DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.
Should you consider integrating an in-house genetics counselor into your practice?
Today’s guest, Dr. Mili Thakur, makes her case on the future of genomics and its place in the REI medicine space. She walks us through how an in-house genetic counselor can boost practice revenue and optimize patient retention.
Tune in as Dr. Thakur gives us insights into:
Her 3-point business plan showcasing the importance of genomics integration into REI practices
The number of cases she believes warrants an in-house genetics counselor [It’s not as high as you think]
Why Carrier Screenings matter [And her criteria on how she vets companies]
The future of Genomics [And why it’s the biggest investment opportunity even beyond the infertility space]
And more…
Dr. Mili Thakur:
LinkedIn
Genome Ally, website coming in May
Transcript
Dr. Mili Thakur 00:00
I think it would be dependent on the total volume that you're able to bring in to the practice. I would say if a doc is seeing about like 10 to 12 some of 15 new cases in a week, you know, there's going to be at least two or three of them that are genetics or their hidden genetics like they're not obviously I but like recurrent pregnancy loss if you're seeing five or six recurrent pregnancy loss patients in a in a week. You know, in about two weeks, you're gonna have a PG DSR case.
Sponsor 00:33
This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Contact bundle at bundlfertility.com. That's bundlfertility.com/contact-bundl. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guest appearance is not an endorsement of the advertiser.
Griffin Jones 01:27
A call for action amidst the turmoil of the reproductive genetics field now I didn't write that but my guest did her name is Dr. Mili Thakur. Dr. Thakur is double train. She was the first fellow to graduate from an ABOG ACMG combined fellowship in reproductive endocrinology and infertility and medical genetics. She did that in 2017. From Wayne State when she left fellowship and join private practice in Grand Rapids, Michigan, she made a business plan she made a business case for why they needed an in house genetics counselor at a four Rei practice in not a very big market. We go through that business plan having an in house genetic counselor and having genomics be a part of the REI practice today, Dr. Thakur supports that plan with three different points. First is the revenue that's generated downstream from genetic counseling, the additional cycles, the testing storage that might be necessary. Second is patient retention. Dr. Thakur argues that if patients really struggling with a genetic abnormality and you're the one that finds it, they're going to stick with you. Third is donor IVF cycles if you can prove that they're necessary from finding abnormalities then that patients going to need donor cycles. I pressed Dr. Thakur on why genomics is so valuable to the practice why it's so valuable to the patients as well. And I come across a point where her background might give her an insight that is not at odds with you potentially and that has to do with carrier screening and the variance in the quality of panels. I've got the impression from my nine non scientific polling of many of you that it doesn't really matter who does your carrier screening. There's a dozen or so companies out there. Many of you have told me it's one or the other doesn't matter too much. Being a geneticist, Dr. Thakur has a different opinion. Dr. Thakur thinks the carrier screener does really matter. And she shares her criteria for how she and her genetic counselor that carrier screening companies criteria such as actionable conditions versus non actionable conditions, and they have to be actionable criteria of the curation of data that labs have to be able to curate that data and I pushed afterthought core on how scalable these revenue upsides are for fertility networks that might be trying to cut the lowest possible deal with a carrier screening company that leads us to the question does someone with a genetics background have to be a part of the governance of a fertility network the same way a chief medical officer and a chief scientific officer are asked Dr. Thakur for a ballpark what number of genetics cases make sense to have one full time in house genetics counselor turns out not that many in her view, Dr. Thakur surmises, we have 10 to 12 new patients a week two or three of them might very well be genetics cases, she gives the caveat that you have to be looking for that which is at the crux of the whole conversation. And she shares more detail about that we talked about the future of genomics and art and how that might become so much bigger of a marketplace than the infertility segment alone. Dr. Thakur thinks that genetics is far and away the biggest investment opportunity in art. So I asked her why the heck doesn't it look like that now with genetics companies closing their fertility divisions? Her answer made sense to me. I want to see if it makes sense to you. Finally, Dr. Thakur talks about her new venture genome ally that she's beginning to prove concept for and bootstrapping my thumb to the wind test of all of this is that we are in an atypical role for genetics in the fertility field and then it's going to come roaring back my perspective. Isn't that interesting? I think Dr. Thakur is more so I hope you agree and enjoy this episode. Dr. Thakur, Mili, welcome to Inside Reproductive Health.
Dr. Mili Thakur 04:57
Thank you Griffin for having me. It's a privilege to connect to your audience.
Griffin Jones 05:01
It's a pleasure to have you on you've become a bit of a voice for genomics in the fertility center, I saw that you were quoted in an article that one of our journalists wrote a few months back about the changing business landscape of genetic testing and genetic counseling. And then I've seen you at a few talks throughout the field. And so let's start there, maybe how did you become a champion for genomics inside the fertility practice?
Dr. Mili Thakur 05:34
So Griffin, I am a combined reproductive endocrinologist and a geneticist, which is great privilege that I had off training that way. So I am a OB GYN, I always took care of women I trained back in India did a residency there then came to Wayne State in Detroit did a residency and fellowship here. And that phenol shear force, namely, for me, was an opportunity to combine both the fields. So I'm the first fellow to graduate from a combined reproductive endocrinology and infertility and medical genetics fellowship. And that's what got me interested because I had a different perspective of both the fields combined together. So even though I trained in traditional genetics, and I know how to do cancer genetics, and pediatric genetics, and, you know, genetics for neurological conditions, and I trained for it with my fellowship, I specialized in reproductive genetics. And because I'm a reproductive endocrinologist, I do IVF every day, that's part of my, my practice, I take care of patients from the infertility struggles, and help them with both of these things combined together and merge, which is an amazing opportunity.
Griffin Jones 06:48
What's his specific use in your own practice in the way that you practice that you feel that you've benefited from having that genetics part of the or that genetics fellowship, that you feel that you wouldn't have been able to implement in your own practice of REI had you not had that fellowship?
