What to Do When Procedures Are No Longer Enough
An upcoming book by Dr. Charles Accurso and Praveen Suthrum
We’re writing this in real time—sharing chapters as they develop.
Bookmark this page to follow the journey.
Premise
Most gastroenterology practices generate the majority of their revenue from procedures. That has worked well—and continues to work. But it also creates a blind spot.
A growing share of value in GI is now being created outside the procedure room:
- Before the patient reaches you
- After the procedure is done
- And increasingly, without a procedure at all
Many practices see this happening but don’t act—not because they disagree, but because the path forward is unclear. There are too many options: AI tools, startups, virtual care models, new diagnostics. It’s difficult to know what actually matters, what to ignore, and how to move without disrupting the core business.
This book is built around a simple objective:
Help a GI practice take the next 12 months and make a few clear, practical moves that reduce dependence on procedures—without increasing risk.
It focuses on:
- Where costs can be reduced immediately
- Where revenue is already being lost or underutilized
- Which new areas are worth building vs partnering
- How to choose a direction and execute without overreach
No predictions. No hype.
Just a clear way to decide what to do next—and how to do it.
Chapter 1 — Where GI Actually Makes Money—and What That Means
Most gastroenterology practices are doing well.
Procedures are strong. Schedules are full. Operations are efficient.
Nothing feels broken.
And that is exactly why this is easy to miss.
If you step back and look at your practice, the economics are straightforward.
A large share of revenue comes from:
- Procedures
- And the site where those procedures are performed
Colonoscopy. Endoscopy. ASC.
That combination drives the business.
Everything else plays a secondary role:
- Clinic visits are under pressure
- Care coordination is largely unpaid
- Long-term management is inconsistent from a revenue standpoint
So the system organizes itself around what works:
Bring patients in → move them toward procedures → perform those procedures efficiently.
It is a well-built model.
It is also a concentrated one.
This is not just how care is delivered.
It is how revenue is concentrated.
Pause for a Moment
Before going further, take a minute:
- What percentage of your revenue comes from procedures and ASCs?
- What percentage comes from everything else?
- Do you know—or are you estimating?
If you don’t know this clearly, you don’t fully understand your business.
The Work You Do That No One Pays For
Now look at what happens outside the procedure.
A patient is diagnosed with IBD. Or colon cancer. Or another chronic condition.
From that point on, you—and your team—do far more than perform procedures:
- Coordinate referrals
- Manage follow-up care
- Help the patient navigate the system
- Adjust treatment over time
This is real work. It takes time, staff, and clinical judgment.
But most of it is not directly reimbursed.
In practice, we take ownership of the patient.
The system does not pay us for that ownership.
The same pattern shows up in an everyday clinic.
Patients with IBS, dyspepsia, or fatty liver:
- Need guidance
- Need follow-up
- Need structure
But they:
- Often don’t need a procedure
- Don’t always stay within your practice
- Don’t generate proportional revenue
So they sit in a gray zone—clinically important, economically underweighted.
A Simple Example
Two patients. Same specialty.
Patient 1:
45 years old. Due for screening. Completes a non-invasive test. It’s negative.
They never enter your procedural pathway.
Patient 2:
30 years old. IBS symptoms. You evaluate, reassure, and guide initial care.
Long-term management—diet, stress, symptom tracking—happens outside your practice, if it happens at all.
In both cases, value is created.
But very little of that value is captured.
The Patient Mix Is Already Changing
If you mentally remove routine screening from your schedule, what remains?
Increasingly:
- IBS and functional disorders
- Dyspepsia and GERD
- Metabolic conditions like fatty liver
These are no longer edge cases.
They are a growing share of what you see every day.
And many of them do not clearly need a procedure.
Once you take out screening, your income depends on the rest of the patients you see—and those patients are very different.
Control Is Shifting—Quietly
There is a deeper shift happening underneath this.
Map the patient journey:
Before they reach you
- Primary care decides whether to refer
- Non-invasive tests filter who needs a procedure
- Patients increasingly self-triage using digital tools
After they leave you
- Many patients don’t stay
- Chronic care is fragmented
- Other providers—or no one—manage the next phase
Every time a patient is filtered before reaching you—or lost after seeing you—you are losing part of the value chain.
In practical terms:
We often own the procedure—but not the journey.
Others Are Already Filling the Gaps
This is not theoretical.
There are now:
- Virtual care models managing chronic GI conditions
- Structured post-diagnosis programs outside traditional practices
- Alternative care pathways patients explore on their own
- AI tools that give patients direct access to clinical knowledge
These exist because they are solving parts of the patient journey that GI practices are not fully capturing.
The Part We Don’t Talk About
Most gastroenterologists see this.
But very few act on it.
Not because they disagree.
Because the current model still works.
You can:
- Run a full schedule
- Perform procedures efficiently
- Earn a good living
- Go home at the end of the day
There is very little time—or incentive—to step back and rethink the model.
So the system continues.
Busy. Productive. Stable.
But not evolving.
Where to Look—Right Now
Before thinking about solutions, look at your own practice:
- Which patients are you seeing who never convert to procedures?
- Where are you spending time that is not reimbursed?
- Where do patients drop off after diagnosis?
These are not edge cases.
They are signals.
The Shift You Can’t Ignore
For a long time, gastroenterology has operated with a quiet assumption:
That we own digestive care.
In reality, what we have built—and optimized—is ownership of a specific moment:
The procedure.
That distinction now matters.
Because value is no longer created only at that moment.
It is expanding:
- Before the patient reaches you
- After the procedure is completed
- And often, without a procedure at all
Procedures are still essential.
But they are no longer sufficient to define the full scope of value in the specialty.
Nothing feels urgent.
Practices are still busy.
Revenue is still strong.
Even if procedural volume declined meaningfully, most practices would continue to do well.
This is not a survival problem.
It is a positioning problem.
The real issue is not that procedures are going away.
The real issue is that:
Value is now being created in more places than just the procedure—and GI is not positioned to capture all of it.
And there is one more shift.
What used to be inside the specialty—clinical knowledge, decision pathways, follow-up recommendations—is now accessible to everyone.
Patients can look it up.
Primary care can apply it.
AI can guide it.
The information advantage is no longer exclusive.
So the question is no longer:
How do we do more procedures?
The question is:
Where does our value actually come from—and where are we not capturing it?
Most discussions stop here.
They describe the change.
They point to trends.
They outline possibilities.
But they don’t answer the practical question that follows:
What do you do with this—inside your own practice?
In the next chapter (Chapter 2 — What Every Practice Should Fix First), we move to that.
Not with theory.
But by starting with what is already in front of you:
- where cost can be reduced
- where revenue is already being lost
- and where capacity can be unlocked
Because the first step is not expansion.
It is clarity.