The question I have for you is the paradigm shift. The paradigm shift in terms of just more practical things, and we'll take PPE, for example. After the HIV epidemic, we have the contact precautions that became a part of our lively life. Now, the PPE in terms of aerosol protection and certain infection control measures we put in place. Do you see some of these things lasting forever? Do you think that these will go away if the coronavirus eventually comes into control and we hit that end of tunnel? I would certainly hope that once we get to the end of the tunnel, some of this will go away. We've sort of accepted that masks help. We are all pointing back to studies looking at N95 versus just regular surgical masks, recognizing that N95s are better in general terms. We've accepted that as gospel, even though half of the time in routine practice nowadays, we're throwing our N95s around. Sometimes they come off the nose, and that was not how those studies were done. I'm not sure as I'm watching all of us, including myself, walk around the Endo Center every day that what we're doing is all that effective beyond just what we did pre-pandemic, which is put on a gown, put on, depending on your policies, glasses and a mask and a hat. I would think that as vaccination rates come up or more folks get infected and recover from COVID, and we make it to herd immunity, that some of this will go away. We're going to, in my view, go back to where we were before, maybe with somewhat stricter reinforcement of the policies we've had in place for gowning all along, but maybe didn't always reinforce. I wanted to also, Latha, going back to your point again of communication and cooperation, I think it's absolutely right that the pandemic got us closer together, be it the GI societies, be it individual practices that are comparing notes sometimes to figure out how to do stuff better. I would say to some degree, shame on us needing a pandemic to do that. Hopefully, that's a learning that we can carry forward as well, that as we're all sitting in our three-person practices, five-person practices, 10 gastro center, 15, and down the road, there's another GI group. The reason private equity came into our space, one of the reasons, there's many other reasons as Jim Levitt will tell me in a few moments when he speaks, but one of the reasons is we couldn't get our act together between practices to say, let's come together, let's work as a larger group because we had egos and all kinds of other structural issues to overcome. If this pandemic does anything useful to us, if it brings us closer together and makes us a bit more cooperative, I think ultimately that's going to contribute to the success of our groups. I agree with you. I have some follow-up questions that I'll hold off on. Colleen, I know you had a question regarding the same topic. I do. Dave will be talking about staffing efficiencies in the next session, but I want to contextualize another aspect of staff, and that is what are your thoughts around GI workforce, the physician side, in the context of COVID, post-COVID, and especially with ending on the topic of collaboration. I think you did that deliberately, and I'm wondering if you can wrap this thought into it and think for me about the future in terms of our physician workforce, what we do, and then bring in collaboration with that. Yeah, and thank you for that question, Colleen. I think it's a critical one, and I'm looking forward to David's talk, and I know he will address this better than anyone else can. It'll be interesting. I mean, there's so many different aspects. One of them being HHS, every few years ago, as you know, does a workforce study, and pre-pandemic had predicted already a significant shortfall of gastroenterologists by 2025. We are all aware our age structure is such that a third of our colleagues are very close to retirement age. As we're renewing that workforce, we have to be cognizant of the fact that the folks who come in, the millennials and the next generation, will have a different outlook on the time they want to spend in the clinic, in our practice, in the endocenter versus at home and on other activities. That most certainly will affect the dynamics within the physician workforce in a variety of ways. I think the maybe more important aspect even, and where again, I'm looking at my own environment here, not pointing fingers at anyone else, where we have fallen short, is creating a team culture, not just within the physician workforce, but with our staff members, with the APPs, with the nurses, with the entire team, essentially. It shows, as I'm looking around the country at practices that I think have been quite successful in these last few months of challenges, it's been the practices that have been a close-knit team. They didn't become a close-knit team the day the pandemic hit. They, as Harish was saying, invested strategically in that aspect of our business, because it's the business, we're in the business of taking care of people, but