Dr. Mili Thakur 07:09
So I think all reproductive endocrinologist or REIs do genetics as part of their job. But the advantage that I had from this additional training was that I was able to be well versed in the lab aspect of it, the moleculer aspect of it. So I understand the test, I just don't offer the test, I understand what's the science behind those tests. And I am also able to take care of like, complex situations that involve genetics. So because of our training, you know, we, during my training, I took care of like newborns who were diagnosed by the newborn screening program in the state of Michigan. So I've seen those conditions firsthand, and how they affect children. So when a couple comes back to us, saying that they have a child that's affected, you know, I've seen the other aspect of it. So the combined fellowship helped me hone into a specific area. So it's not difficult for an area to take care of genetics on a day to day basis, they do it all the time that traditionally it's been done. It's just I've been able to cater to a niche of patients, because I understand that complexity. And it's easy for me to say, you know, what needs to be done here and how to select the test. So there is this specialization that has developed based on that
Griffin Jones 08:36
I won't go too deep into the clinical, because it's not a clinical show is a business show, which is what I'm more qualified to talk about. But I am curious when you're talking about not just being able to read the test results, but to understand the science behind the test results. Can you think of an instance where it was really paramount that you knew the science behind those test results, as opposed to being able to just read the test results to any does any one instance come to mind?
Dr. Mili Thakur 09:04
So one of the common tests that all are used, and I know your audience is primarily people working in the reproductive medicine field is a carrier screening. So preconception carrier screening is a common test, it's been given by different companies. So there's like more than about 10 to 12 companies that offer that test, it may be even more than that. So each one of those companies uses a technology called next gen sequencing. And each one of those companies offers a panel of tests and that panel can range between sometimes 23 conditions to like now 600 700 conditions. So what advantage that that additional testing brought for anybody working in the field of reproductive genetics is that I understand carrier screening testing from a different angle sometimes i i unlike colleagues like myself, would be able to understand more than the medical representative or the salesperson who's coming to sell the test. So for an example, like for cystic fibrosis, you know when for cystic fibrosis is a common condition that we are carriers of that tests can be done by next gen sequencing, most labs are up to par and sequencing that gene and like looking at different spots on there. But then when a certain type of mutation comes through, there is another additional testing called five t testing. So to be able to ask the medical rep to say, do you do five t testing? Is there a reflex that we can do if needed? Same thing for like fragile X? Do you do AGG repeats? And how is your curation of radiant? How often do you guys look back? So we have another stringent layer that I'm putting any tests that I am wearing for my patients through? So it helps me serve my patients better? Because I have an understanding of what they're doing behind the scenes? How is that report being signed off? You know, what are the things that they are not reporting out, because they're not reporting out the whole gene to say, and so in genetics, you know, our colleagues in genetics will relate to this much more, we don't say, hh, you're negative for the condition, we say there is a risk reduction. So you being a carrier, based on an ethnic background is a certain number. So say one in 30, after the test, that risk slows down to being one in 10,000. But it's never going to be negative, because the science hasn't advanced to the point where they can look at the whole gene completely. So by knowing that back end workflow, and what is out there, I can challenge them and have them give us the best possible test.
Griffin Jones 11:47
So you can vet the tests better than you could if you didn't have this background, and you mentioned a couple of different applications for it. So you're ultimately getting more productivity from the test, you're, you're getting better results from the test, is it also to vet so are some tests? Did they have features that are unnecessary that are, that people are paying for? Is that part of the vetting or not as much?
Dr. Mili Thakur 12:12
It is. So basically, what we do is like for each of the patients that comes to me, especially with complicated, complex genetic history, we are able to find the right test for them. And then kind of streamlining the cost of it as well. So as, as one of your previous guests on the show, Dr. Arredondo, Paco, always says, you know, we have to cut the frills out of the thing. So sometimes with these complicated histories, you know, because we are in such a busy practice, you know, you might order five tests, but then if you had that understanding of the test, you would be able to go straight to the test that's right for that family, and be able to serve them. So a quick example is, I had a patient who will their their dad had a condition and five of the boys, you know, three out of those five had a certain condition where their hair nails and skin was abnormal. They now wanted to do IVF. And they wanted to do IVF, because they didn't know that genetic mutation in their family, their dad and mom had gone through some genetic testing 20 years ago, they didn't know you know what the mutation was, at that point, they just wanted to do IVF with PGT A and select for boy embryos, they said, We don't know what's affecting our family, three out of the five boys are affected by this condition, we don't look good, right? So let's just have a boy so at least he wouldn't be bullied in school or have issues there. And because now they were coming to see me and times have changed. Now I could look at him and say you have some form of ectodermal dysplasia, there is a panel available for it. And then we worked with the family and with our colleagues in genetics at a local hospital, called them the right test, we were able to identify a variant now variant of uncertain significance means that you know, we don't know if it's really the causing disease because it had never been reported before. We had a family where three boys who are affected to were not affected, we were able to segregate the variant test everybody in the family. And then not only that person, but we were able to identify a novel variant. It's never been reported. This is the first family in the entire world to report with that condition. And then that person and his brother went through IVF for selecting embryos that are disease free, they were able to transfer all different genders that they wanted to and also have a healthy child for two of the brothers that are affected. And so coming back to your point of like the business aspect of it, had I just gone and done IVF for pcta saying okay, we can't find the answer for you. We would have just finished up with one cycle, the patient wouldn't have been served to the best interest because their mystery would not have been solved their story would still be like, we don't know what's affecting the children in our family, right. But now with this additional testing, our practice, my practice got not just one, but multiple IVF cycles, because they were searching for the right embryos, they're coming again for another transfer each one of those families has had done now for transfers, right, they have two children each. So it's a long term relationship that you build. And the revenue generated from all of that is what then justifies that process. So I spend extra time because I'm extra trained and like, I have this additional training. So I spend extra time but then I make up for my time with that additional revenue that I generate from these cases. So the biggest thing that's driving us is patient benefit. Now they have an answer. Now they have a healthy family. But it took extra effort, it took some time to get to that answer. And you know, we were able to solve that case. So that additional piece is what makes this model sustainable.
