PSG Rumblings Spring 2024

WINTER 2023

Rumblings

President’s Message / David L. Diehl, MD, FACP, FASGE www.pasg.org

The Importance of Mentoring

In April I was able to attend an annual conference that is sponsored by The University of Pennsylvania—the 21st annual Raffensperger Symposium. This symposium is in honor of one of Penn’s gastroenterologists—Dr. Edward Raffensperger, who started on faculty in 1962 and became a Professor Emeritus in 1985. At this conference, gastroenterology fellowship programs from around the Southeast Pennsylvania area meet and present cases to each other—they are presented like a case conference as an unknown and a fellow from another program is assigned to review the case and develop a differential diagnosis. As the Associate Program Director for the fellowship program at Penn State, I was able to attend this conference with the Program Director and many of our GI fellows. I write about this because this conference brought me JOY.

The PSG is launching a mentorship program for GI Fellows and early career GI physicians. We will be reaching out to those of you who would like to participate in this project.

attending physicians at one’s own training program work very hard to train GI fellows, but this is generally different from a mentoring relationship.

JOY – a feeling of great pleasure and happiness. Unfortunately, I have heard many colleagues across the field of medicine losing this feeling of JOY. We entered medicine to help others—we are by nature altruistic and many are feeling disillusioned by the administrative burdens, the pressures to see more patients in less time, and a decrease in autonomy.

Many of us have benefitted from mentors. Perhaps some of us have suffered for the lack of a mentor during our education or training. Mentors can have a lifelong impact on their trainees, but the relationship does not go in only one direction. Mentors can get as much benefit and satisfaction as their mentees can. Gastroenterology, like other areas of medical training is akin to a “guild”, where the experienced take the novice under their wing to train them in the arts of their chosen field. All GI fellows, including us way back when, had trainers and coaches that typically were staff gastroenterologists at our program. Many medical schools provide for mentor relationships, but this is less common in GI training. Certainly,

INSIDE:

But on this afternoon, I felt JOY. It started with the words from Dr. Raffensperger. Years ago, a colleague from Penn interviewed Dr. Raffensperger and recorded the interview and clips are selected and shown at the annual symposium. Dr. Raffensperger talks about always being humble—there will always be a case that challenges you and so remember that we are all here to learn every day. We can learn from our patients and each other every day. And on this day, we all learned from each other. We need to remember that we have patients that come to us at times of stress and concern and look to us for guidance and assistance as they navigate this cumbersome world of healthcare. We have a privilege to work in medicine and we should try and remember that.

I have been lucky enough to have some important mentors in my medical career. The first was assigned to me when I was a firstyear medical student. His name was Eugene “Skip” Felmar, MD and he was a Family Practice attending in the San Fernando Valley area of Southern California. I enjoyed going out to his office and shadowing him closely while he saw outpatients, rounded on inpatients, and did office procedures. Beyond gaining valuable insight into the practice of medicine, I found out why his nickname was “Skip” after he took me out on his sailboat which he kept docked at the Los Angeles harbor. Skip Felmar became a role model for me, and the mentor-mentee relationship was mutually rewarding.

On this day in April while listening to these cases I realized one of the aspects of my career that I enjoy the most—helping to develop the physicians of the future. And I wondered how could I incorporate this more into my days. I thought about how when I am on service I would work to focus a lecture or a chalk talk to the residents every week; I would review in more detail an H&P by a medical student and if time allowed watch them interview someone. Having these moments can

PSG/SOCIAL: @PAGastroSoc

Another highly impactful mentor that I had was someone that I chose myself. Dick Kozarek, MD was (and

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President’s Message

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help to get you past the times that are more challenging. I was told once that if you spend 20% of your week doing something that you enjoy that is enough to combat the burnout that is present amongst physicians.

JOY can be found in so many places— find the time to rejuvenate yourself. My weekends are spent currently driving my daughters between soccer games and theatre performances and not a lot of time to relax, but I would not change that for anything. These

moments and often long car rides with the kids are filled with Taylor Swift songs, talking about their lives, asking them to put down their phone and informing them that it will be fine if they don’t snap their friend back immediately, but mostly it is filled with moments that I know I will never regret having spent.

My hope for you is that you also find these moments of JOY. Remember that day you got into medical school… or match day for residency or fellowship…

or that first day you started at your job as an attending… those days were full of JOY and anticipation for all that was to come. How do you get back to that feeling? For each of us the answer will be different, but it is finding that answer that will allow us to continue to have pride in the work that we do. Our patients need us. Our colleagues need us. And we need to continue to nurture ourselves to be able to be present in the moments with our patients and to continue to provide the excellent care that we all strive to provide.

