Universal Health Services, Inc. (UHS) Earnings Call Transcript & Summary

Welcome, everyone, to this patient-focused webinar. We're just going to allow a few more minutes to allow everyone to get signed on, and we will begin here shortly. Thank you for your patience. It looks like we have a good number of attendees signed on, so let's begin. Today's presentation is for educational purposes. We are very fortunate to be hearing from Dr. Betchen from United Health Services as she discusses focused ultrasound as a treatment for patients diagnosed with essential tremor or Parkinson's disease. [Operator Instructions] Let me begin by introducing you to today's presenter, Dr. Betchen. Dr. Betchen [indiscernible] Neuroscience and Neurosurgery at UHS hospitals in Binghamton, New York. Dr. Betchen completed her Bachelor's Degree at the University of Pennsylvania. She attended medical school at John Hopkins School of Medicine and completed her neurosurgery residency at Mount Sinai Hospital, followed by a neurosurgery fellowship at Memorial Sloan Kettering, both located in New York City. She has over 18 years of neurosurgery experience in a variety of neurological conditions and treatments. Welcome Dr. Betchen, and thank you so much for presenting to us today. The floor is all yours.

Thank you, Katie. Good afternoon. I appreciate that kind introduction. And I appreciate everyone spending some of their time this afternoon with me to learn about essential tremor and focused ultrasound. For those who might be just coming in a few minutes late, I did go to undergraduate at University of Pennsylvania and Philadelphia and followed by getting my MD at Johns Hopkins School of Medicine in Baltimore. I did do my training in New York City and have worked for over 18 years as a neurosurgeon. Currently, I'm the Chief of Neuroscience and Neurosurgery here at UHS Hospitals in Binghamton, New York. I wanted to start by showing you the agenda for today. so you know where we're going with this presentation. First, we'll talk about essential tremor facts. Next, current treatment options, we'll cover what is focused ultrasound and who is eligible for treatment, some of the 5-year clinical results data, what to expect on treatment day and the patient journey, insurance coverage. Then we'll go over the second side procedure. And of course, we'll have plenty of time at the end for questions or anything that needs clarification that I didn't cover. Let's start with some essential tremor facts. Essential Tremor also referred to as familial, idiopathic or benign tremor means that there's really no known cause of this medical condition. It does affect about 1% to 2% of the population. And when we look at patients over the age of 65, it's really more like 5% of the population. It is 20x more common than Parkinson's disease and can be hereditary in up to 50% of cases. However, there is no genetic test to confirm that diagnosis. As those of you with the disease or with family members with the disease can testify to, it is progressive over time. Essential tremor affects many different activities in a patient's daily lives, getting dressed, eating and drinking and writing or drawing. This then has not only physical side effects but emotional ones as well. There's a perceived stigma that many patients feel they have with the tremor leading to psychological distress, avoidance of social situations and going out with family and friends and difficulty at work, all of which can take away a patient's independence and feels very isolating. I do get asked this a lot. So I'd like to go over, close to the beginning, what really is the difference between a tremor from essential tremor versus the Parkinson's tremor. One big difference is the location. In essential tremor, it is essentially the hands, head and potentially voice, where Parkinson's often affects both the hands and the legs. Response to medication is another good indicator of diagnosis, where in essential tremor, something like propranolol or primidone will help, perhaps, they would not help in Parkinson's. The flip is also true, where in Parkinson's, levodopa, otherwise known as Sinemet, can be quite helpful. It would not help a tremor in essential tremor. Also the tremor type, in essential tremor, it can be postural and is really brought out by actions, grabbing a cup, trying to drink, trying to write. Whereas in Parkinson's disease, it is a resting tremor usually and become postural later on in the disease. Essential tremor does not have any other associated symptoms with it, whereas Parkinson's disease does have a whole constellation of symptoms, which includes slowness, stiffness and walking problems, gait disorder. We already mentioned that essential tremor can be familial in 50% of cases, whereas in Parkinson's disease, that's only about 20% of cases. The impact is that it really affects about 10 million Americans that live with this debilitating tremor, many of which do not seek any treatment at all. For those who have treatment medications often do not give satisfactory results. And in fact, up to 50% of patients will not have satisfactory relief from medications or have side effects from the medications that they're unable to tolerate. I wanted to show you this video that's going to take just a moment to load up. [Presentation]