Griffin Jones 16:16
So we ventured into PG ta but back to carrier screening for a second, I had always gotten the impression from doctors that they didn't really care which carrier screening provider, they chose that many of them do care who they use for PGT A but for carrier screening, I'd always gotten the impression that doctors feel like that it's a commodity, is that less so in your view? Is it? Is it not as much of a commodity as doctors think it might be? And that there's a bigger difference between carrier screening providers?
Dr. Mili Thakur 16:45
Yeah, so actually, for from my perspective, and many of my colleagues in genetics, we are extremely thorough and careful in the products that we select, we consider them as products. And like any other thing that a clinician would be offering to their patients, you know, you have to understand what they are doing. Because the main things to consider is one, are there actionable conditions on their panel. And there are conditions that are not actionable, there are very, very rare conditions on there, and they are going to be reporting those out, you would have a very high positive rate, and you will have to deal with the back end of it. So first should be actionable conditions. Like I don't want a panel that has an MTHFR on it. MTHFR is a genetic change. That's very, very common. So I don't want a panel that has that change, because it doesn't change what I do clinically. And it kind of raises red flags for no reason. The second thing is how thorough is reporting, you know, of the different genes that they're doing? And then also about how is the curation? So some of the our viewers will, you know, be able to understand this? Well, it's like these changes that are being reported, some of them are very new, and they are being reported as variants of uncertain significance. We don't know if they're gonna cause disease or not. But because the science is advancing so fast, all of these labs have to curate, they have to keep every six months look back into the database and say, okay, now, is this mutation something that's deleterious? is causing disease or not? Is it something that's going to be causing problems? So if a lab does not curate their data every so often, then you're going to have gaps in there. And then in prenatal testing, or in preconception testing, if a variant is reclassified? Is the lab going to let us know? Because you know, for future, like if this couple is going to have situations where a couple came to us for second opinion, because despite a normal carrier screen, they had an affected baby, because they had a variant of uncertain significance, which was not reported out. So we went back to the lab, and we wanted them to look back at the data, reclassify the variant, and that's why, you know, it's important for busy clinicians, REI providers, doing high volume IVF, all of these networks, to consider working with somebody who's, who can take care of those extra genetic needs, like when you're picking up product, no matter which genetic product you're using. So some of the products that we use, one of them is carrier screening, another one is stereotyping. Another one is products of conception screening. PGT is another product, you have to know what you're offering to your patient. What are the gaps there and challenges there so you can counsel them appropriately. There are some companies that are not reporting out HCG repeats and FMR gene. So if you've got somebody in that certain situation, then you will have to request it extra versus there are some companies that will do the FMR gene, and if they found a certain thing, they will do the AGG repeats. So when the results come to you, you're able to say, yeah, this is something that's actionable or not actionable. So the complexity of it is being lost because of the volume terrible providers are seeing and you know, you were at some recent conferences, there is this shortage of REIs, like all of us are doing a lot of cycles. So in all of that, the piece that a single test is playing is so small that it can be overlooked. And you know, things can fall through the cracks. So there has to be safeguards put in place of like, okay, which, which tests are we doing, if we said to a patient, you are negative. And sometimes, you know, in practices that don't have that expertise, or leverage, a nurse might give out test results. And she might say, Oh, you're negative, and the patient who doesn't know the science of it just thinks, oh, they're negative for cystic fibrosis, but that's not the case, do the test that, that your risk of being a carrier has now been reduced. And now, you know, your partner has been tested and their risk is reduced. That means there is still a likelihood very, very small, though, that something could happen to a child, you know, so the understanding of it is a little bit different. Our viewpoint is different, basically. So I would read, I always read the test, I understand I sit down with the reps, you know, I would look at all the information before I will select the test.
Griffin Jones 21:33
With regard to understanding I read your bio, a little bit of it before we sat down for our interview here. And it seemed that your center, the your fertility center, the Center in Grand Rapids hired an in house genetic counselor in 2017. Is that right?
Dr. Mili Thakur 21:50
Yeah. Yeah. So I started out of my fellowship in 2017. So as soon as I landed the job, you know, I wanted to have an in house genetic counselor.
Griffin Jones 21:59
Tell me about how you made that case at that time, because at that time, you're an independent center. So now you're Ovation now US Fertility at least on the lab side of things, but the at that time, you were completely independently owned fertility center, is that right?
Dr. Mili Thakur 22:14
Yeah.
Griffin Jones 22:15
And Grand Rapids is not a huge market. And so how did you make that case that, that you needed an in house genetic counselor in the practice?
