As realities of gastroenterology practice shift, GIs have an opportunity to use endoscopic therapies to address root causes of conditions they already treat.
This article first appeared in the October 2016 issue of HealthLeaders magazine.
As Hippocrates is believed to have said, "All disease begins in the gut."
And although not classified as a disease by the American Medical Association until 2013, obesity can be a chronic condition for which gastroenterologists have an opportunity, if not obligation, to intervene.
"Gastrointestinal manifestations of obesity are often the first presentation outside of some of the mechanical problems with being obese. Very often, reflux and fatty liver can present even earlier than diabetes or cardiovascular disease," says Sarah E. Streett, MD, chair of the American Gastroenterological Association (AGA) Institute Practice Management and Economics Committee and clinical associate professor of medicine at Stanford University School of Medicine. Streett also oversees AGA obesity-related initiatives.
According to the National Heart, Lung, and Blood Institute, normal weight is defined as having a body mass index (BMI) between 18.5 and 24.9.
A BMI over 25 is considered overweight, while 30 marks the threshold for obesity and more than 40 is considered extremely obese.
More than one-third (37.9%) of adults in the United States age 20 and older were obese in 2014, according to the Centers for Disease Control and Prevention, while a full 70.7% were considered overweight or obese.
"These are the folks that are already in our clinics for their heartburn or their fatty liver," says Streett.
"Obesity is also a risk factor for most gastrointestinal malignancies, so we have an opportunity to step into this interdisciplinary space and partner with our primary care doctors, with our bariatric surgery colleagues, and with our endocrinologists to actually address the root cause of what's underlying a lot of our patients' digestive disorders."
Thanks to advances in endoscopic and other noninvasive therapies, gastroenterologists today have more tools in their arsenal against excess weight than ever before.
As of late 2015, two endoscopic weight-loss devices, both intragastric balloons, have approval from the U.S. Food and Drug Administration. In addition, newer options for endoscopic procedures include endoscopic sleeve gastroplasty and intragastric Botox.
The population of patients who may benefit from such non-anatomy-altering procedures is vast.
For starters, there are the scores of patients who meet clinical guidelines for bariatric surgery—generally a BMI of 30 with diabetes and 40 without—but never make it to the operating room.
The American Society for Metabolic & Bariatric Surgery reports that approximately 150,000–200,000 bariatric surgeries are performed every year, representing a mere 1% of the population eligible for weight-loss surgery.
The reasons patients choose to forgo surgery include fear of complications or death, fear of judgment, or belief that the operation won't help them lose weight, says Vivek Kumbhari, MD, assistant professor of medicine and director of bariatric endoscopy at the division of gastroenterology and hepatology at Johns Hopkins Medicine in Baltimore.
"There's an enormous disease burden that's being underserved," he says.
"Unfortunately, I have encountered patients who aren't qualified for bariatric surgery because they are underweight and were told to gain a few pounds to qualify for bariatric surgery," says Anthony A. Starpoli, MD, a solo practitioner at Greenwich Village Gastroenterology with locations in New York, and Poughkeepsie, New York, and attending physician at the 652-bed acute care Lenox Hill-Northwell Health Hospital in Manhattan, Beth Israel Medical Center, and NYU Langone Medical Center.
"How crazy is that?" he asks. "This is where I believe the gastroenterologist has almost a fiduciary responsibility to have programs in place to start addressing weight issues at an earlier stage of the disease."
In addition to treating all of the conditions traditionally handled by gastroenterologists, such as heartburn and abdominal pain, and performing colorectal-cancer screening, Starpoli offers comprehensive weight-loss services, including balloon placement, gastric bypass revision and repair, nutritional and behavioral counseling, and more.
Success key No. 1: Embrace obesity
When it comes to office-based gastroenterologists taking on obesity directly, Starpoli says he's considered an early adopter.
But to him, addressing the mechanical problems behind conditions he sees every day just makes sense. "How can you treat a reflux patient if you don't address their weight?" he says. "As GIs, we put them on the purple pill and we put them on this and that pill—and these pills don't really do everything."
From a business standpoint, it's also in GI physicians' best interest to broaden their services. "Frankly, looking out at the horizon, if you're banking your future on colorectal cancer screening, you've already lost," Starpoli says. "It's a very commonplace thing. There's no real new skill set involved, and I'm all about adopting new skill sets."
While Starpoli has taken the initiative to learn many skills around obesity management on his own, he suspects that gastroenterology fellowships may soon begin to incorporate endoscopic weight loss.
"The nature of these newer endoscopic, incisionless, surgical-like procedures warrants a hybrid training model, which includes GI endoscopic principles, and the learning of surgical principles and anatomy," he says.
The AGA, recognizing the shifting realities of gastroenterology practice, is working on helping more practicing physicians get involved now, with its first comprehensive guide for obesity and weight management.
The resource, titled POWER: Practice Guide on Obesity and Weight Management, Education and Resources, has been accepted for publication in 2016, and will also become available on the AGA website as a resource. The objective of the guide is to provide gastroenterologists with a comprehensive yet adaptable multidisciplinary process to direct innovative obesity care for safe and effective weight management for patients.
