of GI care — many would be outside of mainstream private practice care.

Based on the above foundation, consider what must happen for entire populations. How can technology be an enabler in taking stock of care and predicting the trajectory of care? The point is not about jumping directly into applying AI or automations for one-off problems. It’s important to reimagine GI care.

ROH: Do you see at-home colon screening tests becoming reliable first line testing soon? Why or why not?

PS: When a field goes digital, it experiences exponential growth. At home colorectal screening relies on digital biology. With more tests, there’s going to be more data. With more data, the specificity and sensitivity of the tests will improve. Other exponential technologies such as AI will contribute to a multiplier effect of the field. Therefore, it’s likely that GI cancer screening could one day be a simple, at-home test much like a pregnancy test.

ROH: What is the role of virtual care in managing GI disease?

SD: Early in the pandemic, gastroenterologists were the 2nd leading adopters of virtual care. Now that stay-at-home orders have long expired, most GI practices have little incentive to provide care away from the office and even less incentive to use virtual tools to reshape care fundamentally. Today, GI care is back to being delivered almost entirely in person.

Enter a group of virtual care upstarts with entirely different incentives. One group aims to fill the gaps in traditional GI care by addressing psychosocial factors, diet, self-management, and remote monitoring. Because they do not provide direct medical management, their critical clinical challenge is integrating with local GI practices.

The other group includes virtual-first providers aiming to diagnose and manage GI conditions remotely. Lacking legacy baggage, they are designing care to be more consumer-friendly, efficient, and effective. One of their key challenges is defining the right segments to serve. Virtual-first may not be as good of a fit for those with complex GI conditions who account for the bulk of total spending because they tend to require more in-person services.

As I mentioned earlier, across our society, all types of services are increasingly moving online. While it may be possible for traditional gastroenterology practices to ignore these trends for now, at some point, most will feel compelled to provide care over both in-person and virtual channels. The key is selecting the right care channel to meet individual patients’ needs and preferences.

Importantly, virtual care should be more than simply conducting traditional office visits over Zoom, which sometimes enables better experiences but does not fundamentally improve access or productivity. Instead, virtual care should encompass both synchronous and asynchronous communication tools and, when clinically indicated, remote monitoring of physiological parameters and/or symptoms. And virtual care must seamlessly integrate with in-person services, when necessary.

PS: Let’s ask a different question. Are you going to watch movies at the cinema? Are you going to watch movies via Netflix? The answer is both and it depends on the movie and individual preferences. Services in gastroenterology will evolve similarly. Those that lend themselves to a virtual environment (e.g., routine follow-up consultations) must be offered virtually. Virtual care also helps extend care to rural and remote environments. It has the potential to make healthcare from a local concern to something that’s more global. The field needs to explore utilizing at-home diagnostic devices to receive more data about the patient to develop a comprehensive picture of care. Taking advantage of virtual will help physicians get more time and disconnect the dependency on a physical workplace. Ultimately, what’s likely to evolve is a hybrid model.

ROH: How do you foresee the application of AI and machine learning within Gastroenterology?

SD: For all the attention and potential promise, AI has yet to penetrate gastroenterology deeply. The most immediate applications are in two areas. First, machine learning (or more straightforward robotic process automation) can help automate routine, time-consuming administrative tasks. Second, because AI is very good at recognizing patterns within images, AI tools can help gastroenterologists identify lesions such as polyps during endoscopic procedures. There are many studies demonstrating AI’s effectiveness here. But it has yet to be broadly implemented in real-world practice.

Beyond these areas, AI tools may one day extend into clinical decision-making in areas where clinical knowledge can be codified into rules. Key challenges include integrating high-quality data, embedding AI tools into clinical workflows, explaining AI recommendations, and finding clear business cases to justify the necessary investments.

PS: Artificial Intelligence has already penetrated the endoscopy room. Medtronic’s GI Genius, an AI product, plugs itself into a surgery room to help endoscopists detect polyps in a patient’s gut. Another startup, Iterative Scopes has raised $150 million in Series B funding to develop AI tools to the practice of gastroenterology and drug development. Another startup Virgo has captured over 400,000 endoscopy videos and plans to apply AI to help clinical trial recruitment. Olympus, a scope manufacturer has invested in Virgo. To foresee what’s likely to happen, put these developments on momentum. Over the next five years, AI will embed itself seamlessly into many aspects of gastroenterology.

ROH: Please provide your thoughts on how gastroenterologists might best utilize technology, data, mobile health apps, etc., to manage and improve patient health and experience.

SD: Healthcare tends to be delivered using a one-size-fits-all framework. To take two extreme gastroenterology examples, those with mild irritable bowel syndrome or slightly elevated liver function tests often proceed down the same care pathway as those with severe functional abdominal pain syndrome or cirrhosis. Consequently, we often overserve those with straightforward needs and underserve those with complex needs. Ultimately, care is less accessible, affordable, effective, and pleasant.

Digital health tools like data analysis applications, virtual care, health apps, and digital therapeutics can help us better tailor care to individual needs. Gastroenterologists should start by defining care pathways for individuals with different GI conditions. As part of this process, they should consider if, where, and how digital health tools fit along the way. Ultimately, I believe gastroenterologists must develop more ways of caring for people and then build an “operating system” that matches patients to the types of care that best meet their needs and preferences.

PS: They must lift their heads out of the sand and stop acting as though nothing has changed. The shift to digital presents a huge opportunity to make systemic corrections. Use disruption as the very tool to disrupt what’s not working. Whether it be mobile apps or data, or some other technological aspect is but an enabler to take care of patients more comprehensively, safely, and longitudinally.

About Dr. Spencer Dorn

Spencer Dorn, MD, MPH, MHA, is Vice Chair and Professor of Medicine at the University of North Carolina. A practicing gastroenterologist, he is an experienced physician leader, clinical operator, and academic. He is especially interested in innovative specialty care models that deliver high value and align with primary care.

About Praveen Suthrum

Praveen Suthrum is an entrepreneur and healthcare futurist. He cofounded NextServices, a company that helps healthcare businesses thrive through better operations and technology. He also cofounded NovoLiver, a company that helps reverse fatty liver disease through weight loss. He also runs a leadership program called the GI Mastermind that delves into digital transformation of gastroenterology.

Praveen has been featured in Forbes, Inc., The Economic Times, The Detroit News, and STAT News. He’s the author of Private Equity in Gastroenterology and Scope Forward, books that have transformed the space of gastroenterology.

He has an engineering degree from Manipal Institute of Technology and an MBA from University of Michigan’s Ross School of Business. He also completed advanced yoga teachers training at The Yoga Institute. Previously, he served as the Chairman of the Michigan Ross Alumni Board of Governors.