Ralph D. McKibbin, MD, FACP, FACG, AGAF ACG Governor, Western PA

ACG Governor’s Update

We all know that 2024 is a Presidential election year and campaigning is underway. Legislative bodies are carefully examining budget items to maximize appeal and minimize risks for the upcoming vote. Similarly, policy and legislative issues can be stalled to delay or prevent risks as well. The ACG will have its next Governor’s fly-in April. Many issues of concern to gastroenterologists as well as their patients and staff are slated for advocacy sessions. Here are some of the key issues as well as our proposals. It is important that you reach out to your Governor with issues of personal concern, but we also need patient perspectives as well. Remember that our legislative representatives work for us, and this election year is an opportunity for us to push for inclusion in the decision making process. Here are some excerpts from the ACG updates.

Key Federal Takeaways for GI

• Physician payments decline: We will urge Congress to reverse the 3.37 percent cut to Medicare physician reimbursement announced in the 2024 fee schedule. This cut is based on a physician conversion factor of $32.74 (in 2023 the rate is $33.89). Medicare payments already fail to keep up with the increasing cost of delivering healthcare. More cuts only exacerbate that problem.

• Hospital and ASC payments increase: Conversion factors increase 3.1 percent to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements. This should be maintained.

• Telemedicine coverage extended through at least 2024: CMS finalized several telemedicine provisions, including allowing telehealth visits to originate at any site in the U.S. (e.g., individual’s home), payment for audio-only services, and permanently including Social Determinants of Health Risk Assessments. CMS will continue covering telemedicine through 2024 with payment rates matching those of office/outpatient E/M visits. While many of the telehealth COVID-19 flexibilities are in place until the end of 2024, Congress and CMS are working toward establishing permanent policies for 2025 and beyond. The GI societies are actively participating in these policy discussions to ensure long-term access to telehealth services for your patients.

• CMS conforms to CPT split/ shared visits guidelines: In good news for facilities, CMS finalized a revision to its definition of “substantive portion” of a split/ shared visit to conform to the current procedural terminology (CPT) guidelines, This means that for Medicare billing purposes, the definition of “substantive portion” means more than half of the total time spent by the physician and non-physician practitioner performing the split/shared visit, or a substantive part of the medical decision making as defined by CPT. This responds to public comments asking that CMS allow either time or medical decision making to serve as the substantive portion of a split/ shared visit.

• New codes to increase health equity: CMS established several new services to help underserved populations. For the first time, CMS will pay for caregiver training services. CMS is also establishing payment for community health

integration services, principal illness navigation services and for social determinants health risk assessments that can be reported with certain services, including E/M visits. We applaud the administration’s commitment to advance health equity and expand access to critical medical services.

Look on the ACG website for more information. https:// gi.org/2023/11/09/cms-finalizesunacceptable-cuts-key-gi-takeaways/

Pennsylvania State Issues:

On the State level I am working with the PA Non-Medical Switching Coalition to push for passage of legislation to prevent changes to formularies in mid year based solely on price. There is a Senate bill that has been introduced and the House is working in committee on a companion bill. Please reach our to your state Senators and Representatives in support of this bill.

Regular Session

2023-2024Senate Bill 348

Short Title:|

An Act amending the act of July 22, 1974 (P.L.589, No.205), known as the Unfair Insurance Practices Act, further providing for unfair methods of competition and unfair or deceptive acts or practices defined.

Prime Sponsor: Senator J. WARD Memo: Prohibiting Health Insurers from Altering Coverage or Premiums

ACG Educational Opportunities:

2024 ACG’s IBD School and Eastern Regional Postgraduate Course

June 7-9, 2024 | The Capital Hilton Hotel | Washington, DC

Early Bird and Hotel

Deadline: May 7, 2024

2024 ACG’s Hepatology School & Midwest Postgraduate Program

August 23-25, 2024, | Radisson Blu Mall of America | Minneapolis, MN

Early Bird and Hotel

Deadline: July 8, 2024

New scholarship opportunity of APP members:

Attention APP Members: ACG is now offering a new Annual Meeting Scholarship Fund Program for 2024! The Scholarship Program provides partial financial support for APPs to attend the Annual Meeting & Postgraduate Course, October 25-30, 2024, in Philadelphia, Pennsylvania. Applications are being accepted until April 30, 2024.

Learn more and Submit your Application

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F. Wilson Jackson, MD

Pennsylvania has 148 general medical hospitals. We are blessed to have some of the best. As with many other states, the majority of these hospitals are not-for-profit.1 According to the Pennsylvania Department of Health, 131 of these 148 general hospitals, are nonprofits. In other words, nearly 90% of our acute care hospitals are classified as public charities 501(c)(3) and, as such, are tax exempt.

