Thank you, Dr. Vakari, for this very thought-provoking idea, and we're fortunate enough to have Sarah that can offer us perspective from APP viewpoint. Yeah, thank you. Joe, thank you for that wonderful talk. I have a couple of thoughts and comments towards that. I think APPs are really uniquely positioned to help in this situation. And so if we think about it from clinical care aspect, we are providers and can certainly see those patients. We can increase the access to care. We can really work on projects to improve EMR optimization and efficiency, and help from that aspect. Like Dr. Vakari was saying, that will help to enable physicians to really focus on endoscopy in those complex clinical cases. I think we have seen over the last 10, 15 years, the APP profession has been rapidly growing, and that's going to be helpful. That's going to help us to fill that physician shortage. We've also seen a trend towards physicians retiring at an earlier age, and we've seen an aging physician population, so that growth of APPs can come to help fulfill that. Additionally, I think one of the things that APPs are trained to do really well is that interdepartmental collaboration. So facilitating that complex patient care, and being able to really be the champions of that. One of the unique things that we have to look at, though, is that our practice is really state regulatory, and it's different for NPs and PAs. So we talk about APPs, it's a very inclusive term, but we do have to acknowledge that our degrees are physician assistant or nurse practitioner, and it varies. In the clinical context, I would argue it's hard to tell the difference after the first couple years of practice, but there are those unique nuances. And so you have to have a champion who really knows what the state regulations are, and you can help the APPs get to the top of their license. And in that, we see the team-based care, right? So you'll see your nurses and your techs starting to work to the top of their license as well. And so everybody's really being optimized in that aspect. The endoscopy is a really interesting concept. It's been done before, it's been done successfully, and the literature does show that APPs are able to have similar ADRs compared to physicians. One of the challenges will obviously be training. We see that in clinic. We see that you're doing that specialization training on the job. And so it would be a similar, probably, paradigm that we'd have to be able to develop. But certainly, ASGE has been a champion for APP education, and the more we can offer that specialty education, I think the more we can optimize these workflows. Thank you, Sarah, for your perspective. Dr. Hennessy, from the physician's viewpoint. So I certainly am in favor of APPs being part of a collaborative team that helps take care of patients. I think that there's almost no evidence to suggest that adding APPs somehow reduces the overall cost of care. And that line, I think, is difficult to draw. I think most of where APPs have been used in society and in healthcare systems is to reduce labor costs, which doesn't necessarily reduce the cost of healthcare. I think it's not necessarily an advantage to blur the line between what is defined as a gastroenterologist in terms of doing endoscopy and APPs doing endoscopy. I think the infrastructure that would need to be built to provide APP fellowships for endoscopy makes me think that we just need to build more GI fellowships. And maybe GI fellowships don't need to be as long. Maybe they could be two years instead of three. I think that the idea that physicians are going to retire early, the question is, why are they retiring early? Maybe we should solve that problem before we add another one. Excellent point, Dr. Hennessy. So in our quickly changing environment and moving into value-based medicine, Dr. Schmidt, can you give us some tips, one-minute tip, what we should be focusing on to really achieve our goals and physician satisfaction yet to meet those challenges of this time? Thank you, Inessa. I think one of the opportunities that we have, and this comes from working in a multi-specialty group, is to really partner with our referring physicians and our patients and how to improve value. And by that, I mean understanding where point of care and expensive services that are in our control, like imaging, can help improve that value. And if you are not communicating that with your primary care partners, you're missing a huge opportunity. Go to them, talk to them about your quality, talk to them about what differentiates you, ask them what imaging center they prefer to send their patients to, and then compare the costs of that imaging. Thank you, Dr. Schmidt. Dr. Leavitt, would you give us your perspective of how you view the future and evolution of value-based care? Well, look, I mean, whether it's value-based or volume-based, I won't get into that debate whether it makes a difference, but cost reduction is going to be a dominant force, right? So whatever you're going to do. And massive consolidation is going on in the marketplace. Optum, 70,000 doctors they own, big deals have been closed by CVS and Amazon buying up physicians, hospitals are buying up physicians. So you're going to have to demonstrate value. And that's the critical part, no matter what you do. But from my perspective, I think it's critical that doctors remain independent. I don't believe Amazon is the best advocate for their patients. I believe doctors are. And I believe doctors have to lead health care reform because we are the best advocates. So I think getting bigger is better. And that's one of the strategies we use. And it gets bigger for a lot of reasons, because all of this is going to be driven by data and analytics. So we now have unlocked 8 million-plus patients in a big data lake. We have all the words we've converted, the notes we've converted into data elements. And so we have more than 8 million patients in our database. I think we have the largest database in the world, maybe, for GI. And so with the increase in volume of doctors, you have increased volume and type of data, which can help uncover stories, align marketing activities, produce a better product, deliver better care. That's the whole point here. And so you can go from hindsight analytics, what happened, to insight analytics, why did it happen, what will happen, to foresight, how can we make it happen? How can we get to prescriptive analytics? And I think that's what's going to drive care. That's what's going to ultimately drive value. So getting larger and more data so you can analyze it is where the future is. And you're not going to do it unless you consolidate. As you can see, we have a wealth of wisdom and experience here. So I hope the panelists can stick around for a few more minutes in case people can outside. And we'll meet you outside if you have any questions.

advanced practice providers

healthcare

clinical care

physician shortage

state regulations