All right, thank you very much, thank you for that nice introduction. I am going to just put that there real quick. Can everyone hear me okay? All right, perfect. Yeah, let's jump right in. So, as you know, the whole concept of kind of bundled payments, transparent pricing has really grown a lot in the last few years, in part because of some regulatory burden that's been hoisted upon us by the federal government and other states. But more importantly, because patients, this is what our patients want, payers and patients want more transparency in pricing. And I think a lot of people look at this kind of thing as maybe a headache. And what I hope to show you today is why this is an important market, how it can really benefit your practice, and how these patients, these direct-pay patients, really can be your best, best patients. For me, they are. Like, I practice in Naples, Florida, just down the coast. It's my hometown. And I treat a lot of small business owners and others who kind of are self-funded. And they're very appreciative of getting access to care for a reasonable price. And I don't have to do a lot of paperwork in order to treat them. I just treat them and get paid. It's kind of the way healthcare should be. So, at any rate, with that, I'll skip through a couple of these. We've already covered them. Check-in code, I think you guys got that. But if anybody didn't catch it, there that is. And we can put that up again later. Financial disclosures, I have founded a company called HealthMe Technology that helps people accomplish these things we're talking about today. But at any rate, our key points, I won't read all of these. But basically, I want to help you learn who these patients are, and how big this market is, how you can apply what you learned today towards implementing a direct-pay process in your practice. And the reason a lot of us haven't do this is there are limitations. We're going to talk about some of the hurdles and difficulties doing it, and maybe how to smooth those out. And then finally, we'll talk a little bit about good faith estimates. So, came down the pipe last year for us, federal regulatory burden. And I kind of hope to show you how, by embracing pricing transparency, you can take something that's a negative, good faith estimates, and turn them into a positive, a revenue generator for your practice, and a way to capture new patients. So, with that quick summary, we really just covered this, but we're going to talk about what is pricing transparency, and the size of the market, and why it's growing. We'll talk a little bit about the No Surprises Act, good faith estimates. We'll talk about how to do it, how to bundle things, how to price them. And then talk about some of those benefits to the practice that I mentioned. And one of the messages I want you to think about here is direct payers, self-pay, people paying directly for their health care, whether it's an employer or a patient. These are my best payers. They're my best patients, literally. And most of the practices that kind of embrace this movement find the same thing out relatively quickly. And we'll talk about why. So, introduction. I'd like to start with a couple of questions. Those of you who heard me talk on the subject last year may remember this, but we've updated some things. So, I'd like to just ask, just by a show of hands here, and don't be embarrassed to answer, but so how much money was spent out of pocket on health care in 2021? These are federal government numbers. So, how many, say 500 million? Any hands out there? 500 million? No? How about 5 billion? Anyone? Got one here. How about 50 billion? Quite a few people are at 50 billion. How about 500 billion? Got two or three or four or five. Great. The answer is, drumroll please, 500 billion dollars. So, this is federal government data, the CDC, out-of-pocket payments, 491 billion dollars in 2021. And that's growing at a clip of about 30 to 40 billion dollars a year. They've not released 2022 data yet, but it went from 430 to 491. And the year before that, it was like 390. And so, it's ramping up. So, patients have more responsibility for the cost of their care is the message here. We'll talk about self-insured employers too, because ultimately they are direct payers, right? A lot of them use the BUCAs for their TPAs, but a lot of others have smaller and mid-sized TPAs, a lot of municipalities and others that are looking for transparent price bundles for their employees. So, anyway, again, show of hands, how many patients, how many people in the U.S. are employed by self-insured employers? So, we'll go down the line. A, 150 million. Anybody for 150 million? No? No? How about 100 million? A couple there at 100 million? All right. 50 million? All right. That's a pretty big number. People are thinking 50 million. 25 million self-funded employers. Got a few out there at 25 million. All right. So, the answer is 100 million Americans. So, there's about 160 million Americans who have insurance through their employer. In the United States, about two-thirds of them work for a self-insured company. And so, a lot of these, again, you wouldn't know it. A lot of people carry a blue cross card or Aetna, because the BUCAs actually operate as TPAs and stop loss for a lot of these. But even these companies, they're going outside those plans to cover their deductible. Because one thing about self-funded companies, they generally are taking on risks to get lower premiums. So, a common number is about 50,000 per insured employee. They'll pay the first 50,000 that care. It could be a little less, could be a little more, depending on the contract. But that's a pretty common number. So, if you're an employer and you employ, say, 1,000 people and you're going to pay the first 50K of healthcare for each of them, do you want to go to the emergency room if they sprain their ankle? It's going to cost you 5,000 bucks or somewhere. Would you rather have them navigate them to one of your clinics that has an urgent care or just seeing one of your doctors? So, that's a pretty common number. Because the ER is not going to really do anything