What I did is I prepared 15 minutes of a little bit of sort of background and slides on quality and my pontificating about that, and then we'll sort of open it up towards what you're all focused on the most. But maybe just in the interest of preparing better, can you tell me all what you work on specifically so that I can make sure I'm going the right direction? I can start. I focus right now on population health and actually colorectal cancer screening. I'm a former endoscreen nurse manager. Now I work over in the biotech industry. Which company is that then? Exact Sciences. Good. And I'm Stacey. I work with Medtronic. I'm the regional manager for the Mid-South region, so I live in Nashville but have several states around me and have all the Medtronic products, but I was telling someone else my background is in cardiology, so I'm newer to GI and learning a lot. Hello, my name is Alexandria Algonian and I work at Steris Endoscopy. I'm part of their product management, so anything from new product development side to supporting the sales team would be valuable to learn from you. Awesome. All right. So I'll sort of give you my rants and we'll see ranting and then we'll sort of talk about how that can impact what you're all doing in your different but interrelated portfolios. So I think you can all see the slides now. So it's nice to see you all coming at this from a slightly different angle. So I will sort of give you the reason why healthcare quality has become such a big deal over the last two decades, really. So this was a New York Times article that came out about 10 years ago, which said the $2.7 trillion medical bill colonoscopies explain why the U.S. leads the world in health expenditures. So it's a really tough thing to wake up to if your career is gastroenterology to realize that you're the reason that the whole healthcare system is failing. But why do they say that, right? What brings us to that point? Well, it's because of price variation, right? So if you look at the prices of the procedures at that time, for example, an angiogram was $900 in the U.S. and it was $35 in Canada. And Lipitor was like 20 times more expensive in the U.S. than New Zealand. And colonoscopies are twice as expensive in the U.S. compared to Switzerland. So the question is, are colonoscopies like twice as good as they are in Switzerland? Are we that much better at getting to the CECM? Or is there just a lot of added costs to our healthcare system that are difficult to take out, a lot of waste? And so I think, did someone say they're from Nashville? I am. Yeah, yeah. So at this time, Nashville, you could get a colonoscopy for $2,000. This was 10 years ago. But if you lived in New York, that same colonoscopy was $8,600, right? So a fourfold variation. So if you're anyone who's interested in health economics, and you're like, you're sitting in the government, you're like, that seems weird, like, why, as a Medicare person, am I paying four times as much for a colonoscopy in New York compared to Nashville? That colonoscopy must be amazing in New York, right? But they're all the same, right? So whenever they see the price variation, people start to get worried that perhaps that this variation in cost is not any associated variation in outcomes. And part of the reason for that is just variation of things like anesthesia care, right? So we can superimpose anything that you're all working on, on this graph, right? So we can pretend, you know, is AI used more in the Northeast, but not in the West? Are the patients in Northeast, do they need AI more? Is stool-based testing used more in Midwest compared to the West? Is it because the Midwest, they have better stool, and that's why they get tested there? Like, it doesn't make sense. You know, for disposal devices, we see variation in hot snare versus cold snare, all these sort of things that people do differently. And these variations are generally things that are where there's waste. You're seeing things that are not appropriately utilized. And you know, out of a typical government dollar, about 23 cents of it is spent on health care expenditures. And since we're spending about a trillion dollars a year on health care expenditures, that's a lot of money that's going towards, you know, our tax money that's going towards health care. So everyone wants to figure out, is it going the intelligent way? And money just keeps going up, up, up, up, up. We keep spending more. It's amazing. And we spend more, about twice as much as the comparable average country. So even though we're spending a lot, in general, we're spending a lot compared to our peers, and that's what makes people wonder, are we getting the bang for our buck? And when we talk about the bang, we're not always getting the best health care. We're ranked 11 out of 11, you know, this is an old slide, 11 out of 11 in health care outcomes, but one out of 11 in cost. It's a bad place to be, right? And so why does that happen? Why do we spend so much, but then get little? All right, so I will ask you, Christine, because you have the best looking office of all of us. It's not real. You're the mayor of Tucson, okay? And Tucson has a horrible rattlesnake problem, right? They're like everywhere. And you're like, I need to get rid of these rattlesnakes, I need to get people to help me get rid of the rattlesnakes. How am I going to do that? So what are you going to do as the mayor