Thanks Sumit and Caitlin for a kind introduction. Thank you to the ASGE to invite me back to this course and to Joe Vicari who founded this course and a pleasure to be back with the team. This is a very unique course in the space that we work in and I think you'll see why as the next two days roll on. In the next 20 or so minutes, my charge is to speak to the foundational principles of what a lot of this course will speak to in the next couple of days. And that really boils down to the collaborative relationship that has now developed quite widely in many practices across the nation between the physician and the advanced practice provider. And obviously for the purpose of inclusion, obviously APP, the term will include PAs as well as NPs in GI practice. So this is the main foundational paradigm that we have tried to establish in the last more than a decade now. And it seems to me that it's now here to stay and is actually making huge strides in this profession. So with that, I will go to my disclosures which are listed here. One of the things I talk about is as you grow older in the business, your CV gets longer and so do your disclosures. And I think for the most part, they serve a good purpose in advancing the field by working with industry along the right principles. The objectives of my talk are listed here. My goal here, as well as in my practice and my teachings and travels around the country is to highlight really the value of the APP paradigm in GI practice. I'll take a little bit of time to speak to the APP physician team concept. That's an important concept to understand for practices, for practice managers and for the principals, of course. There are several strategies that have been defined over the years. We've certainly been part of some of that conversation both in our lectures as well as in our published materials. And I highlight that a little bit going forward and then leave you with some practice pearls and a couple of questions. There is not a question and answer session after this talk immediately, but there will be enough opportunity through the rest of the course to speak to some of the questions, concerns or comments or bright ideas that you might have as you listen to this talk and other talks. So save some of your questions for later for the panel sessions. So to start with, this is actually almost heart of the press. This is a paper that Sarah Enslin, who's my collaborating APP and a lead APP in our university, as well as within the ASGE and other organizations. Now she's on this course as well, and you'll hear her later. She and I collaborated for a couple of years She and I collaborated for this invited review, which I encourage you to look at because A, it's very recent and B, it actually does incorporate many of the principles that I will be speaking to and how the field has evolved and where we are today and where we are going. So it will speak to the foundational principles of the collaborative relationship, but also hearken to some of the aspirational components that you will see in my talk as well. Now, what are the factors that determine a successful integration? Before we even start talking about collaboration, we have to first kind of onboard and integrate. I think integration is very, very important. And there's a lot of points listed here on this table, obviously, and feel free to take snapshots if you need to, but this will be available as a recording. So some of the important factors here are the importance of team-based care. I think that those practices that where there is both practice and physician, administrative and physician endorsement and perception of value for the APP component, those are more likely to be successful. So that's the most important thing is over and above the logistics and the hiring and the orientation, stuff like that in the beginning part, it's very important to understand what value an APP paradigm brings to your practice. And the second part is once you onboard them, what amount of investment will you be putting in the APP cadre in terms of their training, their education, their exposure to different levels of practice within your practice, their potential for subspecialization, their professional development, and truly value them as a partner. I think of this table, if we focus on these two aspects, the rest will follow automatically. And that's what we found in our practice as well. Obviously, it's important to pay attention to all the logistics and the operational workflows and the patient shifting and the division of labor and all of that stuff, which I'll speak to as well. But these are the two most important things is team-based care, endorsement of the value as well as the careful onboarding, orientation, training, and true integration of the APPs into what used to be a traditionally physician practice model. Along those lines, here are some of the key principles for successful collaboration. I think I will keep insisting and kind of repeating the concept of perceived value. I think if a practice doesn't feel that it's valuable to add an APP or any other section of provider for that matter, then they're not likely to succeed. I think it's important to understand what value an APP cadre brings to you. The other thing that's very important is to select the right people with the right competencies, right training, right education, and obviously the right motivation. I think this is true for everybody. This is true for fellows, trainees, physicians, APPs, nursing. I think a high quality practice places a huge emphasis on selecting highly competent people who are motivated, who would be valuable and high-functioning members of the team. The other thing is, of course, that once you get somebody on board, it is much more useful, valuable, cost-efficient, and the right thing to do is to try and retain the right people that you've taken so much effort in bringing on board. So retention is a big thing. And one of the important principles of retention, which we have found in our time managing practices and, of course, talking to people, is what type of ongoing mentorship is available to people. So if there is a constant contact, there is access to physician advice, to mentorship, to professional development, and to other