Dr. Mili Thakur 22:26
So I had to write a business plan. So like anything else, we wrote a business plan. And, you know, I had a strategy of how to make it financially viable for any practice to embrace a new set of paradigm, you know, you have to make the case of how we are going to make it financially viable. And the way we did it, and one of your previous guests, Amber gala talked about it, you have to work with whatever is happening in that state. So in some states, genetic counselors are able to bill at the time, you know, in Michigan, genetic counselors, were not able to build for it. So the way I did the things was one, in my mind, you drag generate revenue downstream from the genetic counseling. So if you are able to one, number one is engaged the patient, if somebody comes to you, and you're able to provide the right service and engage them, you're gonna have a better chance of them going through a complicated treatment. That's number one. The second thing is patient retention. If you've had somebody coming in for failed cycles, and now you're able to do some genetic tests, you find the abnormality, they will, the patient is not going anywhere else, no matter how long it takes. The third thing is because of all the support that you have from a genetic counselor, or that expertise that I have, because of my training, you aren't able to have them go through donor cycles, like if you found a genetic mutation, and they now know that there's something wrong, they're gonna do egg donor or sperm donor, and you're gonna be able to engage them. So when I wrote the business plan, those are the avenues that we were able to do and you wouldn't believe it. Like in the first three months of our genetic counselor working, we were audited, like any other practice with audit their new process, and we were we were cutting even because like I was able to see double the number of patients I like I was seeing my own infertility patients, and also seeing a patient with the genetic counselor at the same time. So her time and my time was build right and then I was able to feel a level higher than what I would with her support. So if you have a comprehensive visit, they are able to spend half an hour with me and then half an hour with my genetic counselor. We are able to provide the best possible care for them. We We are able to solve some of these complicated situation order the required amount of testing on that same day, and then I was able to build a level five visit. And because we were able to get them to write tests, we were able to engage them to do IVF with PGT M, PGT SR, which is like many, many cycles would come out of that one, one situation for that couple, they might do multiple cycles to find the right embryo, and then they will come back for their second and third children, because their embryos are stored with us. So if you are able to do the math there, you know, you did multiple IVF cycles out of that one console that you could do because of your expertise or your partnership with that, that genetic counselor. So and, you know, Amber, gamma had previously told you the salary that a genetic counselor would have, it's usually I heard her podcasts with you, and she mentioned somewhere around 100, 250,000 Is what she mentioned, based on their professional society survey, 100 or 150,000, you are able to do it, get that revenue back in a few IVF cycles. Right? So it's like, yeah, so it's the understanding of the best care for the patient, in a model that embraces that new technology. So you're freeing up your staff, you're freeing up the doctor to do other things they are able to do IVF practice while that person is totally every day doing complicated genetics for you.
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Griffin Jones 27:19
Maybe we should talk about that time that was freeing up for you because I'm understanding the picture of the revenue that is generated downstream from the genetic counseling that you're painting. I, if I were a hiring doc might look at you and say, well, I've got you, what do I need to hire a genetic counselor for you just did this double fellowship, you have this genomics experience and credentialing, so why do I need to hire a genetic counselor when I have a doc that also has this training?
Dr. Mili Thakur 27:49
Sure. So one of the key things pioneers in the field right now are talking about this, you should use or utilizes the right word, everybody at the top of their license. So for me as an REI, the top of my license is surgery. Right? So if I'm doing a hysteroscopy, if I'm doing an egg retrieval, if I'm doing an embryo transfer, nobody else can do it in my practice. The nurse can't do it, the genetic counselor can't do it. So that's my top of the practice. What the genetic counselor does is she works, she or he, you know, any they work on the top of their license, and their top of the license is to be able to take that information, break it down into an actionable plan, get the testing ordered, and then be able to give the test results. And then you're able to utilize the doctor's information of like, oh, yes, you need IVF. And you're able to use their expertise to take that patient through IVF. So the way we have it in our practice, and, you know, I'm about to launch a new venture where I would be working as a liaison like I want to uncover the case for the doctor to then take it through for IVF.
Griffin Jones 29:05
I want to ask you about how you would liaise with them and what you plan to do for that venture. I'm interested and it's making sense the type of license argument for your genetic counselor, there's four or five Doc's in your group four or five REIs?
Dr. Mili Thakur 29:21
Yeah, so there's four,
Griffin Jones 29:23
Do all of the docs utilize the genetic counselor or or just you?
Dr. Mili Thakur 29:29
The way we have it set up in our practice, or the way I set it up for our practice, is that the genetic counselor is available for any of the patients that are going through so we have tried to specialize in genetics for the whole practice. Nobody else except for we and the genetic counselor and we have an genetics assistant are the ones that are holding all the workflows of the genetics so the dogs don't have to worry about it. The nurses don't have to worry about it. They don't even give the test results about They don't even get a phone call, we have kind of streamlined it to just be our area. So it takes away from the headache that the other doctors would have to face. So if the complicated case comes through, we prep the whole thing for them. And then the IVF still goes under, through them, for whatever needs to be done,
Griffin Jones 30:23
How does the way that the other REIs interface with the genetic counselor differ, if at all, given they don't have the double training that you do?
Dr. Mili Thakur 30:34
So they could take care of the case, as anybody else would, like, all of my colleagues in REI, without the extra genetic traces are, are able to take care of most cases, you know, unless there is new testing that's required, but they're gonna be able to achieve that at the cost of time, they're gonna have to spend four or five hours per case, at least in our practice five to 10 hours minimum to get that case to get through, it's a high stakes liability case, when you're doing a PGT M case, right? Because you they are not necessarily infertile, they're just coming to you to be able to have a healthy child. So it's a different kind of scenario. So that doctor will be able to still do it, they will be able to look up the mutation, go through all the history and everything, but then they're going to be utilizing the time, by having our model of like somebody specialized in genetic taking care of all of your genetic needs, you're able to free up that time, you know, I prep the case, I see all my cases with the genetic counselor, I understand it, it's easier for me, because I do that every day, I'm well versed in the technology and keeping up with the science of it. And the genetic counselor is part of a group of elite group of genetic counselors in the country. So she understands what is going on, we keeping up with the science of it, were able to prep the case. And then the doc can just meet with the patient and say, hey, go ahead and meet with our team, and they're gonna take excellent care of you, we prep everything. And then they go see the doctor again and say, you know, we have this is what we found. And this is what we are going to do, then you take them like a regular genetics case. And when it comes time to give results. Again, after the IVF is done, and the embryos been tested, which embryo to transfer, you know, it's a very critical decision making. And again, it comes back to us we meet with the patient, we give them the test results, and then you're back to transferring an embryo vision areas workflow anyway involved. So the doctors can rely with a lot of firsts on our team, and then get back to what they were doing. In the meantime, they're not spending extra time to be able to understand the new mutation or understand what needs to be done. Sometimes you have to call these genetic testing companies, you know, many of these countries have done more than 5, 6000 cases, right? So for 800, 900 disorder, but I feel like 901 disorder comes you sometimes have to call them and say, you know, is this something we can do for this family. So you're spending the back end time, it's just being taken away by this specialized group. So what I'm coming to, again, is that there is this need inside of our field to recognize that genetic testing is here to stay, it's going to become more and more complicated. The technologies are evolving day by day, the doctors in REI can lean on a group that is going to be just doing genetics all day. And they are keeping up with all the things and reading the different tests and the technologies that are coming through and then do what they do best, which is patient care. So they're not like worried about okay, they did get documented in the chart, that a certain embryo should not be transferred or should be transferred, right. It's like a busy practice for most of the areas that I know about, you know, they shouldn't be burdened with something that they're not doing every day. You know, these cases are special cases that require a certain amount of focus that has to happen.