of Tucson to get people to get rid of rattlesnakes? Because it's causing all your tourism dollars to go down. You're going to incentivize people to help you get rid of the rattlesnakes. So is that going to solve the problem? Are all the rattlesnakes going to go away? No. What if you give everyone $100 for each rattlesnake they kill? That's going to help the problem. I'm sure you won't get rid of all of them, but it'll significantly reduce the rattlesnakes. Yeah, so get rid of them and get rid of them and get rid of them. And then what starts to happen? I mean, Medtronic pays well, so Stacey's having a good life, but she's like, actually, I can kill like 50 rattlesnakes a day and I'm crushing it. I'm going to leave my day job. So when you incentivize people to do something like this, unless you care about the end outcome, which is getting rid of the rattlesnakes, you said I have to give you $10 or $100 for each rattlesnake. Stacey's going to start breeding rattlesnakes. That's her job. Instead of just killing the ones that are there, she's like, it actually makes more sense for me to just breed more rattlesnakes and get rid of them. I'll breed them, kill them, and get a quick $100. So you need to always incentivize for what you want. If you, Christine, incentivize $100 for each rattlesnake you kill, not understanding the end result is I want no rattlesnakes, people are just going to build rattlesnake farms and wear rattlesnakes everywhere because they're just going to want to do more volume. And this is the fundamental problem in healthcare. Everyone is incentivized to do more colonoscopy. They're not incentivized to get rid of colon cancer. That's not the individual practitioner's financial incentive at the minimum. And this is that idea of the tragedy to commons, which is that we have a shared research resource, which is healthcare dollars, and everyone is a little bit in for themselves. So like Alexandria comes in, she's like, I'm going to, you know, I have a little cow here and I'm going to raise this cow and make a little money for my family. And then Stacy comes in with her cow and Christine comes with her cow, and everyone's like, oh, there's a lot of money being made here. Let's just keep raising more and more cows. And the whole time no one's thinking like, hey, there's a limit to how many cows we can have on this farm. Like we're sharing this land, but everyone's in it for themselves. No one's thinking about what they can do. And eventually what happens is everyone just like goes crazy, just raises more and more cows. And eventually the shared resource, which is our healthcare dollar, goes away, right? In this case, the analogy is the shared resource, which is the land, right? It all goes away. And this is the tragedy of the commons, which is that if you incentivize people to only care about themselves and not the greater good, which is unfortunately a lot of what gastroenterology is right now, right? So some of you are on the side of population health, and some of you are on the side of individual practitioner. Population health is, hey, all of us can't do like 8,000 screening colonoscopies a day. That's probably not a feasible way to get to eradicate colon cancer. But if we use colonoscopy with stool-based testing with AI, I might be able to say, you do one colonoscopy and you're good for 30 years, that's great. But is that how I'm incentivized as a gastroenterologist, right? I'm incentivized to bring the patient back the next day and do another colonoscopy. So there's a disconnect there, and that's this idea that everyone's doing it for themselves and sort of utilizing this shared resource in some ways to ruin, right? We're each pursuing our own best interests, and we essentially will use up that shared resource. And that's why we can't just focus on healthcare outcomes. So it can't be that, Alexander says, I have this great thing that is going to just massively improve your, pick a device, Alexander, what device have you been interested in recently? The cold snare. I have the X-ACTO, correct? I have the X-ACTO cold snare. It's going to be awesome. And you're going to love it. And everyone's like, wow, this is a great device. It reduces adverse events, gets the polyps out. And Alexander's like, all right, it's $10,000 a snare, right? And she's like, loving it. And as a physician, I'm not paying the $10,000, so I love it as well. But the value that you're getting over the other snare for that cost is very minimal. So you can't just look at outcomes, you have to look at the dollar spent and the outcomes. Problem is, it's very difficult to do that for most things in medicine. We have trouble measuring even the most basic healthcare outcomes. And so trying to measure outcomes over dollar is very challenging. But the area that you're all relatively similarly interested in, which is colon cancer prevention, this is where that value-based analysis has to be, right? It goes from cold snare, which is sure that you may get a little less reimbursement for cold versus hot, but the adverse event rate is lower. And you can do it on patients who are on their anticoagulation, all these sort of things you can think about to help you make that value proposition. And so when you think about the outcomes, and we talked a lot about the dollars, and I was very negative about the dollars we spend. The outcomes are also very important, but it's not just