Our commonwealth is above the national average. Nationally, 57% of the hospitals in the U.S. are not-forprofit according to American Hospital Association 2023 data. Of the 5,157 general hospitals in the U.S., 2,978 are not-for-profit.2

This information is not new or, at one level, particularly notable, and many physicians in our state work within one of the many outstanding health systems scattered around our commonwealth. Both for-profit and not-for-profit provide outstanding medical care. It is worth on occasion, however, to examine how the charitable status of our hospitals relates to changes in health care economics and, importantly, the role of the physician is this evolution.

What qualifies a hospital or health system as a non-profit? In Pennsylvania, a hospital needs to prove that it is a “purely public charity.” The definition and qualifying criteria were established in 1985 by the Pennsylvania Supreme Court.3

By definition, any profits generated are not distributed to members, directors, or officers. The PA Supreme Court decision set forth the following criteria to qualify as a non-profit:

• Advances a charitable purpose.

• Donates or renders gratuitously a substantial portion of its services.

Shareholder Value

• Benefits a substantial and indefinite class of persons who are legitimate subjects of charity.

• Relieves the government of some of its burden.

• Operates entirely free from private profit motive.

The historical backdrop is relevant. (As an interesting aside, the county medical societies of Allegheny, Beaver, Lawrence, and Westmoreland Counties were referenced in the court’s decision for their charitable contributions towards the regional health systems at that time.) Much has changed in health care delivery over the past half century. Relevant trends in health care delivery have been the increasing consolidation of health systems. As hospitals and health systems merged, were acquired, subsumed, or closed, the non-profit status was often retained or assimilated. As a result, we have many health systems, with at times enormous revenue, that are largely exempt of taxation. For one illustration, the City of Pittsburgh and Allegheny County published an analysis of potential, unrealized tax revenue from non-profit entities within their couty in a May 2022 report.4 This study looked at the tax revenue impact of tax-exempt properties in Allegheny County. In total, the annual valuation of taxexempt properties was $127.5 million dollars. The two large non-profit health systems in Allegheny County made up $75.2 million or about 60% of the $127.5 million (the three large universities in Pittsburgh made up the balance). In other words, if the properties owned by these two health systems were not tax exempt, the city of Pittsburgh and Allegheny County would have realized an additional $75.2 million dollars a year.

Hospitals are deservedly entitled to their tax-exempt status. They serve an essential service and need of the community. Additionally, health systems are aware of their special status and provide charitable services. In fact, many have engaged into a program called PILOT – Payment In Lieu Of Taxes where they voluntarily make payment to local governments to help offset unrealized property tax revenue. In reality, however, nationally these PILOT payments are relatively minor relative to potential tax revenue, and the bulk PILOT payments are contributed by a relatively small number of (largely well-endowed) academic institutions based on a report from 2012.5 A few hospitals in our state bear mention for PILOT payments made. These include Saint Vincent Health Care, Abington Hospital, Lancaster General, and Geisinger.

More importantly, however, is the charitable care the health systems provide to the community. The PA Supreme Court ruling said as much. |A qualifying non-profit must; “advance its charitable purpose, donate or render gratuitously a substantial portion of its services and benefit a substantial and indefinite class of persons who are legitimate subjects of charity”. In theory, the tax savings realized by the non-profit should roughly equate the cost of the charitable care provided.

How do the numbers match up? A 2022 Lown Institute study examined the surplus versus deficit of charitable care against tax savings.6 They examined the 25 health systems with the largest surplus of taxes saved against charitable care provided and then the 25 health systems with the largest deficit of charitable care delivered against taxes saved. In other words, the Lown Institute study took tax savings and subtracted the amount of charity care to show either

a surplus savings by the health system or a deficit to the local government potential tax revenue; charitable care – tax savings = net balance. If it is negative, the health system saved more than charitable care provided. If positive, the health system provided more charitable care than tax savings realized.

Provident Saint Joseph Health in Renton, WA ranked number one with a $705 million surplus of tax savings over charitable care. Amongst the top 25 health systems in the U.S. with a surplus balance (tax savings > charitable care), two health systems in Pennsylvania were listed. UPMC was 5th with a $601 million dollar deficit as measured in this study. The University of Pennsylvania Health System was 6th with $571 million gap of tax savings in excess of charitable care. What about health systems in our commonwealth with more charitable care relative to taxes saved? Nationally, Pennsylvania had one health system listed. Amongst the top 25 in the country, Saint Luke’s University Health System in Bethlehem, PA was number 16 with a surplus of $27 million. $27 million more in charitable care than tax savings realized.

How do we as a state line up at a national level? Pennsylvania ranks #2 in the gap between tax savings against charitable care when compared across the nation and relative to other states. Pennsylvania non-profit health systems, in aggregate, realized $2.06 billion net deficit of charitable care provided against their tax-exempt status savings. In other words, all the non-profit hospitals in Pennsylvania collectively realized a net benefit of over 2 billion dollars when the charitable are delivered is subtracted from their tax savings. California is #1 at -$2.544 billion. There is a wide range from state to state. Interestingly, Texas ranks at the top of those states with a positive balance. In aggregate, Texas hospitals provided $606 million more in charitable care than tax savings realized.