A follow-up whitepaper will address the financial aspects of the model, according to Streett. It will outline "what this might look like on a nuts-and-bolts level to a GI practice and to the GI practice's partners, whether they are hospital-based service lines that are already in place or something that the GI creates on his or her own," she says.
"The POWER program is designed to be flexible so that in different parts of the country, depending on what resources are available, if you're a gastroenterologist, you can develop the structure and tools to address patients' obesity in the context of their digestive disorders."
Success key No 2: Team up
The treatment of obesity is quintessentially multidisciplinary, so strategic relationships make sense, notes Streett.
The vision behind POWER is to guide gastroenterologists toward a model that works for them, which may involve joining or partnering with a practice already offering weight-management services or, for larger practices, building a team of their own, says Andres Acosta, MD, PhD, an assistant professor at Mayo Clinic in Rochester, Minnesota, and lead author of the POWER working group.
Regardless of how it's configured, weight management is best provided by a team, says Acosta, including an internist or primary care physician, bariatric surgeon, behavioral psychologist, dietitian, an endoscopist, and perhaps an endocrinologist.
"Gastroenterologists can join this team with endoscopic devices as their tool to contribute to the team and the practice," Acosta says, "or they can serve as the primary physician and invite, partner, or contract with other team members."
Opportunities in this space abound for hospitals as well.
"Every academic center really should have a weight-loss service line," says Kumbhari. Johns Hopkins Integrative Medicine & Digestive Center in Lutherville, Maryland, a part of the Johns Hopkins University School of Medicine, division of gastroenterology and hepatology, has been in operation since 2013.
"It's a critical part of patient care. And if you think about it, you're treating the source of multiple comorbidities. From a patient-health perspective it really makes sense to have a weight-loss center of some sort as part of a hospital."
His long-term vision for the weight-loss center is to have all services centralized in one building housing a nutritionist, behavioral psychologist, exercise physiologist, internal medicine physician, an endoscopist, and a bariatric surgeon, Kumbhari says.
"And basically a patient would come in saying, 'I want to lose weight. How could you help?' and they'd be seen by one or two providers and then make a decision to commit to some sort of weight-loss program. That's the vision Johns Hopkins is working toward."
Despite having vastly more resources than a private practice, there are challenges for hospital-based systems in managing the many moving parts of a weight-loss center.
"Different divisions have their budgets and abilities to raise revenue. And when you're thinking about a multidisciplinary program, it's a challenge to bring different divisions together who have different finance groups into one center. To divvy up the revenue generated is very challenging," Kumbhari says.
To make the finances work, hospitals must have one account that is controlled by one division (the GI division, in Johns Hopkins' case), he says, and then distribute revenue to respective parties, such as a nutritionist, endoscopist, and anesthesiologist.
"The issue with us is that usually this same division is the one that takes on the 'risk' by buying the minimum product, setting up the center, marketing, and so on."
Success key No. 3: Don't be scared off by reimbursement issues
While many payers now cover obesity screening and counseling, some weight-loss medications, and bariatric surgery for those who qualify, most middle-ground endoscopic procedures are not reimbursed.
"The main barrier to dissemination of endoscopic weight loss is the fact that insurance companies are not covering it," says Kumbhari.
"If they did, I would be doing endoscopic weight loss procedures all day, every day, because there's a significant disease burden," he says. "So as a GI community and as a weight-loss community and as public health professionals, we need to lobby together to have these endoscopic procedures covered."
In the meantime, service lines can thrive serving those willing to pay out of pocket. According to Kumbhari, such patients are usually between ages 25 and 70 and have a combined household income of about $85,000.
While $7,000 or more for a gastric balloon, band, or sleeve may sound steep, it's on par with amounts Americans already spend trying to lose weight.
"Keep in mind that when somebody joins Jenny Craig or a similar program, they spend $300 or more per month in meals—in perpetuity," Starpoli says.
Nonetheless, the AGA is committed to push for better reimbursement, but encourages providers not to be scared away from self-pay business.
Success key No. 4: Get the word out
With the need for weight-loss services so grossly underserved, competition isn't really a problem for the Johns Hopkins center, which gets much of its business from the institution's 30,000 employees alone.
To help referring physicians learn about the center's offerings, Kumbhari speaks at medical grand rounds to specialists including endocrinologists, orthopedic surgeons, and obstetrician/gynecologists. "There are many women who struggle to conceive because of weight issues," he says. "If you go to those healthcare providers, you should start to build up a service."
The Internet represents the most important means of funneling patients interested in weight loss toward a service line. But website optimization isn't enough, according to Kumbhari.
"Once they find you, I think it's important to have a capability for patients to immediately interact," he says.
"People who are interested in services such as ours are professionals sitting at home late at night looking at options. If you have a 24-hour live chat, which we're looking to implement, or a phone line that is able to respond quickly, I think you will capture those patients."
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.