the effectiveness, right? Not just how many polyps you find, it's not just how many cancers you prevent. It's this whole continuum of care is quality care, right? So quality of care includes effective care, which is what most gastroenterologists think about. When I think about my ERCP, I'm like, did I get into the bottle to remove the stone? But it's not just that, right? It's that the care is also safe, right? So that the adverse event rates are low, and it's timely. And so if I'm promoting colonoscopy as king, but it takes two years for a patient to get a colonoscopy, then maybe the person who says, I can get you a stool-based test tomorrow, has a very good argument why stool-based testing is more timely in high quality care. Efficient care, can you do it, if I do one colonoscopy a day, it's not very efficient. Equitable is my, am I just offering care to people that are English speaking and insured, because that's just where my target audience is, or that's where the ability to deliver this new technology is like robotic surgery, all these things that tend to just get put into upper echelon hospitals. So that's the question of equitable care, are we really distributing care evenly? And then patient-centered, do you know what the patient actually wants, right? I'll sort of dive into the stool-based testing versus colonoscopy. I think colonoscopies, if everyone agreed for the procedure and you had only high quality colonoscopists do it, I think colonoscopy would do better than stool-based testing at preventing colon cancer, it's very clear. But that's everyone has to agree to do the procedure, which most people won't, right? Because that's not being patient-centered, right? Patient-centered means you take into account what the patient wants and understand their value systems, right? And so that's part of quality of care. You need to understand what they want in their care as well. And so I think that that's something for you to think about when you're talking about what's in your industry. When you're talking about quality, you don't just have to think about the effectiveness of the care, you have to think about all these sort of factors. And from a procedure's perspective, it's really a wide variety of things besides just adenoma detection, right? How many polyps you find, right? It has to do with all these ideas, population screening, patient satisfaction, cost per procedure, adverse event rates, all these things you need to be thinking about when you're talking about your new medication device, a laboratory test, are you meeting these metrics of quality at a cost that's reasonable for the healthcare system? And the reason that we even have these discussions is because quality does vary between providers, right? So if you ask most providers, you say, how are you at colonoscopy? They're all like, I'm amazing. Like, I'm just so good, it's weird. And that's great, but that's probably not true, right? Most people are not, by definition, not everyone's above average, unless you, you just like to skew the data a little bit. What the data would generally look like is that there's some below average, some average, some above average performers, right? And so when you have this variation in care, we know it's out there, but until you measure it, no one believes it, right? And so when we measured ADR a decade ago, and everyone probably thought they were above average, but there was a market variation in actual performance, right? Some people were ADR of 10%, some people 50%, but until you measured it, no one was going to really know where they stood on this curve. And that's why quality and gastroenterology is so important because there is this technical skill variation for all of us, right? We also have this, someone is better than someone else at XYZ procedure, and we have to account for that when we think about quality of care and the healthcare system. So what do I sort of dive deeper into that, right? So Alexandra, you have a friend, unfortunately, or an enemy, you have an enemy that was diagnosed with early stage pancreas cancer, right? But for unclear reasons, your enemy asked you to come to the clinic visit with them to see the oncologist, right? And your enemy, you're a good person, so you don't want your enemy to do poorly, by the way, so make this clear, your enemy is offered drug A or drug B for their pancreas cancer. So what kind of questions are you going to ask? Which one has the most high likelihood that they will have a quality of life over an extended period of time? That's kind of like nine questions lumped into one, but- So the quality of life, maybe safety, which builds in safety, outcomes, all those things, right? A lot of patients will ask, how likely am I to live? Tell me, if I take this medication, am I going to do well or not? And for those of you who ever came from a pharmaceutical background, this is a super normal thing to talk about, right? This test, what's my likelihood of living? But when you change drug A and drug B to endospice A and endospice B, it becomes much more of a black box. Everyone is like, oh, no, we are all the same, it's all, I'm going to get a colonoscopy, you're going to see one of our 50 providers, you're just going to show up, you're going to have no idea what their adverse event rate is, you have no idea how much they find polyps. None of these sort of quality metrics are really advertised for