If you can relate to Michel, this gentleman, I would urge you to get in touch with us and set up an opportunity for screening. There are a spectrum of treatments for essential tremor. Like we mentioned, medication, always the least invasive and first line of therapy for any problem. There are several classes of medications that are common to use for essential tremor. Beta blockers is the first class, so that includes propranolol, antiseizure medications, such as primidone, but also patients can try Topamax or gabapentin as well, which all can potentially give benefit. And then lastly, the anti-anxiety medications can dull the tremor also. There are wearable devices, probably the most well-known one is the [ Cala kIQ ], which mediates the -- and disrupts the median nerve activity at the wrist and helps with some of the tremulous activity in some patients. Lastly, there's procedural interventions. And those range from the leads that we can implant for deep brain stimulators, to radiofrequency ablations, Gamma Knife radiosurgery and then what we're here to discuss today, which is focused ultrasound. It's important to understand why we're targeting the area of the brain that we are. It is felt that the generation of the tremor is in our back of our brain, in a deep part called the cerebellum. It sends a signal to the thalamus where the red X is on this pictograph to the right. It is this relay station that it then sends the information to the motor cortex and causes the tremor. All of these treatments are targeting that area in the thalamus, that's the relay station that has the faulty signal that we're trying to disrupt with a therapeutic lesion with the focused ultrasound. When we look at things like surgical intervention, while a deep brain stimulator for some patients may still be the best option. There are some disadvantages as well. It is a conventional surgery with an incision, risk of infection hemorrhage and then needing frequent generator changes and visits for programming. Gamma Knife for radiosurgery also has the disadvantage of it being radiation as well, you can't test the location, which we'll talk about a little more later in focused ultrasound, and it takes time, 9 months at least, to see the results. I really want to show you these pictures on the right, mostly in that B panel. You can see there's that little p shaped white on the right-hand side, that lesion is in the thalamus, and that's about the size of the therapeutic lesion that we're talking about making with the focused ultrasound to disrupt that relay station. Focused Ultrasound uses MRI that can read the temperatures and guide the waves to create a focus of the spot in the thalamus to disrupt the tremor activity. Testing is first done with low doses while you're awake and able to be checked frequently for improvement and any adverse effects. Once we have confirmed our target, then we can make a more permanent or final lesion. This cartoon version of what to expect I think is helpful. [Presentation]

