In this interview, learn how a multispecialty GI group made a decision to ally with a regional hospital. Understand what steps PACT GCC took to navigate COVID-19 and what they are doing now to continue endoscopies safely. More importantly, Dr. Alaparthi reflected on how there could be more women in leadership positions in gastroenterology. And how physicians must take care of themselves first.
Praveen Suthrum: Hi Dr. Latha Alaparthi. Thank you so much for joining me today and I welcome you to our conversation.
Dr. Latha Alaparthi: Thank you. Thanks for having me.
Praveen Suthrum: You are part of the Gastroenterology Center of Connecticut and also the Vice President of DHPA (Digestive Health Physicians Association). So, I want to begin by asking you to share a little bit about your practice.
Dr. Latha Alaparthi: Thank you again Praveen for having me. I have listened to some of the other speakers on this and it’s very informative. So, I hope I can be useful to whoever is tapping into this. So, I joined the group in 2001, I actually met the then program director as part of my program at Yale-New Haven who was actually one of the three physician groups that founded this company – Gastroenterology Center of Connecticut. So, he recruited me to the group and I’ve been with the group since 2001.
The group is grown from a three-member group. By the time I joined it was a seven-member group. I was the seventh person. And now it is at 13 and soon to have three new physicians to be joining us from different parts of the country, including one of them being a Yale-fellow (New York) and one that’s transitioning from California to us. We’ve had some physicians who have joined us and then moved to different parts of the country. But we are 13 at this point and have three more joining us in Connecticut.
Praveen Suthrum: Okay. So, I know that there is a relationship between GCC (Gastroenterology Center of Connecticut) and the group called PACT (Physicians Alliance of Connecticut). Can you clarify what the relationship is?
Dr. Latha Alaparthi: Sure. Gastroenterology Center of Connecticut was an independent PC since founding until 2013 when it became part of the multi-specialty group. We’ve had a close affiliation with the Yale hospitals in terms of admitting our patients, taking care of our patients, teaching obligations, and appointments. In 2012, around that time it became clear that many hospitals, including Yale, were acquiring primary care groups in the area… which was troubling to us. It was troubling because that’s how we get our referrals. And one of the things we wanted to do is to make sure we stabilized our referral base. And one of the founding members along with a few in the community decided to brainstorm forming a group, that allows us to remain independent and secure at least part of our referral base, not all of it, but at least a good part of our referral base so that we don’t feel so threatened.
Praveen Suthrum: Did that happen? Did you secure your referral base?
Dr. Latha Alaparthi: Definitely. It has made us feel more secure. As I said before, it is not that all the referrals are coming from this group but majority do. And it definitely helps us in terms of feeling more secure.
Praveen Suthrum: So, this is a multi-specialty group versus a single-specialty group. What are the pros and cons of being in a multi-specialty environment as a gastroenterologist versus being in a large single-specialty group?
Dr. Latha Alaparthi: So, when PACT formed, it had internal medicine, gastroenterology, nephrology group in the beginning, and then its surgical group joined our group and more recently orthopedics. Majority of the physicians were for internal medicine. The way the group was formed was to make sure that the primary care physicians were always given enough of a voice to impact the long-term process of the company. Because that was really our main intention, to make sure that they were stabilized in order to help us stay secure with our referral base. So, initial issues with the company were just really learning to work with multiple physicians rather than running our own company.
So, if you can think of running a GI group versus a primary care group, they’re completely different. When you’re forming an MSO, a billing group that now has to cater to not only colonoscopy codes but also nursing home codes, that becomes a challenge. So, there was a significant amount of learning in that perspective. Plus, the electronic medical record system had to be catered to different types of visits. So, all that posed its own challenges. So, those I would say are the main challenges, learning to work with other physicians but in general, we learned a lot definitely in the first four-five years. Everything from day-to-day visits to navigating through HR, to billing, EMR, we had to almost start from scratch and build it up.
Praveen Suthrum: How did you manage to divide the cost and responsibilities because, like you said it’s two different worlds, and GI as a specialty is procedure-driven, primary care as a specialty is not as procedure-driven, so the earnings are different. How did you figure out how to work on the costs of the MSO?