anyway. They're just going to say, well, you know, go see an orthopedic surgeon. And so, if you can kind of interrupt that and allow these people to navigate to your practices, that's a lot of value to the patient, the employer, and your practice. So, anyway, large, large group of people. So, why do I do this? And anyone that saw my talk this morning, there's two or three slides here that are repetitive just because they kind of make the same point to kind of set the table for our discussion. But I started doing this about seven years ago. I practice in my hometown. A lot of my high school friends are people I grew up with. They're small business owners, right? They own restaurants. They're contractors. They're realtors. They're people that make good money. But they've elected not to carry health insurance because they're paying $30,000, $40,000, $50,000 a year between premiums and deductibles. And they're business people. And they're like, I'll just pay as I go, right? And so, these people exist in every market. I realized I was turning them away because they called me out on it. My staff, even though we had a self-pay pricing piece of paper, my staff was turning them away because they didn't have a good process. They couldn't predict the future because we hadn't bundled our services. And if you don't bundle your services, you don't really have a product to sell. You can't tell a consumer, well, it might be this. It might be this. Depends if it's this. Depends if it's that. Most of what we do as orthopedists can be bundled pretty easily in the office. And then you need a fixed price for that. So, there's no haggling and this, that, and the other thing. But because we don't have an empowered our staff to know those things, it's easier for them to say no. And we'll talk about that a little bit. But why do I love this? I did it to kind of accommodate my high school buddies. And it turned out to be a much bigger market than I thought. And, you know, basically, then we wanted to automate it. We built a software solution. And next thing you know, other people wanted to use it. So, it kind of became a company. But at any rate, I set the prices, right? There's not an insurance company telling me how much. They're not telling me what I'm worth. I'm able to name what I'm worth and my partners as well. Paid it in time of service, no 30, 60, 90 day revenues, you know, cycle or any of that. I can spend more time treating my patients. At the end of the day, as a physician, I want to be able to, you know, take good care of my patients, get them better. But in exchange for that, I want to be paid a fair price in a timely manner. And that's not the case, I think, right now with a lot of third party payers. So, more importantly, my patients and staff love it. These patients love getting access to the fine care that you provide at your practices. And right now, a lot of folks are being turned away. They end up in the emergency room. Not a good situation for anybody. And then the last thing, which this is a new addition in the last, you know, year and a half, is being compliant with federal law. GFE, good faith estimates, are very onerous and cumbersome to manually prepare. But if you've bundled and priced your services for direct payers, for self payers, it makes it a lot easier to provide a good faith estimate. And there are automated tools that can help you do that. So, why is this market expanded? I mean, I talked about those numbers going from 330 billion to 360 to 390. You know, now we're at 500 billion over the last, say, five years. Because everybody's frustrated here. Patients and payers, healthcare is just simply unaffordable. You know, patients have increased responsibility for the healthcare costs, these high deductibles. And we're frustrated as providers. You know, there's a study out of Stanford that showed docs spend like 50% of their time in the office on administrative burden, right? So, documenting, you know, all the stuff that you're doing to get paid, right? We want to keep a good medical record. But I think we all agree that most EMRs we use, they create, you know, a great platform for billing. But if you look at those medical records, if you're a provider, like, I get referrals, I don't even look at the medical record because it's just, you know, it's CPT and ICD codes. Like, it's nothing relevant clinically in there unless I want to spend a long time deciphering it. Revenue cycles are lengthening. A lot of docs are burned out on this. And EMRs and data entry are cited as the number one reason doctors say they're burned out and are retiring early or not going into the field. So, how can we address some of this, not all of it, but the direct pay movement can help us here? I talked a little bit about the size opportunity in my slides. So, the out-of-pocket we talked about. Self-employed employers, about an $800 billion spend, depending on the study you look at. Some are higher, some are a little lower, but bottom line, big market. And we all are, you know, Medicare is a big chunk. It's an orthopedic surgery practice. I mean, it's a big chunk of all our practices. I practice in South Florida, so it's maybe a larger chunk of mine than some areas. But we do all this stuff. Medicare, $695 billion. It's a smaller market than the self-funded employers spend and a fewer number of patients than those who work for self-funded employers. So, this is a very large market that's missed by a lot of folks. You know, I talked about this this morning at the end of my talk, but what these people really want is kind of a consumer-centric solution. Most of health care, especially in orthopedics, most of what we do is shoppable. Someone hurts their knee, they don't necessarily have to go to the ER, not open fracture or compartment syndrome infection. You know, those are orthopedic emergencies. But most of what we do is shoppable. And guess what? 82% of patients want to shop. Not just uninsured people, this is everyone. Even people with insurance want to know the price of their care. And the reason there's this disconnect, and more than half of what we do is still transacted by snowmobile