Griffin Jones 34:16
So I'm seeing the focus that's necessary and the support that's necessary from the genetics counselor, and even the revenue upsides that can come from it. I want to push a little because as we talk about scaling, I imagine that this is the people who do the scaling what they think about in that okay, so I buy your case for a genetic counselor, I see the revenue upside I see how much they help the doc why in house though, why isn't this something that we can outsource that we can do via telemedicine that if we've got a network we can you know, maybe you will maybe we got 100 doc's in our network across the country and we have four or five genetic counselors. Why is this something that has to be in house in your view?
Dr. Mili Thakur 35:00
For me, it needs to be in house because you know the type of volume that I do. So the volume justifies what you're able to build for and keep up with it. So if it is network, or if it is a high volume, practice for sure, they should have some sort of partnership with either an in house genetic counselor or a company that just takes this whole genetics and does it for their practices or you know, the clinics that they are. Or if you're a small practice, you're not going to be able to afford a genetic counselor at all. At that point, you could have a hybrid model. So hybrid model means that you know, you could do some of your regular day to day genetic results giving through the company. So all of these reference labs will have genetic counselors, and they can give easy test results. They're not based inside of the practice. So they're not able to tell the patient what to do or what not to do, they don't basically take away the work from a nurse or the doctor, but they are just a resource. So that can be some of the results that can be given. And then you could have a group of practices in sharing a genetic counseling service or telemedicine genetic counseling service, there's a few of them right now. And a lot of people are leaning on them after what happened in the IVF field with some of these big tech companies, genetic testing companies, you know, entirely dissolving their fertility units, there were no genetic counselors available for a short period of time. So telemedicine companies to con that extra work, and then if you're a big volume, practice, and you're able to justify a genetic counselor, you should have some partnership with either an in house genetic counselor or through a company that takes on that work for you and not worry about it. Because the revenue will be generated in no time, you know, I have no doubt about it. But if you're a small practice, you're doing like less than 100 cycles, you're gonna see maybe one or two generic cases in in a month that it doesn't make sense to have a genetic counselor. Although another thing that I wanted to kind of point out as if somebody has that genomics business aspect of it, we are only scratching the surface of what is the potential out there. So there is a lot of families that want answers, they just don't know that they want answers. So if somebody wants to build a bigger practice, they are smaller practice, but they want to do more cases, by building your genetics brand, you can like be stronger. So there's all sorts of models. And I think at this point for what I see in the field, a hybrid model is good. That means, you know, depending on what you can and cannot do you lean on a certain way.
Griffin Jones 37:48
So for you hybrid wouldn't work because your volume is big enough, can you give us a general rule of thumb, like a ballpark rule of thumb of what number of genetic cases make sense, where the genetic counselor should be full time in house,
Dr. Mili Thakur 38:03
I think it depends on the total number of patients coming through in a year or a month for a patient for practice. So if a doc is saying about, like, I would say if a doc is seeing about like 10 to 12, some of 15 new cases in a week, you know, there's going to be at least two or three of them that are genetics, or their hidden genetics, like they're not obviously I but like recurrent pregnancy loss. So, you know, if you're, if you're seeing five or six recurrent pregnancy loss patients in a, in a week, you know, in about two weeks, you're gonna have a PGT SR case, because you're going to find a balanced translocation in one or the other patient. So I think it would be dependent on the total volume that you're able to bring in to the practice.
Griffin Jones 38:56
But that's not crazy, high volume, I suspect that the probably the median of people listening is probably doing that doing that about 10 to 12 new patients a week. And so you're saying of those 10 to 12 new patients, you're likely going to have two or three cases that,
Dr. Mili Thakur 39:11
If you're looking so the caveat to that is are you looking, you're gonna only find those cases, if you're looking very well. So like, in our practice, we have a protocol. And you know, for my new venture, I have a protocol that if you have a couple that has male infertility, and the count is lower than 5 million, you have to look for the karyotype of the male to find the translocation. And then if you have to do the Y chromosome testing, so if you did enough tests, you know, about 10% of them are going to be abnormal, and then you're going to find that one extra case that you solved. So you have to be looking, there are other ways of doing it. You know, the count is low, let's just do IVF. Let's just, you know, make embryos and that's why you have sometimes failed IVF cycles after failed IVF cycles, because the protocols that have been given by our professional societies are not being able to be followed. Because you know, it's like a cookie cutter type of model that's going through, like everybody comes in, let's do some IUI. And let's do IVF. And then if you don't get pregnant, that's bad luck for you. But there are these cases that are hidden, you have to go and follow the guidelines to be able to find those answers. So we look for them, and we find them. And then because of our relationships with geneticists in the area, just because of my interest and my expertise, you know, we get direct reference. So I, I don't find PGT M cases based on carrier screening alone or male factor testing alone, I get direct reference. So people will come to me and say, we just had an affected baby who was in the NICU, and this couple is thinking about another baby in two, three years, can you see them? So we are getting these other reference cases, which right now, most practices, and I've talked to all the big networks, mostly, you know, about what they're doing, there is no process right now of capturing those cases, which, you know, by having that genetics, specialization, you're able to get those relationships. And then another thing that we have kind of leverage quite a bit is oncofertility. If you have relationships with oncologists in the area, you're going to get to serve patients who have a genetic mutation for cancer. And then you're able to do IVF procedures for them, whether it be like egg freezing or it be sperm freezing, or it be you know, embryo freezing, and an embryo freezing with genetic testing for those. So you have to genetics is an all encompassing thing like it, it percolates different areas are male factor is one pregnancy losses. And other one, cancer is another one, we capture them from all different areas. And you know, we are able to bring it to the forefront, sometimes the patients don't even know they have the issue. And now the whole plan is changed. So sometimes they will come for like, okay, male factor infertility, we wanted to semi, but then you find something and you show them and say, this is a condition that, you know, could affect the children. And you know, we can test for it. And then you change the plan to an IVF plan.