physicians who do procedures. We're used to it with our medications, we're just not used to it with our procedures. And so that's why, in this sort of partnership between industry and physicians, we need to start to think about how do we get everyone to perform at a good enough level? Because I'm not sure we're going to be able to change the system to where patients and providers are going to be openly sharing outcomes data. We've tried that before, where there's been publication of outcomes data. I think I'll show you a slide in a little bit. When you look at outcomes data, it's very confusing for patients, because there's just so much uncertainty. So the big thing is to understand that there's a quality difference, and then try to get everyone to be at least good enough. Because we're not going to get rid of endospice B, we just have to make endospice B better and be more like endospice A. So all of you are in the colonoscopy space, at least to some degree, and you understand that the reason that this ADR or colonoscopy effectiveness is so important is that people who get a colonoscopy of someone who's low quality have a five times higher likelihood of developing colon cancer than someone who's a high quality colonoscopist. And that's because when you get a low quality colonoscopy, you're probably missing a precursor lesion called an adenoma, and that eventually turns into a colon cancer. So we think most cancers diagnosed after a normal colonoscopy are due to diagnostic errors, missed adenomas. A portion of them are diagnosed due to incomplete polyp removal, but most of them are due to missed polyps. And again, what is an ADR? I think some of you said you're new to the space. So an ADR is just something important to really get in your head. It's a pretty easy concept, right? So Dr. A, he sees 100 patients and finds adenomas in 15% of them, 15 of them. That's a 15% ADR. That doesn't seem very good, but the reason we know it's not good is Dr. B could have seen the same 100 patients and she found adenomas in 45 of them, or 45%. Her ADR is 45%. What that means when you actually think about it is you can't actually do this. You can't have them see the same 100 patients, but on a large scale, you really know that what that means is Dr. A probably missed polyps in 30% of his patients, right? Because he's finding polyps only 15% of the time, whereas Dr. B, she's finding polyps 45% of the time. And that 30% difference translates into Dr. A's patients developing colon cancer more frequently down the line than Dr. B. So until you measure that variation, we can't impact it. But again, each 1% increase in ADR is associated with a 5% disc decrease in the risk of fatal interval colon cancer. Every time you get someone's ADR to go up by 1%, the risk of dying of colon cancer goes down by about 5%. And so I'll close before we do questions on why outcomes reporting is controversial, right? We talked so much about measuring ADR, which is great, but there's so many other outcomes you might say you want to measure, like, oh, we should measure colon cancer rates after colonoscopy or post-polypectomy bleeds if you use our snare versus another snare and all these things. For a lot of these things, it's really hard to measure outcomes. So this was ProPublica, which tried to measure outcomes after gallbladder surgery to guide patients. And so Christine's like, I'm going to get my gallbladder taken out just for fun. And I'm going to try to find the doctor who has the best safety profile. So she pulls up this website, and she's like, ooh, Dr. A's complication rate is 3.6%, Dr. E is 4.8%. But if you look at what's called a confidence interval, which is the range at which their complication rate could plausibly be, we call this a 95% confidence interval, it varies between below average complication rates to above average. Because when you only measure something 50 times, you could be getting statistical noise to say someone is better than someone else. You have to measure something closer to 200 times to really get a good sense of how you perform relative to someone else. So not everything can be measured on this outcomes level. We're lucky that ADR can be, because colonoscopies are pretty common. But if Alexander's trying to figure out post-polypectomy bleed rates, they're pretty uncommon in general. So showing that a cold snare is going to be better than a hot snare takes a huge study. And so the safety studies are difficult. Christine wants to show stool-based testing, and I got that right, you're doing stool-based testing, Christine, exact? She wants to show stool-based testing is easier than colonoscopy, and it's easy. There's so many people out there. She could run a trial of 10,000 people in three days. I mean, probably not that easy. But it's a lot easier. But some of us are working in spaces like ERCP, things like that. It's a much harder thing to show outcomes. So we have to sort of think about what other factors we can measure to try to improve quality. So I pontificated for too long, so I'm trying to leave five to seven minutes sort of on that framework of what we talked about to sort of see what questions you might have. Anyone sort of resonates with them or disagrees with everything I said? I love your candor. It's great. The slide you showed with the, we were number 11 of 11, the outcomes versus the cost. What was the outcomes based on for the outcomes? Going