we also need to take care of the people who are taking care of people. So, I think if the pandemic can be a reminder to all of us that there's an investment that doesn't immediately measure out in dollar revenue, but is critically important for how we provide care to our patients. Thank you for that. Go ahead, Colleen. I also wanted to thank you for that. I couldn't agree with you more. I want to be sure that we have engaged the broader audience that is listening in on this, physicians and practice managers, other staff. So, please feel free to use the Q&A box there. I know the faculty are keen and even eager to hear your questions, too. So, please join in the conversation, Latha. It's the post-prandial time, though. Don't push them too hard. Well, I think you're pretty riveting in that you can keep them awake. The topic itself is so broad, and I'm really hoping that we, myself and Colleen, are representing some of the questions that the audience might have. But please send us questions through the Q&A, and feel free to email us as a follow-up, and we can always navigate through the questions. And the other questions I have are, in terms of what you mentioned at the onset of the pandemic, no one really expected it, and it just totally caught everyone by surprise. We really hope that there is no pandemic, but there are paradigm shifts that will happen from different perspectives in terms of what might affect our business, whether it's virtual money or whether it's business changes or complete change in structure of the payers. How do we navigate through this? How do we monitor this? Are there any resources that we should be looking at to keep ourselves updated? Yeah, I appreciate the question, Latha. It gives me the opportunity to, again, emphasize what I think, for me personally, is key. It's a bit of maybe a sobering perspective that comes from having gotten old enough to have my kind of hairdo and having seen the last 20 years and sat in on these kinds of discussions. As I was trying to say at the very beginning, they have not changed much over the last 20 years. We can talk all we want about some great new technology that we're envisioning helping us in XYZ number of ways in five years. The reality is, and some might see as bad news. I see it as very good news. All you need to do is the basics. Just do them well. You know what they are. They are essentially manage your practice like any business would be managed. Manage it professionally. Build a strong network. And I would encourage the audience not to... This is a tough time for all of us. We would rather be in the same room with a cup of coffee, being able to network, exchange business cards, and so on and so forth. Do that even this year. The ASG would be happy to give you contact information. I know of all the faculty that are part of this conference. And you'd be surprised that most of us, if not all of us, are quite happy to respond to your questions, even if there's not a conference. So build your network. The main point, Latha, to your question is we don't know where the next hit is going to be coming from, which direction. What we know is that everyone's going to have to deal with it. And if I can speed dial Colleen and you and Bruce and Jim Levitt and Harish and say, hey, what are you guys doing about it? I can save myself 90% of time and effort and money. So network is just absolutely critical. So that's my main recipe for dealing with the unexpected is to have a lot of folks to bounce thoughts off on. And then, as I said, from a purely financial, economical business angle, if it is true that every year our costs go up and our revenues go down, there's only a few things we can do about it, unless you can find me more ancillary revenue streams. And it has to do with cutting costs. And if you can't, if you get to the point in your practice where you're getting to the limit of what you can do in a smaller group, the only way I know is to then find partners, not give up your identity, not give up your goals of providing the best possible care by just selling yourself to the highest bidder. But at the same time, you're going to have to find partnerships. And ultimately, probably for the time being, get larger to be able to share costs and be able to have the money to invest in all the stuff we were talking about related to IT and AI and otherwise. Yeah, thank you for that answer. And couldn't agree with you more in terms of sticking to the roots of what we deliver and how we deliver. One last question, and I'll hold off on the rest, and I'll probably ask you in private, is I agree with you in the skepticism you expressed with Camille's slide on site of service, site neutrality payment. And I really hope that the changes that are being proposed will positively impact the ASCs. One of the things that we found in our practice, and I want you to help us with any answers you may have, is the current sort of bundled pay, if you may, in terms of procedures for ASCs. For example, you cannot do