aspects of practice growth, then people are more likely to stay. And so it starts with value, and then it kind of stays on with you with ongoing mentorship and professional development. So these are important principles to keep in mind. Now, the other aspect that I speak to a lot is that this is not a forced engagement, right? So American medicine in general, and GI in particular, and many other subspecialties right now are in a relative shortage. There are blocks of individuals and providers concentrated in many communities, but there are many parts of the country that are not served very well, including some of the bigger cities. The demand and supply ratio is quite adverse in the GI space right now. And there are many reasons for it that I can't get into on this talk, but that is the state we are at. So this is a model that's born out of necessity. It's not something that we are forcing onto the system, but this is a model that will survive and do well if there is mutual trust, respect, and partnership. I keep saying that. I mentioned that at the top of my talk. The value, the partnership, the true sense of respect for each other is extremely important. Obviously, we still work in America, so American medicine is fee-for-service for the most part, and it is increasingly under a lot of pressure. As chair of the Reimbursement Committee, I am acutely aware of the financial pressures that we have in all settings. So this model has to be financially feasible. It has to be at least budget neutral, if not positive, and you cannot lose money in this engagement. But at the end of the day, whether you look at it from a financials perspective or a patient clinical care perspective, or even from an administrative or academic or professional development perspective, it has to be a win-win for all parties in the engagement. So that's important to keep in mind. Now, in terms of collaboration, there are a couple of formal things that one needs to keep in mind. This is a typical, I believe it's a New York State form, for a physician assistant and physician to collaborate. There is a proper formal engagement that is in place. It does have clinical practice implications. It has medical legal implications. It has policy implications. So that's in place, for example, in this case between Sarah and myself. And when I was department chair, I probably did this for more than a couple people at a time. This is a similar form for the NP physician paradigm. So these exist out there. We can have a chat about the importance of these and how they play out from state to state if those questions come up during the course. Now, the case for the collaboration is further strengthened by the fact that in at least American Medicine, we have the physician provider on the one side, and then we have nursing at varying levels, as you've all encountered. There is also a component of advanced nursing, but there's this critical gap in the middle where we don't have a, many of the nurses cannot prescribe medications and such, and don't necessarily have the training and education that would support advanced practices. So that's a very important critical gap that the APPs will fulfill. The other thing is that we have a huge problem with access, and the APPs will definitely help with that while the endoscopist will be able to focus on endoscopy. And in many cases, this relationship works out just fine. And the final piece that we've kind of become very acutely aware of, especially in the era of Obama healthcare and the last two decades or so, is the increased emphasis on patient satisfaction, patient outcomes, physician and provider wellness. So I think when you have more competent, capable, trained partnering members in the team, all of those aspects are well-served as opposed to if you have a lone soldier fighting the battle alone. This is what we call the team-based model in the APP-physician collaborative relationship. It is a busy slide, but basically it looks at the components that are related to finance, shared visits in the clinic, obviously the increasingly well-known paradigm of inpatient service. And one of my favorites is this non-endoscopic aspects of clinical practice. You know, all of the phone calls, the biopsy results, the communication, the liaison function, as I call it, for APP is extremely important. On the left side here are some of the more aspirational elements. Of course, many of our APPs are involved with education, training, and clinical research as well. They can do ancillary procedures. And in some cases, in some states, in some practices, they're also doing some endoscopy procedures. Again, born out of necessity, but also out of an aspirational component that many of you have. These are some of the other examples of meaningful collaboration. So a little bit of the same notes here, but I think that it starts with highly effective and financially feasible and clinical best practice type of clinical models. And then, you know, you pay forward with training the newer staff that are coming in. You know, some of the nurses are great early students for APPs. We have certainly that in our daily practice. And then your own professional development. And then more and more as you grow in the field, you can have more regional and national roles. We certainly have many faculty from the APP group here today who are national superstars. And then within your own institution or within societies, you can have leadership roles as well. So these are very, very important elements that I see on a continual basis now. And I've had the great pleasure of engaging with many of these folks who have achieved this already. Now, for me, the big things in this practice model are increased access, division of labor, so to speak, between the clinical aspects of things and the endoscopy aspects of things, a big emphasis on patient education, satisfaction, and communication. I think we all suffer, and we can never over-communicate in our business. I think that's one thing I've learned as a previous clinician administrator, and now as a busy clinician as well, is that we can never communicate enough, and this is something that's important to keep in mind, and this collaborative model allows us to do that much better than if we were working