What, though, do all these numbers, comparable data and statistics amount to? I’ve written before that health care consolidation has increased cost of care yet without a commensurate increase in quality.7 Health care consolidation has been sanctioned by boards of directors overseeing the largely non-profit, integrated health systems in our state. The professional experience and skillset of most board directors lie largely outside of health care. Among the 20 largest health systems in the U.S. physicians only makeup 13% of the members of the board of directors. Directors are largely from drawn from outside health care.8 More than half of directors work in finance and business sectors to include private equity and wealth management. Other sectors include law, real estate, and insurance. Presumably, a significant majority of these directors in industries outside healthcare work in forprofit industries, whether publicly or privately held, where they represent shareholders. A fundamental duty of board directors is to advocate for the shareholders whether they represent a privately held or publicly traded entity.

By definition, non-profit entities have no shareholders. Who then do they represent? Where is the fiduciary duty?

I would submit that the shareholders should be the citizens of the community that the hospital serves. Non-profit health systems need to reflect and represent their community. They have a duty to provide care to those in need to justify their tax-exempt status. They also need more directors with personal and professional experience in health care. Physicians best understand the reality, the dynamics and the economics of patient care and are best poised to serve in these leadership roles. These physician board members will provide a servicefocused counterpoint to the financial emphasis of other directors. I am not advocating lager boards rather

larger physician representation on health system boards. We physicians understand the dynamic of patient care, the sacred space of the physician – patient relationship and how care is ultimately delivered at the granular level. The defining 1985 PA Supreme Court ruling declared, amongst other criteria, a hospital is non-profit if it “operates entirely free from private profit motive.”

Over the years, health care consolidation has increased the cost of care. $2.05 billion is the current gap between tax savings realized and charitable care delivered amongst the non-profit health systems in our Commonwealth. The current composition of health care board directors works largely in the for-profit sectors of our economy. As such, they understand the prioritization of maximizing shareholder value. More physician representation on these boards would bring better understanding of the needs of the citizens in the community, the ultimate shareholders.

REFERENCES:

1. https://www.health.pa.gov/topics/ HealthStatistics/HealthFacilities/ HospitalReports/Pages/hospital-reports.aspx

2. https://www.aha.org/system/files/ media/file/2023/05/Fast-Facts-on-USHospitals-2023.pdf

3 https://law.justia.com/cases/pennsylvania/ supreme-court/1985/507-pa-1-2.html

4. https://apps.pittsburghpa.gov/redtail/ images/18106_PILOT_Special_Report_Final. pdf

5. https://www.lincolninst.edu/publications/ working-papers/payments-lieu-taxesnonprofits

6. https://web.archive.org/ web/20230313105316/https:/ lownhospitalsindex.org/2022-fair-sharespending/

7. https://www.pamedsoc.org/list/articles/levelup?Site=pamed

8. Gondi, S., Kishore, S. & McWilliams, J.M. Professional Backgrounds of Board Members at Top-Ranked US Hospitals. J GEN INTERN MED 38, 2428–2430 (2023)

A Perspective on Navigating Self-Directed Learning in Fellowship

Nicholas Noverati, MD

I often hear others in medicine say that they have signed up for a career of “lifelong learning.” I would bet at some point during my training I’ve been told something to the extent of “if you don’t like to be constantly learning, medicine probably ain’t for you.” By this I think they mean that, as people taking care of people, we are constantly learning new information in a field of ever-changing knowledge and new treatments or therapeutics. But what does this actually look like?

Malcolm Knowles describes a model of adult learning known as Andragogy, which he states has five tenets.1 In short, these tenets stress that adults learn differently compared to children (pedagogy); they are primarily motivated by real-world experience and want to learn material that is useful and practical.1

You might think of learning occurring in two major silos: formal and informal. For example, formally, as a fellow, I attend lectures my program organizes, “rotate” through different areas of training on a month-bymonth basis, etc. An attending might think of “continuing medical education” as a form of formally organized learning. Informally, we either intentionally seek out information in a self-directed fashion or happen to encounter it throughout our day. We might listen to a podcast, scroll through a feed of posts on X/Twitter, or look to society guidelines and educational videos. In my experience, informal self-directed learning can sometimes be the most impactful and, as Knowles’ would support, I probably feel that way because it is inspired by my own internal motivation to be a better doctor.