Dr. Latha Alaparthi: So, MSO is based on the fee structure and the fee is the same. Our endoscopy center is not part of PACT. It’s actually completely separate from the medical practice. It is still a very much physician-owned entity. We have currently a four-room ASC in two different locations of our practice. So, in terms of cost allocation in the beginning there was a little bit of a give and take. Some units needed more help in certain areas and not others and vice-versa. So, in the end, I think it was a trade-off. For example, some primary care groups were on paper charts and they had to convert to EHR completely so that took a significant amount of time in the beginning. But in terms of this individual cost allocations, it’s all completely kept separate.
Praveen Suthrum: You’ve recently made a big decision to join Hartford HealthCare Medical Group. So, that’s a sea change from probably the existing structure or any of your previous structures. So, I was curious to know how you went about with your decision and the story behind that.
Dr. Latha Alaparthi: That’s a very good question and a tough one to answer in a small-time format but I’ll do my best. We, historically as you can think of are in the greater New Haven area catering to Milford New Haven suburbs and into the Guilford, Branford area along the shoreline. So, historically our practice has always been at the Yale-New Haven entities. We still are very much affiliated we have teaching affiliations; we have leadership positions at Yale-New Haven Hospital. What became clear for PACT is for it to align with an entity that would allow us to remain independent. And what PACT has been able to secure at this point is an ability to continue to remain independent with our structure and MSO intact. So, what we have done is to create a professional service agreement that allows us to remain independent and I’m really hoping that this will be a structure that will be alive for many years to come because I think it is very important for a group like ourselves who fiercely protect their independence to remain so.
Praveen Suthrum: Did Hartford have similar agreements with any other group in the region?
Dr. Latha Alaparthi: Well, as I understand, there are PSAs with groups but this is their first and only MSA.
Praveen Suthrum: The reason that I asked that question was because I wondered if you had a template or they had a template that they followed or are you familiar with similar arrangements in other parts of the country that you’ve said, ‘Oh they’ve done it this way, we can follow them’
Dr. Latha Alaparthi: Apparently not for the MSA. There have been templates within the state for PSAs and they followed that to a large degree but the MSA was unique.
Praveen Suthrum: Practically speaking how does this all work? Does life look the same or does it look different?
Dr. Latha Alaparthi: As of right now not much of a difference except for the change in the way we address ourselves when we pick up the phone. That has been one of the major changes. We have changed our name effectively from the 1st of July from PACT gastroenterology center part of Hartford HealthCare Medical Group. Obviously, that becomes a long introduction so we introduced ourselves as PACT gastroenterology center. In terms of the day-to-day work not much has changed but there’s a significant amount of work ongoing to see where we need to make changes and one of the big things that any company venturing into something like this looks for is to make their footprint known. And I believe Hartford Healthcare is no different and understandably so. There will definitely be more of a presence in terms of logos and signs and signage that will change in the next few weeks.
Praveen Suthrum: How did you navigate through the competitive landscape while making this decision with respect to other hospitals that I’m sure you’re close to and so on.
Dr. Latha Alaparthi: It’s a tough one and I’ve said this to many of my colleagues and as a physician that’s very passionate about what I do and the care I provide for my patients and really respecting my independence and wanting to practice the way we feel is best it has been a tough one to navigate and make sure that we are allowed that freedom as we go forward. And to that end, we’ve had to be very open and discuss this clearly with all sides. So, historically as I mentioned, and I trained at Yale so it’s my fellowship mentor and I know many people from that area and we work very closely at the same time we decided what’s best for us is to align ourselves with Hartford healthcare Medical Group for the prior reasons mentioned.
And so, we’ve been very open both sides stating that we will do what’s best for our patients and we will send our patients where their best cared for and where they feel comfortable. And so, to that end, I really don’t care for feeling like a pawn in territorial situations in states and I’m really hoping that both sides will respect that and we will continue to. I mean it is early stages, but we are led to believe at this time from the conversations we have had, I don’t believe they will really force us to change anything. Both sides have been very accepting, and very open in allowing us to be who we are and actually respect us for who we are.
Praveen Suthrum: Would this arrangement be restrictive for you to go see patients at Yale or there’s nothing like that?