Griffin Jones 42:31
And part of the all encompassing of what you're talking about is being used in ways that are applied beyond infertility cases, but simply for anyone that wants to avoid genetic disorder using genomic says part and using ART as a means of how they have their kids. I want to talk about that broader market implication, I have one last question on the carrier screening that I can think of because you've you've made the case for a certain volume, where it makes sense to have genetics counselor, where you've made the case for the the revenue streams that come downstream from generating that you generate with genetic counseling, you talked about the patient retention benefits, and you talked about the donor cycles is all of this enough at scale, for you to choose a carriers screen name company that might not be able to do a certain deal if another carrier screening company can cut a really low deal. So I'm thinking of the MSOs as they start to consolidate fertility clinics, as they start to broker these deals to ostensibly drive down costs. If they go with one that is they can do a really, really low deal. And perhaps one that meets your vetting criteria can't Is there enough in those three areas, patient retention, downstream opportunities and donor cycles, that makes that is enough to offset big deals being done at the enterprise level?
Dr. Mili Thakur 44:13
So the point of the whole discussion at this point, Griffin is that the experts in that field should be part of the decision making process. The reason being that if if a non clinical person takes the decision, and you know, makes it a low cost test is available to everybody and everybody binded is bound to use that test. Then at some point it's going to be affecting in an indirect way. So what I mean to say by that is if you have a non clinical person somehow cut a deal without understanding the test and its implications downstream. There could be an error that can happen or an oversight that can happen and then that one or two cases will suffice for, like a huge liability. And that's why you know, all all of these clinical decision making, especially in complicated areas, so some of the complicated areas that I see in, in IVF, or infertility care as such, one of them is genetics. It's like, really, really multifaceted, complicated. There should always be a person with specialized genetics training, be it like an IVF doc with genetics training, or a genetic counselor who's trained in that field be part of that decision making, they should be sitting on the table and saying why or why not? We can do that.
Griffin Jones 45:35
Let's zoom in on that for a second, because I think that might actually be more at the crux, because it could be a clinical person that makes that decision. It could be the chief medical officer, who is an REI, I've had multiple REIs, to me say they don't care who the their carrier screening provider is that it's all the same to them. And so does there need to be, does there need to be something in the governance of a large network where genetics is represented? Or is it simply the case that the docs and the genetic counselors with that experience need to make that case to their, their chief medical officer? Or do you think there needs to be something baked in to the governance of an organization where there's more consideration of genomics?
Dr. Mili Thakur 46:20
So the way I see it is like in any organization, the head of the organization or the decision making, they have advisors? So So a good example is the President of the United States signs off on a lot of things or, but they have like NIH chief, as being their advisor who sits with them and says, Why or why not they should be doing something, or they have a surgeon general. So if a Chief Medical Officer or CEO is going to be taking those decisions, they should have a clinical genetics train person when they are saying yes or no to a certain company and say why or why not? Because if you're going to have, say, $5 difference between which is like what is happening in the field, right now, genetics is becoming less and less expensive right now. And it's going to be available. There is a $5 difference, but there is a huge difference in the clinical strength of the test, you know, would you go with, the better test? Or would you go with that $5 deal? Because I think I in one of your previous episodes, do you know, one of the doctors who talked about how to cut costs in the in IVF talked about that they would never negotiate the price or go with a crappy incubator, because the embryos are going in there, versus a speculum is easier to make the decision making. So like, if you're going to be doing something. Right, and taking a decision about it, that's binding to multiple clinics, you should always have an advisor. So you know, I've been an adviser to a lot of those, those experts that are taking the decision in multiple different categories. And that's the way to go. Like you could have somebody who can give you advice and tell you what's happening in the field and why and why not that things should be happening. Because when a non clinical person or a clinical person who's not an expert in that area takes the decision. They don't know, you know, what they're saying yes or no to and the drug reps sometimes don't know, I've had multiple instances where myself and our genetic counselor is the one who's telling them, can you tell me this? And then they'll say, Oh, let me find out from the genetic counselor in our lab, she probably will, they would probably know better, as to what is happening. So the, and the salesperson is doing their best. They're not clinical people. You know, they're not doing genetics every day, they are selling the genetic tests, but their education is in marketing or in sales. So you know, the person. Any REI physician out there, who's now offering a test to the patient is going under their license, all the testing all the results giving all the downstream effect of it is under the REI who did that, that care. So sometimes we don't have the bandwidth to do all sorts of things. So you have to quickly decide how how you are going to navigate that whole system. Like if you have the capacity, there are some areas who might feel extremely comfortable, they have done 1000s of cases of this complexity, and they feel great, wonderful. But then if somebody has been practicing in the field for a number of years, and they are not kept abreast with the technology right now, they're better served with like having somebody else be their partner for just that little piece of it, and then you go back to doing what you're doing. But you consulting advisors, or I think the way to go, I don't take any of the network's would want to take decisions on a clinical thing. without consulting the right expert for anything like if I wouldn't set up an IVF lab without an embryology lab director, like I don't know what happens inside of that place, right? I'm gonna have an embryology person, a PhD in embryology, set by me and tell me and then we can do it together. Right? If I was opening the door for a new test to be brought into the system, I would want to know, you know, what does the test do? Why is the cost higher than the other company next door? Like what are you doing extra that other person is not doing? And they can like tell you they very well, the salespeople would exactly be able to pinpoint the difference. And then you say is the difference like something that's just a frill? Like, is it just something that's additional? Or is it like really something that's like a clinical change, it affects us, it has a huge patient advantage of going with a certain company.