Here are some practical ways

I self-direct my learning as a first year fellow:

Using social media

“Doomscrolling” is a new coined term to describe the process of almost mindlessly swiping through a feed of posts on a social media app in a state of zombie-like consumerism.2 By “liking” or “following” accounts that share medical education, one can turn doomscrolling into micro-learning. This then allows for the possibility of either intentionally choosing to look at only this content or simply changing the landscape of your feed so that your personal and professional content is inter-mixed. Personally, I’ve found the Med-X space (previously Med-Twitter) to be extremely useful to a learner by both introducing novel content and making room for healthy discussion, professional development, and mentorship. There are various GI-specific accounts including our very own @PaGastroSoc, @ AmCollegeGastro, and @GI_Pearls, to name a few. The next time you are waiting for an endoscopy case to start, consider spending a minute or two scrolling your med-X feed and you might be pleasantly surprised by what you encounter.

Taking advantage of what societies have to offer

There are several national and local societies withing the field of Gastroenterology and Hepatology that offer free or discounted membership to fellows. By becoming a member, you can gain access to educational materials, information about how to present research at national meetings, join mailing lists to stay fresh on the latest research, therapeutics or treatments available, among other information. For example,

the American Gastroenterology Association and American College of Gastroenterology offer educationspecific sections on their websites with an abundance of free content.

If there is a topic in particular that you are struggling with as a learner, or want a different perspective on, these spaces give you a great option to jump-start your search. Not to mention, local societies in particular (*hint* like PSG) can be a great way to stay involved with nearby practicing clinicians and join local meetings that offer educational sessions. I’ve found it helpful to keep a list of all of the societies that are available to join as a fellow, the usual time frame of when they hold their conferences, and…my log-in information. I try to be intentional to at least scroll through some of the various e-mails that they send with educational content and have been pleasantly surprised by how much I’ve gained from them.

Reading journal articles

As a fellow-member of many of the previously mentioned national and local societies, I’ve found myself receiving many top GI and Hepatology journals in the mail. Yes, physical paper delivered to my home. Admittedly they sometimes become coffee coasters, but they have undoubtedly increased my exposure to new and developing research. Someone once told me to read at least one new thing every day (on average) while in training to keep yourself fresh, and what better way to do it then by flipping through a freshly minted academic journal? I’ve also found it helpful to jumpstart my inner curiosity and some of my own research projects were born out of ideas kindled by the flame of others’ work.

Looking to peers, especially those further in training

Experiential learning, especially in a procedural field, is priceless to an adult learner. Although what fellows can learn from their attendings may be “gold standard,” I think it’d be remiss to not include upper-year fellows. They have been through the same training process and have more recently gone through the journey of growing from basic to advanced endoscopic skills and content mastery. I’m always learning from one of my co-fellows when I ask them for help.

Scholarly pursuits

Arguably, the process of lifelong learning also includes maintaining a healthy level of curiosity. With curiosity comes the desire to seek answers, which can lead to engaging with a larger scientific community in the form of review articles, research projects, case reports, poster presentations, or even on a smaller scale in the form of a social media post. There is research to support the process of creating something—

and maybe even teaching others— activates higher learning centers; it’s the highest tier on Bloom’s taxonomy of cognitive learning.3

I’ve found self-directed learning to be invaluable in my career thus far and have named only some of the many examples that exist. I hope this resonates with and inspires others to be more creative in how they continue to learn for a lifetime!

REFERENCES

1. Bennett EE, Blanchard RD, Hinchey

KT. AM last page: applying Knowles’ andragogy to resident teaching. Academic Medicine. 2012;87(1):129.

2. Leskin P. Staying up late reading scary news? There’s a word for that: ‘Doomscrolling’. Business Insider] URL: Архів оригіналу за. 2020;14

3. Krathwohl DR. A revision of Bloom’s taxonomy: An overview. Theory into practice. 2002;41(4):212-218.

Point-Counterpoint: The Role of Private Equity in Gastroenterology

(reprinted with permission from GI & Hepatology News, the official newspaper of the AGA Institute)

The expansion of Private Equity (PE) into medical practice is a trend that has been going on for more than a decade, with the number of acquisitions increasing six-fold from 2012 to 2021. In this period, PE firms have spent almost $1 trillion on almost 8000 health care deals. PE also is a big player in the hospital market, with about 30% of United States forprofit hospitals being owned by PE firms.

As medical practices become more consolidated, pursuing a PE buyout pathway has become a common exit strategy for senior physicians. Many doctors are eager to hand off their practices, as running a private practice has become increasingly difficult. PE firms are increasingly interested in investing in highmargin specialty physician groups, such as dermatology, urology, gastroenterology, and cardiology. In this “Point-Counterpoint”, Drs. Berggreen and Weinstein summarize their personal experiences regarding interaction of Private Equity and gastroenterology practices.

David L. Diehl, MD, FACP, FASGE, AGAF

PRO

The Future of Medical Practice

BY DR. PAUL J. BERGGREEN

The future of medicine is being written as we speak. Trends that began in past decades have accelerated. Consolidation among massive hospital systems and health insurance conglomerates has gained momentum.