Dr. Latha Alaparthi: No. In fact, in one of the smaller hospitals in Milford where are the only GI group and we have very much of a presence it’s a small hospital and I used to be the President of medical staff before it became part of the Yale healthcare system and now it is part of a Bridgeport hospital which is Yale healthcare system and I’m still the chief of GI there. My colleague David Hass who is the chief of GI at St. Raphael campus. We have leadership positions, I’m on the medical executive board of Yale-New Haven medical practice. So, we have a presence at Yale and I do not believe it will change the way we practice And I really hope it doesn’t come down to that because then I would have to fight for what’s right for my patients.
Praveen Suthrum: Okay. I’ll get to COVID now. Connecticut was one of the earliest affected states when COVID hit. How did you navigate the pandemic and how are things going now?
Dr. Latha Alaparthi: When COVID was sort of erupting in the New York region, we were wrapping up our DHPA meeting in DC. The last day of our meeting was very interesting. We had several meetings. I had I believe 12 meetings at the congressional offices and senate offices and it dwindled down to about three meetings and at the end of the day, we weren’t even sure if we would take our train back because of the New Rochelle shut down because the train Amtrak goes through New Rochelle. It was very interesting, the whole evolution of that. One of the people that was first diagnosed with COVID in Bridgeport hospital was a New Rochelle physician. A physician that lived in New Rochelle but practiced in Bridgeport who unfortunately has since passed; he was a pulmonologist.
So, that’s how things began for us and the first few weeks were surreal and I went from having a normal office day or at least seemingly normal office day that Monday after we returned to within two days to go into a complete shutdown and having to change all of our patients that were on schedule for endoscopies telling them that we don’t know when we will open again. One of the things that we did early on is to try and switch to telehealth. We had been doing telehealth in terms of telemedicine phone calls prior to this I was one of the first few physicians that was using it in my office. But we soon transitioned to telehealth and at that point, the biggest crunch was trying to find the right platform to offer telehealth to our patients that was easy to understand and was reliable in terms of connectivity. And then the endoscopy center. That was a huge issue there was so much unknown. What we could only fall back on were the experiences from Wuhan because we didn’t have any in our country at that time.
We were one of the few ASCs that didn’t completely shut down. We had about 5% of patients coming in per week. Those that absolutely needed their procedures and could not or should not be done in the hospitals for the reasons of COVID. We took extreme precautions like an hour in between patients and such just to make sure that those individuals were able to get through their procedures and since the opening, it has been a whole new paradigm. While we were in the first two weeks of the shutdown, I quickly got thinking that we will need to open our ASC at some point down the road when COVID is still here. We can’t be shut down forever. And we have an obligation to offer these procedures and diagnose patients in a timely manner. So, I came up with a format that I thought at that time made sense because I was very excited about the antibody testing which obviously has not panned out as we expected and I presented it to a few people at DHPA, the exec team and to one of the physicians who’s also a DHPA member and also on the AGA leadership and there was a significant amount of interest and that led us to work with AGA and DHPA and in developing that joint guidance along with all of us involved which was a very relevant practical step for us and still to this day is being used.
Praveen Suthrum: From the patient’s standpoint what kind of change did you notice? Like were they as open to come to the ASC? I know you’ve restarted but what is the sentiment right now?
Dr. Latha Alaparthi: Since we’ve reopened in the last three or four weeks it has been a whole different paradigm shift and now because of the guidances and the increased number of cases, one of the major steps that we take is testing everyone. We have developed a ten-day symptom log not just temperature but other symptoms that can affect gastroenterology in specific including bowel changes etc. We expect our patients to fill that symptom log and also have PCR testing within 72 hours of the procedure. So, testing, tracking, and reminding patients to keep their symptom log and making sure the results are in the chart before they arrive or the procedure or actually before they prep for the procedure has been a task of its own.
It has really put a strain on our staffing which is suffering, which is a whole discussion in itself, added complexity to what we do every day. This is in addition to what we have already done in the endoscopy center which is a significant amount of cleaning in between procedures and PPE that everyone is recommended to wear.
Praveen Suthrum: Are you contact tracing post-procedure? And how are you doing that?
Dr. Latha Alaparthi: So, fortunately to date we have not had anyone that has tested positive after the procedure. So, we have not had to elicit that but we do have a process thought through in place as to how we would contact trace if that were the case. So, what we do now is call patients a week to 10 days out and make sure that they have not had any new symptoms that are suspicious with COVID and also instruct them to call us back if they develop any symptoms within the few weeks after the procedure. Fortunately, we have not had any cases.
