Endoscopy centers meet pandemic challenges with resilience, determination
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Endoscopy centers have encountered significant challenges long before the COVID-19 pandemic started. Reimbursement for endoscopic procedures has gone down significantly in recent years while practice costs have increased. Given the realities of a complex and costly U.S. health care system and rising national debt, these trends are likely to continue. Adding pathology labs and anesthesia services as ancillary revenue streams has helped endoscopy centers in the past, but many of them have now exhausted these opportunities and are left with few mechanisms to compensate for the rapid narrowing of profit margins.
The pandemic has further accelerated this challenge. The business profile of an endoscopy center, similar to the airline industry, is that of a high fixed cost, low variable cost operation. As such, centers are dependent on high throughput of patients to maintain steady cash flow and healthy margins. When the COVID-19 pandemic led to mandatory shutdowns of elective medical interventions, including GI endoscopies, this model was suddenly and profoundly challenged. Endoscopy centers had to quickly develop mechanisms to reduce expenses and to repair revenues through retooling of workflows and by expediting the safe reopening of endoscopy units as quickly as feasible.
This provided us with a powerful reminder, if we needed one, that in this time and age, we are no longer able to run our endoscopy center as a convenience operation. Instead, we need to invest in professional management, either through partnerships with other organization or via hiring experienced administrators who can work with their physicians on optimizing the efficiency of endoscopic operations. Most endoscopy centers continue to have significant opportunities to optimize their efficiencies, keeping their schedules filled, minimizing cancellations due to poor bowel preps or for other reasons, and establishing mechanisms to quickly fill vacant slots at the last minute to allow those extra exams at the end of the day at a low variable cost. Making these adjustments and putting endoscopy operations in a position where they can quickly and effectively respond to sudden unexpected calamities and crises requires an investment in solid professional management.
Increase Use of Non-endoscopic Testing
One critically important issue with long-term impact relates to the procedure backlog that has accumulated as a result of endoscopy center shutdowns. Colonoscopy is the most commonly performed GI procedure, and its widespread use has been a major factor in the decline of colorectal cancer in this country. With endoscopy unit shutdowns for several weeks in 2020 and persistent reductions in procedure volumes in many centers due to the ongoing pandemic, some centers have accumulated procedure backlogs of several thousand procedures. Some groups are also reporting staffing shortages and challenges with rehiring a highly specialized workforce that experienced layoffs and furloughs during the earlier stages of the pandemic. As endoscopy centers develop strategies to triage backlogged patients and provide a higher priority to symptomatic and acutely ill individuals, some of them have begun resorting to noninvasive stool testing as the preferred option for screening asymptomatic individuals for colorectal cancer. This is not an unreasonable approach. While some believe that colonoscopy should be the preferred test, randomized trials comparing the two approaches are still pending and are not expected to yield final answers for a few more years. At this time, if endoscopy capacity is limited and a programmatic application of stool testing with reliable follow-up can be assured, it should be considered a viable alternative. My personal preference in this situation is the standard fecal immunochemistry test (FIT) which is inexpensive and has been well studied. Leaving some specific situations aside, there are no convincing data to prove that more expensive DNA stool testing is superior for the purpose of general CRC screening.
Future Predictions
With apologies to professional baseball catcher, Yogi Berra, “it is tough to make predictions, especially about the future.” But one thing seems clear: Consolidation in health care is bound to continue! Hospitals and insurance companies have already consolidated, not always for the benefit of patients. While better coordination of care has been touted by hospitals as a driving factor, the main consequence to date has been a stronger negotiating position of large health systems and thus higher prices. GI practices have realized that practice consolidation allows for spreading costs over a larger entity. Under the leadership of Jim Leavitt, MD, Gastro Health in Miami, Florida, has been the pioneer in our field for promoting private equity funded GI practice mergers, starting with their transaction with the Audax Group in 2016. This trend toward larger GI practices will continue. Twenty years ago, practices with 10 and more providers were considered large. Now, the GI Alliance, under the leadership of Jim Weber, MD, from Dallas, Texas, includes several hundred physicians.
Artificial intelligence will soon be considered a standard component of any high-functioning endoscopy unit and will serve to increase efficiencies, quality of care and patient service. And endoscopes may finally see some significant technical innovation. Since Gene Overholt, MD, developed the flexible sigmoidoscope in 1961, the steering mechanism has not changed much although the optics are much improved. In the near future, we will see wide-angle cameras that allow us to view a full 230 degree circumference of the colon (ie, look behind mucosal folds while simply performing a straight withdrawal of the endoscope), and, who knows, maybe some innovative changes to steering mechanisms as well.
The future of GI endoscopy is indeed bright. Endoscopy centers will continue to play a critical role in this future, and we will come out of the current pandemic with many learnings, with resilience and with determination.
- For more information:
- Klaus Mergener, MD, PhD, MBA, is president of the American Society for Gastrointestinal Endoscopy and is affiliate professor of medicine in the division of gastroenterology at the University of Washington School of Medicine.
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