Physicians have been slow to organize and slower to mobilize. We spend our time caring for patients while national forces shape the future of our profession.

These trends have motivated many physicians to explore vehicles that allow them to remain independent. Creating business relationships with financial entities, including private equity, is one of those methods. Before exploring those models, some background is instructive.

More than 100,000 doctors have left private practice and become employees of hospitals and other corporate entities since 2019. Today, approximately 75% of physicians are employees of larger health care entities – a record high.

This trend ought to alarm patients and policymakers. Research shows that independent medical practices often deliver better outcomes for patients than hospitals. Physicianowned practices also have lower per-patient costs, fewer preventable

hospital admissions, and fewer readmissions than their larger hospitalowned counterparts.

The business of medicine is very different than it was 40 years ago, when more than three in four doctors cared for patients in their own medical practices. The cost of managing a practice has surged. Labor, rent, and malpractice insurance have grown more expensive. Physicians have had to make significant investments in information technology and electronic health records.

Medicare’s reimbursement rates have not kept pace with these higher operational costs. In fact, Medicare payments to doctors have declined more than 25% in the last two decades after accounting for inflation. By contrast, reimbursement for inpatient and outpatient hospital services as well as skilled nursing facilities has outpaced inflation since 2001.

Given these economic headwinds –and the mounting administrative and financial burdens that government regulation poses – many independent practitioners have concluded that they have little choice but to sell to larger entities like hospitals, health systems, or insurers.

If they do, they lose autonomy. Patients lose the personal touch an independent practice can offer. To stay independent, many physicians

Paul J. Berggreen, MD

Michael L. Weinstein, MD

are partnering with management services organizations (MSOs), which provide nonclinical services such as compliance, contracting, legal and IT support, cybersecurity, marketing, community outreach, recruiting assistance, billing, accounts payable, and guidance on the transition to value-based care.

MSOs are typically backed by investors: perhaps a public company, or a private equity (PE) firm. But it’s important to note that the clinical entity – the practice – remains separate from the MSO. Physicians retain control over clinical decisionmaking after partnering with an MSO.

PE is best viewed as a neutral financing mechanism that provides independent practices access to capital so they can build the business, clinical, and technological infrastructure to compete against the vertically integrated health systems that dominate medicine.

PE firms don’t “acquire” independent practices. A partnership with a PEbacked MSO is often what empowers a practice to resist acquisition by a larger hospital or health care system. The experience of my own practice, Arizona Digestive Health, is instructive. We partnered with GI Alliance –a PE-backed, gastroenterologist-led MSO – in 2019.

My physician colleagues and I have retained complete clinical autonomy. But we now have the financial and operational support we need to remain independent – and deliver better care for our patients.

For example, we led the development of a GI-focused, population-based clinical dashboard that aggregates real-time data from almost 3 million patients across 16 states who are treated by practices affiliated with GI Alliance.

By drawing on that data, we’ve been able to implement comprehensive care-management programs. In the case of inflammatory bowel disease, for instance, we’ve been able to identify the highest-cost, most at-risk patients and implement more proactive treatment protocols, including dedicated care managers

and hotlines. We’ve replicated this model in other disease states as well. This kind of ongoing, hightouch intervention improves patient outcomes and reduces overall cost by minimizing unplanned episodes of care – like visits to the emergency room.

It’s not possible to provide this level of care in a smaller setting. I should know. I tried to implement a similar approach for the 55 doctors that comprise Arizona Digestive Health in Phoenix. We simply didn’t have the capital or resources to succeed. Our experience at Arizona Digestive Health is not an outlier. I have seen numerous independent practices in gastroenterology and other specialties throughout the country leverage the resources of PE-backed MSOs to enhance the level of care they provide and improve patient outcomes and experiences.

In 2022, the physician leadership of GI Alliance spearheaded a transaction that resulted in the nearly 700 physicians whose independent gastroenterology practices were part of the alliance to grow their collective equity stake in the MSO to more than 85%. Our independent physicians now have voting control of the MSO board of directors.

This evolution of GI Alliance has enabled us to remain true to our mission of putting patients first while enhancing our ability to shape the business support our partnered gastroenterology practices need to expand access to the highestquality, most affordable care in our communities.

Doctors caring for patients in their own practices used to be the foundation of the U.S. health care system – and for good reason. The model enables patients to receive more personalized care and build deeper, more longitudinal, more trusting relationships with their doctors. That remains the goal of physicians who value autonomy and independence.

Inaction will result in more of the same, with hospitals and insurance companies snapping up independent

practices. It’s encouraging to see physicians take back control of their profession. But the climb remains steep.

The easiest way to predict the future is to invent it. Doing so in a patient-centric, physician-led, and physician-owned group is a great start to that journey.