Griffin Jones 50:51
Well, let's talk about what it's going to be like as it becomes more of the marketplace. So Dr. Stable has been on the show, and he talks about genomics and ART as infertility just being a fraction of what that could be for the general population. I've had other people on like Jamie Metzl, the author of Hacking Darwin, who I don't want to paraphrase him too much, but he posited something like, within a few decades time, we would expect almost everybody to be born from ART and using genomics as part of that. Where do you see the marketplace going?
Dr. Mili Thakur 51:31
So I think in the next 5 to 10 years, you know, there is going to be emergence of a lot of new things. So what we're going to see in my mind, is whatever has been available is still going to be continued to be available. But there's going to be this emergence of new technology with all the big data analysis that's now going to happen with artificial intelligence, there's going to be new things that we are going to be suddenly be able to offer to patients. And that's why you need to develop the workforce. So if there is any listeners out there who are looking for the next big opportunity of like, where to invest, you know, genetics is one of those big areas. And that's because there's going to be this influx of information that's about to hit us, that's going to be all these new tests and all these new data analysis that is available, are we ready for it? Is there a company out there, you know, that's able to just handle all that needs that these doctors are going to suddenly have to face? You know, that's the, for the next 5 to 10 years, we're going to be in transition, like it's not going to be an overnight change. And artificial intelligence in all different forms needs to learn, and it's going to learn from humans. The second thing is that on the other side, have any of those tests like or any of that artificial intelligence, data analysis is a human, you're still going to give it to patients, and patients have physical needs, they have their emotional needs, they have their family needs. And you know, no, no deep learning language model is able to tell a patient or comfort a patient who's crying, you know, sometimes these genetic test results bring an overwhelming amount of information. And, you know, so there is going to be the transition. So we will have our traditional models still be there, and then this new emerging technologies are going to overlap. And then at some point, you know, hopefully, we are able to get to a point where everybody is able to benefit, like, I'm a huge, huge proponent of proactive genetics, like in my mind, at this day and age, a young person should never be in the blind, they may or may not choose to do the testing, or any of the IVF process to take care of it. But they should, they should not be a single young person in this day and age in the US who doesn't know that they have a high risk cancer gene in their family that either they are a carrier or they're not or that they're a carrier of a certain preconception genetic carrier condition that's available by a saliva test done in about two minutes, and doesn't cost too much. And they still don't know their carrier status, like we have to change that we have to bring genetics to the mainstream in an easy way. So everybody knows I'm a carrier of cystic fibrosis, and you know, I'm going to test the partner if they're going to ever be in a relationship before they have a child so no child is then affected.
Griffin Jones 54:47
You're making a really strong case that this is one of the biggest investment opportunities in this space, partly because, why does anyone have to be born with a chronic disease that could have been preventable and that pool of people is even larger than the pool of people that we're serving now. But if it is one of the biggest areas and opportunities for investment, Mili, why doesn't it look like it is right now?
Dr. Mili Thakur 55:14
So the reason why it does not look like right now is because the two fields are being seen separately. So the advantage that I have is that I see both the fields and I have this view, vantage point that's different. So IVF, doctors specialize in doing IVF and taking care of couples who are trying to conceive by non IVF processes, right, they are busy with it, that's what they do. The doctors in genetics are busy taking care of people who are sick. So any genetics department is mostly situated in an academic center, and they are taking care of the reference that they get to find answers after the disease has happened. You know, from my vantage point, though, there is this huge gap in between those two specialities that can be filled. So if there is somebody out there who's able to uncover the risk for individuals who are not sick yet, you know, we are able to prevent the disease from happening, and also be a partner to the IVF practices for something that they're not even getting a referral off. So the reason why it's not been seen as an opportunity is because it's an untapped market. It's not been tapped, because the two specialities are not being able to see that. But from my vantage point, and with the expertise that, you know, we are able to have, you know, I'm able to see it, like it's right there. And it's been pointed out by a number of prominent speakers, you know, preventing adult onset cancer in our child, it would be huge, like, they would not have to go through all these screening tests and risk reducing surgeries that, you know, adults now are going through, but you don't test for these conditions in a baby or a child you test for these conditions and a transfer a disease free embryo. The same thing for neurological conditions, you know, there is conditions that that can be prevented the same thing with newborn condition. So newborn diseases, you know, are inherited metabolic diseases, and it's preventable. It's like completely preventable, if we are able to merge those two fields, and that merger will happen. But the opportunity lies now because it's untapped.
Griffin Jones 57:45
These genetics companies that have closed their fertility divisions, are they going to be able to get back into this space, this merger of the two worlds as you describe it? Or are they going to regret closing their fertility divisions?
Dr. Mili Thakur 57:59
So I think what is driving their closure is not a disinterest in the field. I think it's the challenges that the financial world is facing right now. And, you know, if they're part of your audience, you know, I would want them to look at that, again. So at this point, when the technologies are emerging, you know, you have a better view of investing in that thing. So right now, you know, a good example would be the artificial intelligence field, it's not there yet. But all the venture capitalists are looking for the next best thing that's going to be there on the horizon. And in our field, you know, one of the there are multiple fields, multiple things that are important. One of those things is reproductive genetics. So right now, whoever focuses on reproductive genetics and builds a strong infrastructure around it is going to have a definite advantage, not at the current time, it would start to show in the next 235 years, so technology in genetics is not going anywhere else. The biggest advantage they would face is the same advantage that the practices that invested in genetic testing for cancers have so good analogy for some of the people who are thinking about jumping into this field or, you know, thinking about it, is that in cancer, feel you you are able to serve the patient by doing chemotherapy. And right now, there is a whole science and a field that has developed inside of the cancer field, oncology field, that banks on molecular testing for the right mutation and the cancer and then giving the right chemotherapy. So any pharma company who was going to be developing these new tests needs a genetic mutation, and anybody who's going to give that chemotherapy so that hospitals benefit by giving the chemotherapy to that patient and the insurers the insurance companies better become stronger. So everybody in that whole system that so basically what I'm trying to say is we need to develop an ecosystem that combines the different genetics inside of the reproductive field right now they are scattered, they are in different locations. And we need to create that ecosystem with the understanding and the nurturing under a specialist.