Praveen Suthrum: Okay. That’s good to know. How has your staff taken all this and how are you managing that?
Dr. Latha Alaparthi: Yeah. I think it’s a good question and a tough one as well. Well, before I get on to that I want to let you know that between our group and CTGI which is another major group in the state we have tested a thousand patients and we have only a handful of patients who have turned positive. That was at the beginning of the pandemic when the cases were still high so it makes sense. And I believe our case rate was 0.02% or so at the time of positive rate. So, it has been very low in terms of the risk and we continue to test everyone. Our staffing, due to the shutdown of business before furloughed for a couple of weeks until the loans became reality and we were able to bring back our staff. Few staff members went on FMLA or took unemployment because they just could not afford to come back because of young children. Because unlike many other companies that can work remotely. We cannot work remotely. We did stagger our staff when the social distancing was still a significant issue in Connecticut and we quickly created HIPAA reliable home access to some of our patients that could room a patient for me to do telehealth.
So, we had to do a significant amount of workaround to make sure that everything was in place. As many people have said, among my colleagues, we put on a significantly higher number of hours as administrators to take care of fewer people in the pandemic time because of the number of workaround and processes, that we had to recreate as we took care of our patients. As of right now we still have a shortage both on the practice side and the endoscopy side or in the hospitals and in our endoscopy centers because many nurses that were on the borderline, thinking about retiring have decided to retire and many with health issues have decided not to work for the right reasons and many with childcare issues and other obligations have decided not to return. So, it is significantly straining ones that are in the mix and having to absorb work for other staff members that are not in the mix. And this is something that I am trying to navigate through every single day including yesterday. Making sure that nothing that is fully associated with our patient care is compromised because of shortages.
Praveen Suthrum: As a physician, you are putting yourself in risky situations and you are taking care of your patients and then you come home, and then you have to take care of yourself and your family. So, how do you navigate these two worlds of taking care of your patients versus taking care of yourselves and I’m asking on behalf of all physicians.
Dr. Latha Alaparthi: So, like any other first responder or physician out there that is interfacing with patients, I think many don’t realize that we perform procedures that are aerosol-generating. And that’s one of the reasons why our societies have come up with such stringent guidelines. For example, recently restarting the manometry or motility study that we perform in our office we had to come up with clear stringent steps in terms of a precaution we take not just for the patient but for the nurse that performs the testing and for everyone that uses that room subsequently. So, yes, it is a real risk that we take every single day in terms of exposure.
One of the things we should always remember is to make sure that you think about yourself because it is apparent from the statistics and the deficits that we are seeing, we are a very valuable commodity and we need to make sure that we take care of ourselves to be able to continue to take care of our patients. So, in that sense, we use the appropriate PPE and we make sure that we don’t compromise on the steps we’ve put in place to make sure that the patients that are coming in are not high-risk patients. The other aspects are to make sure that there are things that we have in place to relax. Whatever it is that takes your mind off and really takes you to a different sphere. Physical health and of course, my pet peeve is ergonomics. Don’t forget that despite the PPE, to ensure that you’re taking care of all the things that you need to establish your endoscopy rooms to not physically strain yourself or hurt yourself.
Praveen Suthrum: So, Dr. Alaparthi, you are one of the few women physician leaders that I know of in GI. I have a twofold question here. One is that how did you reach the role that you currently have, you play multiple roles. So, how did that happen? The second more important question is why is that the case? Why are there so few women leaders in gastroenterology and medicine as a whole?
Dr. Latha Alaparthi: Thanks for that question. I’ll answer it the best I can with my own experience and maybe the second one I can’t answer fully but I’ll do my best. The first was really… working with my office staff and really handling some of the challenges that became known to some of my peers and my senior physicians and administrators, ‘Oh she is good at this!’ and most of the times it was out of necessity. For example, I was extremely efficient with my schedules because of necessity. I had two young children at home and I had to navigate through hospital rotations, seeing patients in the office, making sure my results resulted back to the patients, etc. When they saw that the billings were at the same as some full-time physicians, and they asked ‘How do you manage this?’