Dr. Paul Berggreen is board chair and president of the American Independent Medical Practice Association. He is founder and president of Arizona Digestive Health, chief strategy officer for the GI Alliance, and chair of data analytics for the Digestive Health Physicians Association. He is also a consultant to Specialty Networks, which is not directly relevant to this article.

CON

Thinking Strategically About Gastroenterology Practice

BY MICHAEL L. WEINSTEIN, MD

Whether you are a young gastroenterologist assessing your career opportunities, or a gastroenterology practice trying to assure your future success, you are likely considering how a private equity transaction might influence your options. In this column, I am going to share what I’ve learned and why my practice chose not to go the route of a private equity investment partner.

In 2018, Capital Digestive Care was an independent practice of 70 physicians centered around Washington, DC. Private equity firms were increasingly investing in health care, seeking to capitalize on the industry’s fragmentation, recessionproof business, and ability to leverage consolidation. Our leadership chose to spend a weekend on a strategic planning retreat to agree on our priorities and long-term goals. I highly recommend that you and your practice sit down to list your priorities as your first task.

Next, a SWOT (strengths, weakness, opportunities, and threats) analysis of your position today and what you project over the next decade will determine a strategy. There is a current shortage of more than 1,400 gastroenterologists in the United States. That gives us a pretty powerful

“strength.” However, the consolidation of commercial payers and hospital systems is forcing physicians to accept low reimbursement and navigate a maze of administrative burdens.

The mountain of regulatory and administrative burdens can push physicians away from independent practice. Additionally, recruiting, training, and managing an office of medical personnel is not what most gastroenterologists want to do with their time.

The common denominator to achieve success in the current practice environment is size. So before considering the private equity (PE) route, I recommend consolidation of medical practices as the strategy to achieving long-term goals. Practice size will allow physicians to spread out the administrative work, personnel cost, the IT systems, and other specialized resources. Purchasing power and negotiation relevance is achieved with size. Our priorities are taking care of our patients, staff, and colleagues. If we are providing highvalue service and have a size relevant to the insurance companies, then we can negotiate value-based contracts, and at the end of the day, we will be financially well-off.

In contrast to the list of priorities a physician would create, the PE fund manager’s goal is to generate wealth for themselves and their investors. Everything else, like innovation, enhanced service, employee satisfaction, and great quality, takes a back seat to accumulating profit. Their investments are made with a life-cycle of 4-6 years during which money is deployed by acquiring companies, improving the company bottom line profit through cost cutting or bolt-on acquisitions, increasing company profit distributions by adding leveraged debt to the corporate ledger, and then selling the companies often to another PE fund. Physicians are trained to provide care to patients, and PE fund managers are trained to create wealth.

The medical practice as a business can grow over a career and provides physicians with top tier incomes. We

are proud of the businesses and value we build. PE funds acquire medical practices for future revenue and not past results. They ensure their future revenue through management fees plus 25%-35% of future physician income for the current and all future physicians. The PE company will say that the physicians are still independent, but in reality providers become employees of the company with wages defined by a formula. The PE-owned Management Services Organization (MSO) controls decisions on carrier contracts, practice investments, purchasing, hiring, and the medical office operations. To get around corporate practice of medicine regulations, the ownership of the medical practice is placed in the hands of a single friendly physician who has a unique relationship to the MSO.

In my opinion, PE is not the best strategy to achieve a successful medical practice. It comes at a steep price, including loss of control and a permanent forfeiture of income (“the scrape”). The rhetoric professes that there will be income repair, monetization of practice value, and opportunity for a “second bite of the apple” when the practice is sold to the next owner. PE’s main contribution for their outsized gains is the capital they bring to the practice. Everything else they bring can be found without selling the income of future partners to create a little more wealth for current partners.

The long-term results of PE investment in gastroenterology has yet to be written. The real stories are often hidden behind non-disparagement and nondisclosure clauses. Recent reports have shown that PE ownership can lead to higher costs to patients and payers, employee dissatisfaction, diminished patient access, and worse health outcomes. The Federal Trade Commission and Department of Justice have vowed to scrutinize PE deals because of mounting evidence that the motive for profit can conflict with maintaining quality.

In 2019, Capital Digestive Care

chose Physicians Endoscopy (since acquired by Optum/SCA) as our strategic partner with the goal of separating and expanding our backoffice functions into an MSO capable of providing business services our growing practice and as well as practices outside of our own. The MSO is now a partnership of our gastroenterologists and Optum/SCA, but the practice remains 100% owned by the physicians. A Business Support Services Agreement defines the services we receive and the fees paid to the MSO. We maintain MSO Board seats and have input into operations.

Consider your motivations and the degree of control you need. Are you willing to hire people to advise you?

Will your practice achieve a balance between the interests of older and younger physicians? Becoming an employed physician in a large practice can be an option to achieve future career stability. You do not need to sell yourself to a PE fund to achieve improved quality, expanded service offerings, back-office efficiency and clout to negotiate value-based payment deals with payers.