alone. There are many types of practice models that are there, depending on the needs. Of course, there is a shared visit model that we have employed very effectively for the last more than 15 years. There's, of course, the model where physicians will see the new patient, and the APP will see the follow-ups only. I'm not a big fan of that because that doesn't really create some independent growth. There's also the inpatient-outpatient model. I am a fan of that. I'm a big fan of the independent practice model with the right training competencies and mentorship in place, and then, of course, the inpatient-focused model, which is a huge unmet need right now in GI practices, as many of our GI colleagues will be covering many hospitals at one time and are not physically present. To me, the collaborative model ultimately is a divide-and-conquer strategy. All of the points that I've already spoken to, but particularly in sub-sub-specialty areas, complex IBD, cancer care, liver, for example, even without transplant, these are complex arenas, and it needs a lot of people, a lot of competent people who work well together to deliver high-quality care and achieve a better day. Moving on to the financial components, of course, billing and reimbursement is a huge aspect of things. I mean, despite being in academics, I'm acutely aware that without margin, there is no mission, right? So one of the first things that a practice has to do is to figure out how they're going to pay for this model. So it's not that hard to do, but there has to be a significant focus early on to say, okay, well, we're going to do this, and these are the benefits, these are the ROI or return on investment on this project, but this is also how we're going to justify this FTE, this salary, this benefit, and so forth. So there are many, many ways to kind of look at it, but one of the models that we work with a lot is a shared and split service model where there are some relatively new burdens that are in place when you see patients together in the clinic. The attestations have to be a certain way, the burden of documentation, the medical complexity, all of that is something that we can discuss further in the panels, but safe to say that the shared model does work, and is in place right now. The incident two billing is where the criteria are a little bit more stringent, and there is a high level of scrutiny on this. So we have generally not advocated this as something that folks should start out with, but obviously in some practices that are very mature, where there is internal, very strict compliance policy and financial and legal oversight, it's certainly very easy to do because there is an incremental reimbursement rate here, nearly at the physician level, as opposed to the shared model where you have an 85% reimbursement. But in general, this is a red flag item, and not something you wanna start out without proper oversight. So here are the three models that are in place, the independent model. If you see patients alone, you're gonna be paid at about 85% of the physician rate. The shared model, where you go to 100%, the MD is really the billing entity. And then the incident two, where you will be billing also at 100%, but with very strict criteria and some restrictions on what type of patients you can see. So three models that are in play. This hasn't changed much over the years, although there has been some change in the medical complexity, attestation burdens, and there might be some future changes also for the shared model, more to come on that. Now, all this is good, but every story has a bright side and a dark side. And the dark side of medicine practice in any country for that matter, but particularly in America, is the liability component. This is, in general, has been traditionally considered a litigant society. You hear about a lot of lawsuits, many of them are frivolous, some of them are genuine. But regardless of lawsuits also, there is other types of liability. Vicarious liability, where the physician may be held responsible for the acts of the APP. Negligent supervision, which in my mind is one of the bigger ones that state authorities will come after or institutions will look at. And of course, negligent hiring, where you bring somebody on who's not really qualified. So this is an important slide. This has been published already. And I think this is an area for further research as well, as the APP paradigm grows, is what are the common malpractice claims? Where are the gaps? So here are some of the gaps. I think inadequate supervision is one of the big problems. It's not only a medical legal liability, but it also goes against all principles of best practice and emphasis on patient outcomes and such. So keep an eye on that. If you have this model in place, you wanna have, especially early on, with the young APP, with the young, relatively inexperienced APP, you wanna have that in place very well. The other issue is related to timeliness of care. And especially in the realm of cancer care and serious illness, that becomes a big problem. And of course, there's not much to be said about fraud. Fraud is fraud. It does still occur. And obviously it's best avoided. Anytime you have a question, go back to your policymakers and administrators and take their wisdom in terms of what is appropriate billing and levels and so forth. So this is probably the easiest to avoid if your intent is good and you're sincere in your practice. Mitigating risk, of course, for me, I think setting up the model well in the beginning is important. Appropriate training and supervision is really, really key. And then remember, we have collaborative agreements signed in place. So a periodic check-in is important, especially with the new people coming on board. Performance reviews are there. Knowledge, administrators having knowledge of the state, institutional and regional policies that apply. All of this is knowledge that we have already accumulated. It's available. And those references are cited here. So pay attention to this as you build these practices and models, because someone sometime will come around and do a check and you don't wanna be found missing on these points. So these are some of the summary strategies to include APPs in your