Hopefully, that helped to understand a little bit more of what goes on during the treatment. The therapeutic power of focused ultrasound is impressive immediate results as we can see from the before and after of these Archimedes circles on the right-hand side. Many patients will have this immediate tremor improvement with minimal complications. Most common question we probably get is who is eligible for this treatment. And I wanted to go over that in a little more detail. And of course, if there's further questions, we can answer those later as well. You must have a confirmed diagnosis of medication refractory, meaning failed medication treatment essential tremor or tremor-dominant Parkinson's disease. You must be 22 years or older for essential tremor treatment, able to tolerate the procedure and communicate with us during it, obviously, able to hit the stop button if needed and to fit within the MRI scanner. If you do have any implantable devices that are not MRI compatible, then unfortunately, we would not be able to complete this procedure. The other contraindication is the density of your skull or a skull density ratio, that is something that we have to calculate after a CT scan. And unfortunately, there's nothing any of us can do to influence what that is for you one way or the other. While you may be learning for focus -- about focused ultrasound for the first time, this is something that has been done since 2016. Up to over 20,000 procedures worldwide have been done at this point. The graph on the right shows the exponential growth of this procedure over time, and we're fortunate now to bring that technology to the Upstate New York region. I just show this to show that there's been multiple studies by different groups publishing in different journals to attest to the effectiveness and safety of this treatment. The 5-year data that came out in 2021 shows that there is a 73.1% tremor improvement at 5-year follow-up, really telling us that this is a durable treatment with lasting effects. There is always a risk of adverse events. Those are listed the most common ones on the right, which include imbalance, numbness and tingling and headache and head pain. Many of these resolved within 30 days and within the first several months after treatment. And evidence is that 5 years, there's no new adverse events or effects of the treatment that weren't there to begin with. The day of the procedure, patients come into our outpatient MRI center. We do need to shave the head, so nothing interferes with the localization of the ultrasound waves. After numbing medication is applied, we do have to apply a frame to secure the head so that there is no movement during treatment. During the treatment, you're wide awake on the table and in and out of the MRI scanner. Images are taken to plan the treatment, and once the treatment is done, lighter doses of energy are applied to pinpoint the target and test for not only tremor improvement, but to identify any potential side effects. Very small target adjustments are made, and once we are confident in our location, a higher dose of energy is applied to create a more permanent therapeutic lesion for improvement of the tremor. The benefits that patients should expect are immediate and durable tremor improvement with a significant improvement in their quality of life. It is outpatient, home the same day with little or no risk of infection, no implants, no wires, no probes, no ionizing radiation and no need for anesthesia, so patients with medical problems at baseline, don't have to worry about the anesthetic complications. It's really quite transformative for the patient before and after the treatment. We really only can treat one side to start with. The second treatment can be done and the eligibility for that is largely the same with the caveat that it must be at least 9 months after the first side is done. The data for the second side surgery at 6 months demonstrates an 80.2% tremor improvement at 6 months follow-up. What this really means for our patients, again, is that this is a durable second side procedure. The side effect profile for the second side is very similar to that of the first side. You might be thinking so why choose UHS for focused ultrasound treatment. And I will tell you that UHS has a long history as being recognized as a leader in the treatment of brain and spine disorders, and a top neurosurgical center in the upstate New York region. Many of the same reasons I chose to work at UHS are reasons why UHS is a great choice for receiving your care here. This is a team that is deeply committed to providing cutting-edge technology and the highest standards for our patients. We provide with comprehensive care throughout your journey from the screening to the follow-up, and we care about you as individuals. We understand and tailor our approach differently to each patient. And we are the first and only health care system in the state of New York that will be using the latest iteration of this technology, which means our patients will benefit from the most efficient and advanced treatment experience currently available. We also aim to provide ease of care with virtual screening options for patients who may live farther away. And when in-person visits are required, we certainly have ample parking for patients and families and local hotels if that's a more comfortable commute for you to do overnight. We do recognize that, obviously, where you choose to receive your treatment is a significant decision and encourage you to reach out and meet our team. I want to go through these frequently asked questions, the FAQs. I find that these are things that I've been asked most commonly and it's nice to be able to talk to them -- talk to you about them because I'm sure that more than one person here is wondering about these. What if I'm interested but live far away? We absolutely can do virtual visits for the beginning and our initial discussions to see if this is something that you're eligible for and see if this is something you're interested in moving forward with. Is there an upper age limit? There is not an upper age limit as long as the other requirements are fulfilled. I've heard of 90 year olds getting these treatments. What we need to understand is that patients need to be able to tolerate the MRI and do need to be able to interact. So we know whether they're having side effects and whether the tremor is better or not. Does my insurance cover this treatment? Almost all of the private insurers, the commercial insurance companies do cover this. And Medicare and Medicaid also cover this procedure. If you're curious about your specific insurance, please reach out, and we're happy to look at it on a case-by-case basis. Will I need to keep taking my tremor medication afterwards? Really common. If you have tremor in both hands, remember, we can only treat one side at a time. Therefore, many patients do choose to stay on their tremor medication afterwards because the second side hasn't been done yet until at which point they're eligible for that in 9 months out. Do I need to hold my anticoagulation before the procedure? Yes, you will need to, and that will be discussed with you at your visit about how many days beforehand, you would have to stop that. Do I need to hold my tremor medication before the procedure? Yes. We want to see your tremor in all of its glory on the day of the procedure to know whether it's not -- we're hitting the right target and it's getting better. So you're -- so we will discuss with you how to taper off beforehand. What if I have an implantable device already like a pacemaker? Again, it depends on the specifics of it, and we have to look at the manufacturer card and determine whether or not it's compatible with the MRI machine or not. What if I am claustrophobic? While we can't give you anything sedating because we do need you to be able to interact with us, we will absolutely do everything possible to make you comfortable and get you through it. With the newest technology, the scan times are much shorter. While we can't completely take you out of the MRI suite, we can certainly move the bed in and out of the machine, and you are not in the MR machine itself during the entire treatment. Treatment itself usually lasts about 1.5 to 2 hours. And you'll be at the facility about 5 to 6 hours from start to finish. How do you determine the best treatment for essential tremor? This is something that you have a discussion with, with either a provider that you're currently seeing for your essential tremor or you can call us and we can discuss that with you as well. I think I mentioned, we always start with something least invasive like medication. And if that fails, then we can talk about essential -- focused ultrasound as a treatment. I think I touched on this briefly, from your time of arrival to departure is probably about 5 to 6 hours. And then always asked is the focused ultrasound effective for voice or head tremor? It is not at this time. While there is some early suggestion that after treating a second side, we have seen some voice or head tremor improvement. It is not an indication or reason why we're treating. At this point, we are treating with focused ultrasound to improve the hand tremor. I wanted to give some time for questions and answers. Hopefully, if you have any questions, you feel comfortable putting them in the chat. Also, you'll see there are many ways to get in touch with us. Our web address is here if you just want to poke around and get more information. Our e-mail and telephone number are there as well with a QR code, if that's easier for you to scan, and we're happy to reach out, get you more information, screen, send you a copy of the webinar as you request.