Dr. Michael L. Weinstein is a founder and now chief executive officer of Capital Digestive Care. He is a founder and past president of the Digestive Health Physicians Association, previous counselor on the Governing Board of the American Gastroenterological Association. He reports no relevant conflicts.

References

The FTC and DOJ have vowed to scrutinize private equity deals. Here’s what it means for health care. FIERCE Healthcare, 2022, Oct. 21.

The Effect of Private Equity Investment in Health Care. Penn LDI. 2023 Mar. 10.

Olson, LK. Ethically challenged: Private equity storms US health care. Baltimore: Johns Hopkins University Press. 2022.

Digestive diseases are common, impacting millions of Americans every year.1,2 Challenges remain for many — especially in under-resourced communities — as the journey to diagnosis and the right management can be complex, frustrating and slow.3,4,5

For nearly 30 years, Takeda and our collaborative partners have worked to improve the lives of people with gastrointestinal (GI) conditions through innovative therapies and dedicated patient support programs. It’s why we focus on areas with the most significant unmet needs, such as GI inflammation, short bowel syndrome, liver disease and motility disorders.

Despite advances that have been made, there is still so much more to be done. In many ways, we’re just getting started.

www.takeda.com

1. Centers for Disease Control and Prevention. National Center for Health Statistics. FastStats – Digestive Diseases page. Centers for Disease Control and Prevention Website. https://www.cdc.gov/nchs/fastats/digestive-diseases.htm. Accessed January 19, 2023. 2. Mathews SC, Izmailyan S, Brito FA, Yamal JM, Mikhail O, Revere FL. Prevalence and financial burden of digestive diseases in a commercially insured population. Clin Gastroenterol Hepatol. 2022;20(7):1480-1487. 3. Singh ME, James SP, Germino GG, Rodgers GP. Achieving health equity through digestive diseases research and scientific workforce diversity. Gastroenterology. 2022;162(6):1597-1601. 4. Kinnucan J, Binion D, Cross R, et al. Inflammatory bowel disease care referral pathway. Gastroenterology. 2019;157(1):242-254. 5. Popov J, Farbod Y, Chauhan U, et al. Patients' experiences and challenges in living with inflammatory bowel disease: a qualitative approach. Clin Exp Gastroenterol. 2021;14:123-131.

©2023 Takeda Pharmaceuticals U.S.A., Inc. All rights reserved. Takeda and the Takeda logo are trademarks or registered trademarks of Takeda Pharmaceutical Company Limited.

US-NON-9097v1.0 1/23

Colorectal Cancer Awareness Month

Jackson Siegelbaum Gastroenterology employees wore blue jeans and a blue colon cancer awareness pin on National Dress in Blue Day to promote Colorectal Cancer Awareness Month.

It’s time to think BEyond dysplasia

TissueCypher goes beyond the watch-and-wait approach to non-dysplastic BE. This extensively validated, precision medicine test analyzes 9 protein biomarkers in the context of 7 tissue structures to objectively predict a patient’s 5-year risk of progression to esophageal cancer. Non-dysplastic patients scoring high-risk on TissueCypher progress at a rate similar to expert-confirmed low-grade dysplasia.

Meet the first precision risk stratification test enabling better management of Barrett’s esophagus. Explore TissueCypher castlebiosciences.com/beyond

TissueCypher predicts progression of Barrett’s esophagus to high-grade dysplasia or esophageal adenocarcinoma

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BOARD&STAFF

PRESIDENT

PRESIDENT

David L. Diehl, MD

TREASURER

Karen Krok, MD, FAASLD, FACG

Penn State Hershey

Kim Chaput, DO

Geisinger Medical Center

Gastroenterology

570-271-6856

717-531-1017

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Gastroenterology/Nutrition

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@DavidDiehlMD BOARD&STAFF

President-Elect

1st Vice-President

St. Luke’s Gastroenterology 484-526-6545

kimberly.chaput@sluhn.org

EDITOR

David L. Diehl, MD

Geisinger Medical Center

STAFF Jessica Winger Meeting Manager

Tom Notarangelo Design Manager

Karen Krok, MD

Manish Thapar, MD

Gastroenterology/Nutrition 570-271-6856

Penn State Hershey

Gastroenterology (717) 531-4950

Jefferson Einstein Philadelphia (215) 456-8242

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Neilanjan Nandi, MD, FACP

SECRETARY

ADMINISTRATIVE OFFICE ASSOCIATION EXECUTIVE

Dawn Swartz (717) 909-2584

Manish Thapar, MD

University of Pennsylvania 215-662-8900

info@pasg.org

Thomas Jefferson University Hospital (215) 955-8900

Neilanjan.Nandi@pennmedicine.upenn.edu @fitwitmd

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