Griffin Jones 1:00:26
Where does the new venture that you're working on fit into that ecosystem?
Dr. Mili Thakur 1:00:30
So I want to create that ecosystem. So the new venture that I'm venturing in is is genome ally. So we want to be partners for anybody's genetic needs. The first phase of that venture is to be able to help patients uncover their risk. So proactive genetics, to be able to make them aware, have them do the testing, get the test results, and then you know, if the test results are negative, they go back to their normal trying or, you know, family building as they please. But if we uncover a risk and we find something, then they are able to go through the process of IVF to prevent the disease, that they are a carrier, often, it also helps them proactively take decisions to be not getting the disease that they carry. So if it has an adult onset condition, if we take care of somebody who's like in their 20s, or 30s, they're not going to be suffering from lung cancer, because you already picked the condition and you're able to do it, it's going to also benefit some of the other specialities in our field. So if there is an employer based benefits company, if they're able to provide that to their employees, you know, it's a huge advantage, you're going to have a person not drop out of the workforce, as a young person with an adult onset condition are you going to have a family not get affected by a newborn, who suddenly so sick, and then they can't come to work? You know, these conditions are very rare in individuality, but then when combined together, it's a very big group. So I was looking at the data the other day, you know, there are about 3000 babies born with a certain number of a certain condition, and then 3000, more and 3000, more and 3000 more of certain other things. So if employer benefit company is able to provide the service to the employees, we are going to find some some families that are going to not then use up a whole lot of insurance and have sick children or have a disease to themselves. And it's a win win situation, it's the biggest win for the patient, that now doesn't have a preventable condition. It's a big win for the child that is born that is healthy, and doesn't have to worry about it in the future generations. And then it's a huge win for the employer because they get the goodwill of the company plus also for the benefits company, because they are they were the one for you know, your listeners and Walt progeny and carrot and Maven and all of these employee benefits company, it's such a huge win for them
Griffin Jones 1:03:15
Will Genome Ally be a carrier screening company, as part of it, or is it partly genetic counseling platform that interfaces with any kind of carrier screening company? How does that work?
Dr. Mili Thakur 1:03:31
Yeah, so I want to partner with industry partners. So what I would like to do is I would like to be the one providing the consultation and ordering the test, giving the test results and then bridging them to the required specialist. But then I would work with the industry partners and select them carefully to see you know, which one we are going to be using. And it changes over time. Sometimes these companies as you know, are evolving, you know, they come out of a certain test and don't do that test anymore. So, you know, you should be able to do what you do best and not reinvent the wheel. So if there is a donor company, right, that has like egg donor sperm donors, they're only needed to like match the intended parents with the right donor, and then we would, we would be able to handle that little piece of it while they do their job of matching and doing the cycle and everything. So what I'm suggesting with this company, and you know, that's my vision of the company is to be able to develop that ecosystem of having different partners and being providing the service that is required for reproductive genomics in a wholesome way. The first phase of it is going to be direct care. So be able to see patients whether they are coming to us, you know, by direct marketing or whether they are coming through employer benefits, you know, with that would be a huge advantage for the patients.
Griffin Jones 1:05:01
How far along are you with this venture? Are you just proving concept right now? Are you raising money? Are you selling any early stage customers?
Dr. Mili Thakur 1:05:09
Yeah, so we are about to offer the services to patients, you know, the website should be ready in the next few weeks. So by the time I think your episode will air we there should be a website that's available, you know, I have all the other required things. And because, you know, in this day and age, you have to be ready to scale up pretty quickly, the scalability, I might consider investors at that point, but right now, you know, I just want to take some patients through and to and to be able to, you know, be in the know, of like, how the whole system works.
Griffin Jones 1:05:49
Yeah, I think that it's also really good to have something that you know, is going to scale, when you get the investors to help scale it. I think there's been a lot of people in the era of free money that have had ridiculous valuations, just to prove a concept that was never proven, we might be going back to the era of you work hard to build something to prove the concept. And then and then you can get people to scale it. And so you've got something here in that school, that it's that right now. It's you, you know, it's your your venture, and there's no outside money in it. We've covered a lot of ground today, Mili, and we got deeper into carrier screening than I thought we were going to, but I'm glad we did. Because you've you've convinced me to the extent that I can be convinced I'm not a clinician, but you've convinced me that it isn't the commodity that maybe I'd gotten the impression that it was but of all of the topics that we covered today, how would you like to conclude?
Dr. Mili Thakur 1:06:48
So I would like to say that, you know, in your audience, there are different types of stakeholders, and they all have like a different vantage point of the field for reproductive genomics. At this point, we are at a point where there would be a lot of emerging technologies, we have to be ready for taking care of the patients as we are bombarded by these technologies. And we should be ready to take care of the physicians and the clinical staff in an IVF practice, to be able to support them and giving the best patient care is going to cause them to have better patient engagement and retention, and then it will help them generate revenue for the practice.
Griffin Jones 1:07:36
Dr. Millie Thakur, thank you so much for coming on the Inside Reproductive Health podcast. I look forward to having you back on in the future.
Dr. Mili Thakur 1:07:44
Thank you so much for having me, Griffin.
Sponsor 1:07:46
This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Contact bundle at bundle. That's bundlfertility.com/contact-bundl. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guest appearance is not an endorsement of the advertiser. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.