back. Was it just cost? Was it death? It's really old, though, right? Oh, sorry, no, no. The outcomes are based on, I'm just saying, no, no. We're 11 of 11 on cost. We're on the quality of care, like that's effective care, safe care, coordinated care, patient-centered care, efficient care. What we really do bad about, to be fair, is things that we know we do bad about, which is like you're all presumably well-insured with your well-heeled companies that give you good insurance, but there are people in America who are underinsured and uninsured who have very poor access to care. And so that brings our rate down. It's maybe, again, to editorialize, I'm a huge believer in AI, but if you had to ask, should I pay for AI for a colonoscopy, or should I take that same money and go to an inner-city federal health care, FHQC, which is a lower-income clinic, and just try to get people to the first colonoscopy ever, or get them to stool-based testing, the money is probably better spent on the people who have no care at all versus making someone go from an ADR of 45 to 55%. So it's our disparities in care that occurs that you've heard a little bit about. That really puts us down low. We spend a ton of money on the same people, end-of-life care, cancer care, and then not enough money on the stuff we really need to, which is upfront care and people who don't get care at all. Yeah. And you can make an argument for driving the ADR increases in those lower-served patient populations as well, like give the AI to the physicians who are not trained in GI and are doing colonoscopies. We've made those same arguments, but that's a great point. It's like, where do you spend your money? It's just not what usually happens, right? What usually happens is people who are great get even greater, and people who are not doing so well just get nothing. But that is part of the reason you all did that program to get AI in places that are underserved. Yeah. Equity. Yes. Yeah. I was hoping that Dean and I would talk more about outreach, because it's not even just, even from stool-based testing, it's just hard to reach these people. And there's a lot of biases and fears, and it's very taboo to talk about your stool. It's just a lot, let alone go through a prep. And like I said, having been an endoscopy nurse manager and being on the other side, it's just very complex. Yeah. So what are we doing to actually get to them? And that's where I feel like there's a huge disconnect all over. It's the population health question, which is what we try to follow here, right? And so you, in your role, want to work more with primary care, which is more in tune with population health, and sort of the heads of quality of the healthcare systems who are also in tune with it, rather than the GI physicians who are not very good at population health. And the FQHCs. Yeah, exactly. Getting people who are not getting access to care. The problem is that the individual providers are not incentivized on population health in general. Primary care, some places they are, right? So some places, the primary care panel, they'll say, you know, your patients are not getting colonoscopy or colon cancer screening at a high enough level, and your bonuses will be less, right? So part of your job is to try to incentivize people to get these life-saving care. It just changes the approach. In GI society, and, you know, I put Vanessa at fault for this because she's in charge of ASGE. You know, GI society is very focused on individual patient outcomes, and not enough on how we're doing as a whole to sort of reduce the disease burden. And so I think you're completely correct. There's people out there who care. It's just getting in their offices that are important. I will say here, you know, just from a perspective of how you get people in, there are obviously ways. Nurse navigators, I think, are going to be a really key thing for all of these things, which is shepherding someone from their doctor recommending a test, making sure they get the test. And if they get a test that's not colonoscopy, then making sure they prep well, and then making sure once they come to the colonoscopy that they follow up after that, all these sort of things. I just think there's certain people that are underserved that get really lost in the system. And I think all of these things can work together, but it takes a particularly motivated endoscopy group, sorry, medical group to do this. I wonder what the data would be now, because I mean, this is, you know, 2014. Yeah, I don't think we're doing that much better. I think I looked it up last week to update the slide. We haven't fundamentally changed much, except we have better insurance now. We have more people who are insured, but I'm not sure that people who are insured are getting preventive care to the level they should, right? So we still have that issue of sort of people not getting, you know, I haven't looked at this. I'm sure there's a study that come up. I'm sure when you look at moving colonoscopy up to age 45, everyone who's getting colonoscopy at age 45 is well insured and sort of already very big advocates of health. We still have people who are not getting their colonoscopies at all. So it's a tough thing.

quality in healthcare

colon cancer screening

measure and improve quality

cost variation in medical procedures

incentivizing healthcare providers

Adenoma Detection Rate (ADR)