anything that uses too many instruments, like EMRs are cost prohibitive for ASCs. Flip studies are cost prohibitive for ASCs. Any thoughts on how this might evolve over time? No specific advice here, but the hope would be, and not to be misunderstood, I'm optimistic about site of service neutrality, and I think that actually provides an opportunity for ASCs. The big hurdle there is, to state the obvious, the hospital lobbies that have prevented a lot of these discussions from even occurring and going forward. But if we were able to overcome that, or the pain point gets such on the part of Congress and decision makers that healthcare is just so expensive that something has to give, then I'm optimistic that the ASCs are going to be in a good position. And at that point, I think the points you're bringing up need to be brought into that discussion, which is that for higher cost interventions, we just currently don't have a mechanism on the ASC side to get reimbursed, and that needs to be changed. Now, having been the CPT advisor for ASGE for several years, and the RUC advisor, I've gotten old enough to realize that the way Medicare and CMS work is at a glacial pace. I wouldn't want to predict how quickly we could inject those important points into the discussion, but I think that needs to be obviously part of it. You're absolutely right. We need to have the ability to use dilating balloons and clips on the ASC side because overall, we're saving the health system money, but we're not getting reimbursed. We all recognize it, and I know our attendees, our listeners are extremely frustrated with the lack of reimbursement, as was pointed out very nicely by Seth and others earlier this morning. I just would ask everyone to understand that it's not for lack of ASGE, AGA, and ACG lobbying groups trying. It's just our system that prevents a lot of this from happening. Thank you for that. I think the complexity of US healthcare that you have so well demonstrated is just unbelievable. Every time I bring that topic up, it's just mind-boggling in terms of the complexity. The other aspect that highlights that, for me at least, is that if Warren Buffett and Jeff Bezos attempted to simplify it and then gave up on it, it says a lot. Can I make a very last point? Because I would want our audience to hopefully get on the same page with us. That is all absolutely true, and it's the most frustrating environment to work in. But I want all of us to not lose our optimism in terms of what we're accomplishing and what we can accomplish. Ultimately, Don Berwick said it best for me when he said the greatest sound for him is the click of the door when it shuts behind him and the patient. Because ultimately, the way we provide care every day is one-on-one with the patients. If we allow ourselves to get cynical and frustrated and depressed, it's going to affect that part of the care as well. I would choose to stay optimistic and small increments in the right direction, but definitely not an easy challenge. I'm sorry, I'll just take one more minute. There's a last-minute question that came up in the Q&A box, which is nurse-provided propofol would save billions of dollars and make patient care better. Is that feasible to get back to us, overcome the anesthesia lobby and FDA restrictions? Yeah, so we have a trifecta conference where Glenn Litmerk is leading some of these discussions, and Glenn is probably the best person to speak to this. I'll give you my short answer, no. Unfortunately, again, it goes to the bureaucracy and the complexity of our system. We clearly know that the person who's asking the question is absolutely right. Dr. Rex showed that in a series of way over 100,000 patients that non-anesthesia-provided propofol is safe. Other countries are using it as their standard. I just got back from Germany. That's how propofol is being provided there. We know it works. Unfortunately, it's a political and regulatory decision on the part of Medicare CMS that I do not see change. I don't know if Colleen wants to weigh in, who has led our health and public policy efforts at ASGE for many, many years, but I'm skeptical in that department, unfortunately. Thank you. I personally want to thank you again for leading this session and sharing so many valuable thoughts with us. I'm, at this point, going to hand off to my colleague, Colleen Schmidt. Thank you for a superb airplane, notwithstanding 30,000-foot view of the future. It's always enlightening and extremely thought-provoking. I know folks in the audience are going to have more questions generated as they think about what you've told them, and as we work through the afternoon sessions. If you do have those and you want to target those for Klaus or for others at the fireside chat later this evening, or for our next group coming in in the many afternoon sessions, please do so. We'll bank those and pull them up as we go.

paradigm shift

COVID-19 pandemic

infection control measures

teamwork

physician workforce

ambulatory surgical centers