So, I went into looking at everyone’s schedule, I started involving myself in making schedules efficient. Sitting down with the physicians, and telling them how they can navigate through schedules. And some of the issues that came up on a day-to-day basis and how I could handle them diplomatically with the patient and the staff. That became known to some of my staff members who then asked me to take on some leadership roles which like any female physician I said no in the beginning because my children were still younger and in schools. One of my administrators waited until I dropped off my younger daughter at college and met me the next day. And that’s when I took over as a managing partner of our company.
It’s basically like running a house. You look at every aspect of what you’re doing on a day-to-day basis and also the business aspect of it. Making sure that it is efficient and every employee is taken care of. Financial aspects are met with and staying accountable to yourself and your company. One of the things that will engulf you is the number of hours you have to put into the company. So, my involvement was a slow trajectory and before I became a managing partner, I was a president of medical staff, just being involved in with the medical staff at the local hospital, Chief of GI at the same local hospital. So, I had been doing more leadership roles in the community and small leadership roles involved in the executive committee of my company just to help.
In terms of why there are fewer female physicians, especially in private practice, I can’t ask for the past but I do see many women rising into the rolls at this point. And I’m hoping that they’re able to see themselves as leaders just as good at understanding the business aspect of the companies. I believe that is the part that many of us, men and women don’t really get a significant amount of exposure during training. But early on in the group, it is important to pay attention and really get into the details and realize that it’s not difficult to understand once you put your mind to do it. And I’m hoping that… that will change going forward. As we know the double AMCs data and my own daughter’s med school class shows that there are more female positions and medical students now than in the past and I believe that this is a number that will continue to increase and it is important to engage everyone into the leadership mix.
Praveen Suthrum: So, my final question Dr. Alaparthi is, what is the future of GI post COVID?
Dr. Latha Alaparthi: I was thinking through, And I think it is going to be technology. Patients still rely on us and the stress increased recently has definitely worsened functional bowel diseases. I do think that we will focus a lot more on putting technology so that we can take care of patients remotely. And coming up with treatment algorithms that are slightly different from what they are at this point. And hopefully adapt some of the technology that’s available whether it’s social media platforms or along the lines, where we can address patients individually but yet in a group through platforms that are secure and are accessible to patients. I think that this is going to be a new paradigm in the future in trying to keep the social distancing which I believe will be in place for at least the rest of the year if not into the next year.
Praveen Suthrum: What do you see to happen if we fast forward four or five years from now?
Dr. Latha Alaparthi: So, I was about to read a pill cam right before this [interview] and I’m probably going to go back to reading it. So, I think we’re going to try and look for platforms like that for diagnostic purposes which are more wireless and remote that can give us the view that we need and for diagnostic purposes or therapeutic purposes that we can intervene and be therapeutic in terms of interventions or procedures we perform and actually fix things. Home-based testing to some degree, of the things that we do including the pill cam-type testing, will probably increase. In terms of technology, we really need to focus on the platforms that we have and one of the things, for example, even today when I have to take care of patients, I sometimes have to have three EHRs open, which to me, is so detrimental in terms of patient care. I really wish there was interoperability and a lofty goal would be to have a single platform. But interoperability or ease of transitioning from one to the other instead of having to print, scan or import information from one to the other two just so I have information in one place I think is really affecting patient care.
The last would be to make sure that we have patients that have access to the platforms that we are putting in place. I was working with the fellows two days ago in one of the Yale GI clinics and it was clear that several patients that otherwise would have had to take public transportation to come to clinics have really embraced the telehealth platform and they really appreciate the fact that the doctor will call them, go over the treatment options and make sure that they’ve done their testing, that is a very time-sensitive one especially for inflammatory bowel disease, cirrhosis, Hepatitis C, along the lines. And that’s the population that oftentimes has the least access to many of these platforms. So, I feel we need to really keep our minds and eyes open to ensure that while we are innovating that we are also making sure that people have access to them.
Praveen Suthrum: Dr. Alaparthi, thank you so much for all the insights. It has been tremendously educational for me and I’m sure people who are watching this will feel the same. Was there anything that you wanted to share before we close?
Dr. Latha Alaparthi: I think the challenges that we’re facing as people. I really want people to know that each one of us are going through the same things about COVID and the transition. But with the whole challenge, has come the thought process and it almost makes you feel you can innovate because you have a challenge in front of you. And I’m hoping that we all embrace it and bring new ideas to the forefront and make them work.