Awesome. Thank you so much for a wonderful presentation. I love listening and learning, and I learn something new every single time, and I hope everyone that is on feels the same way. As you said the Q&A, we'll start that. We have 1 question already in. So we have plenty of time to ask and we'll get going here. So people want to know about what would cause someone to have a more successful outcome and a less successful outcome? Is it age factor in that? How long they've had essential tremor? Is there any kind of rhyme or reason to that success rate?

So nothing in the literature about age or length of tremor being a marker for success. I think that one thing might be just your skull density ratio, which none of us can control for you because that does dictate how we get the energy to -- the sound energy to the point. And what temperatures we can utilize and how effective it is. But really, there's no factor that I would look at you and think about the effectiveness based on anything in your history necessarily.

Perfect. So E-mail. I know we have people from all over on the webinar. Can you give a little historical context, how far you guys are from Pennsylvania city, the ease in which it is to come in and get treated and evaluated?

Right. We're about 10 minutes from the Pennsylvania border, about three hours from Philly, about 3 hours from New York City, about 4 hours from the Boston region. I think depending at Rochester, 2.5, Buffalo probably 2.5 to 3 hours. Syracuse about an hour and 15 minutes. Is this what we're looking for Katie? Did I miss any of that?

Useful to know and I love that. I love that because we're -- not that I live in New York, I'm a Midwest person, but those are all reasonable things that -- we drive all the time in a day. So I love that. So someone wants to know what the next step is. So they e-mail, they call you, what happens now?

Right. So if you e-mail and call and are interested and want to be screened, we have a program coordinator, Sheila Smith. She will reach out to you and do an initial screening and answer any further questions you have. If there's anything that is a hard stop, for instance, if you had an implantable device, that's not compatible, we'll have -- we can help you to get you to the next level of a treatment for something else, if that's what you're interested in. But after that initial screening, then you can set up an appointment to see me either virtually or in person as whatever is easier. My office can set that up either way. And we continue the conversation from there. If things look good, we get a CT scan to look at that skull density ratio to confirm eligibility. I also get an MRI on the magnet that we use, knowing then that you're comfortable in the space and we want to get some special imaging that we then can fuse with the images on the day to give us more information and better targeting. And then after that, we can talk to your insurance company and get you scheduled.

Perfect. And that patient coordinator is the person that's going to answer when they call the 607 phone number and that e-mail address, correct?

Correct.

Perfect. Awesome. So if someone only notices their essential tremor maybe at night, not every day, they've been seeing a neurologist for 2 years and have been on medication with really no change, how can they be sure that it's essential tremor or there are good content? Is tremor consistent on a day-to-day basis with medication? Does it work for all 24 hours? Are there other things that might you can maybe offer to this person and the audience and advice on that?

Right? Essential tremor can get worse with stress, with anxiety, with lack of sleep. Many patients tell me as the day goes on, it gets worse. For us to successfully treat you, we need a significant tremor that we can test in the machine on the day of the procedure to make sure it's getting better. Sometimes if your tremor is very minor, then it might just be changing the medication or the dose or the time of day that you take that medication to make sure to improve its effectiveness.

How many total visits? So would someone come through this whole process, whether it be in person, virtually and a follow-up post?

Right. Definitely, it kind of depends if you're in person or video to start, right? I think I can give you an example of both. If you're going to start with virtual -- one virtual visit to discuss. I would -- we would need you to come 1 day to do the scans beforehand, and it would be great to meet you in person at that point as well to do some of the testing like the Archimedes circles, et cetera. And obviously, we can plan that all for one afternoon or morning for you, so that there's no back and forth. And then the day of the procedure itself, the follow-up after the procedure can all be done virtually. The initial follow-up will just be via phone with our coordinator. And then I would like to see all my patients about a month out, and again, in person, virtually whatever is your particular preference. After that, if you're doing well, we don't need to have regular follow-up unless you have questions or you want to talk about at the 9-month mark, having the second side done, if that's something that you're interested in?

Perfect. So I'm going to kind of bridge these 2. So we have a question that wants to know like how long has focus ultrasound being performed at UHS? Let me start with that because then that will kind of lead us into the next question.

Right. So focused ultrasound is going to be a new treatment for us here at UHS starting this quarter.