practice and help them grow. So obviously include them in your practice discussions, be open and constructive about your communication. That's really, really important. Increasingly so as we get busier and busier is to have very clear communications, clear expectations from each other and be able to close the door, sit down and speak to each other about both good and bad things as you grow together. I'm a big fan of professional development for all cadres, for fellows, for nurses, for faculty, for APPs. I think that this is something that really allows you to grow in your practice and your career. And I think for the right candidate who's motivated, willing to put in the time and the energy, I think many of the physicians should step up and invest in that on a regular basis. I'm also a big fan of performance reviews. Many of us at the university level have 360 reviews. Many of you have those in place in the private setting as well. In some fashion, I think when done right and when done constructively, they really make a difference in the performance and in the outcomes. And one of the big things that I find is still a gap is the inconsistent assistance with conflict resolution. Excuse me, conflicts arise a lot in our practice and they come in varying forms. And I think the senior physician partners who have experienced a lot of this already can serve a major mentor role here when conflicts arise for APPs. So we can talk about that in the panel. So the next level of successful collaboration for me after you're done with the clinic model, done with all the patient stuff that we all need to do first is some of this stuff here. This is regardless of your practice setting, professional development, investment in some academic and scholarly productivity. There's no reason that APPs cannot be co-investigators or sub-eyes in clinical trials. Many of them are already. And then a big part of our, in our regions and our communities is to engage patients through advocacy groups and of course work with industry in whatever capacity you can. A lot of this is available. These are all unmet needs right now. The physicians cannot do it all. And I think this is a big area for aspirational growth for APPs. Again, from our paper, this is kind of a comprehensive slide looking at all the things that I spoke to, direct patient care and then some ancillary procedures, liaison function, care coordination, education, leadership, of course, and more aspirational things, both institutionally and outside as well. So for me, the practice pearls are listed here. I think the model for APPs and physicians has tremendous value. It has tremendous potential. And I think we are only just getting started. I think as we spread the message and we talk more about it and we incorporate it in our practices, this is an area of tremendous future growth. As I see the need for GI services only getting more and more. Obviously, this can only be successfully done if the practice has investment in it, they will see perceived value in this, and that there is mutual trust and respect within the parties that are engaging in it. The strategies for successful collaboration have been defined in my mind. And of course, this is an evolutionary thing, but we already have many principles in place. I do feel it has a direct impact on patient care and outcomes in those settings where it is done right. And for me, one of the great joys is after you've accomplished many of the basic things is to then go to the next level where you can do more serious professional development and train the next generation of leaders and APP scientists, if I may say, coming of age as time goes on. And that's a legacy that we can build. So with that, I thank you for your attention. And we have a polling question one, if I may do that, Michelle, is that okay? That's fine. Okay, so we have two questions based on the lecture that I just presented. The key principles for creating a successful APP-MD collaborative partnership are all of the following except. So in general, the American Board of Internal Medicine does not like except type questions, but we are not with ABI-M today with ASGE. So the ASGE is more lenient. So what is the correct answer? One of these answers is wrong. Practice buy-in is important. Mutual trust is important. Collaborative partnership, level of financial incentive and APP professional development. I deliberately made it a little difficult. So let's see what the audience says. One of these answers is wrong, okay? Just reminding you, this is an accept question, so. And there are your results. All right, so the results are two thirds of the folks feel that the level of financial incentive is not a key principle. The others are key principles and infinitely more important. The money will come if you have a relationship and a model in place. That's absolutely correct. You guys are off to a great start already. So I'll close that one and go to the next question. The next question is all of the following are strategies which contribute to a successful APP-MD collaborative relationship. Again, accept. So one of these choices is wrong. And that's the one you have to pick. Open, constructive communication, clear performance expectations, exclusion from practice discussions and career and professional development support or opportunities. One of these answers is wrong. 99, okay, hopefully you'll be the winner of the day. That's amazing, guys. I think that, you know what that tells us? It basically tells us how important it is to this group as it should be to be really considered a part of the practice as part of, not just as a member of the practice community, but also as time goes on to be involved with discussions that impact the practice. And it also tells you when you don't do that, how this group feels and what negative impact it has on a practice. So we can talk a lot more about it in the panel. I don't want to take up more time. Excellent answer, very important concepts. And I'm gratified that nearly 100% got it right. Thank you. And with that, I will hand this proverbial floor back to Caitlin Cookson.

collaborative relationship

advanced practice providers

gastroenterology practice

patient outcomes

billing and reimbursement

team-based healthcare