and telephone, is because we're not really equipped for e-commerce. And this is what patients want. McKinsey, a big consulting firm, asks patients, what companies do they wish their health care organizations to emulate? Like, what do they want them to be like? And Google, Apple, Amazon are the top three. So, technology that works, convenience, value. Rounding out the top five were, interestingly, Chick-fil-A and Walmart. And so, Chick-fil-A, great customer service. We have all been to Chick-fil-A, I'm sure. And Walmart, good value, right? You're getting value for your money there. So, at any rate, that's what I think we need to start doing a bit more of in health care. And so, I mentioned this earlier. Why don't people do this? There's a lot of reasons, and we'll dive into it a little bit more. But when I realized that I was turning these folks away, I actually did a study. This paper is out of Florida, but I also did a national study where we looked at groups and polled really 4,000, roughly 4,000 orthopedic surgeons and 100 very large groups, right, around the country. And again, more than 90% of these groups effectively turned away self-pay. About 80% flat out said no, like my practice. Another roughly 18% effectively turned, they said yes, but they couldn't give the patient a price. They're going to talk to their supervisor, call the patient back. And basically, they effectively turned them away. So, only 1.2% of those groups surveyed actually could give the patient a price for a new patient visit and x-ray when they call to ask on the phone. So, why do we miss this? I think we all think we're doing this. We all have pricing on a piece of paper, as I've said. But generally, what we're asking our staff to do, first of all, we've trained our staff in nothing but third-party billing and collection for the most part, because we underestimate the size of this market and the value to our practices and our local patients, our friends and neighbors who don't have insurance, who need care. But we haven't bundled our prices. So, if you're selling something, number one, you need to know what you're selling. So, if they say, how much is a visit? Well, it depends if the doctor does this or this, or if we do an x-ray, or maybe we do this, or maybe we do that. But the bottom line is all that can be bundled. In ortho, it is relatively straightforward. So, if your staff knows what they're selling, now you can assign a price to that, right? Instead of saying, well, it might be this much if we do this, and this much if we do that, you can bundle it all, right? And you just take into account, and we'll talk about how this is done and some of the logic behind it. But you can bundle things. Staff doesn't know the self-pay price because they don't know what you're doing. But once it's bundled, you have a price there that they can quote. Collection, everyone says, I always, when I used to go to business meetings, when I first started practicing, everyone says, oh, it's self-pay, or you got to collect at the desk before you see the patient, which is a great business practice. I, personally, as a physician, never liked doing that because it just made me uncomfortable. The patient's first interaction was me hitting them up for money. So, we'd collect after, which is not a good business practice, and half the time our staff forgets, or whatever, the patient left their wallet in the truck, and you never see them again, right? So, that's why, you know, self-pay equals no pay in many people's eyes, but I hope to convince you otherwise today. So, how do we capture this market? We have to bundle, I talked about that, up front pricing, market them to patients, adopt systems and protocols to handle this, and really train your staff to do this. So, it's really more than just setting a price. A lot of folks will say, well, yeah, we've kind of done all this. We have, you know, the piece of paper with the pricing, but there's a whole process there that really needs to be done to make this successful for your group. So, we'll talk a little about the No Surprises Act, and then I'll kind of dive into some details of how you do this, how do you bundle, how do you price, and whatnot. So, the Good Faith Estimate No Surprises Act went into effect January 1st last year. This is something the government said they're not going to enforce in year one. Now, we're a little into year two. Who knows when they're going to start doing this, but the point I'm making here is basically it's federal law, so the fines for violations are similar to HIPAA, up to a $10,000 fine per incidence. Probably not going to see that soon, but they started enforcing hospital pricing transparency about a year and a half in, and we're a year and four months, basically. So, this is something important as a compliance measure for your practice. It's more than just quoting a patient a price. Some people say, yeah, we got a price, we'll just quote them. Like everything the government does, it's more complicated than it needs to be. And so, you need practice information, provider information, patient information, and contact info, a clear price, description of services must be clear, must be provided in the patient's native language if requested, diagnosis codes, CPT codes, what's included, disclaimers. The government has disclaimers about what you do if you're not happy, if your estimate's not accurate. And so, this is what needs to be sent to the patient, basically, for a compliant good faith estimate. The solution is really, as I said, is kind of commit to pricing transparency. Once you've bundled your services and priced them, it's much easier to provide somebody a good faith estimate. The other comment I'll make is I think a lot of people conflate the requirements of the No Surprises Act and good faith estimates with giving patients an estimate of what they owe under their insured plan, right? So, there's a lot of tools that do that and do it fairly well. Hey, I've got Blue Cross, what's it going to cost to see the doctor this day? There's tools that say, oh yeah, you're going to owe us $38 or whatever. The No Surprises Act specifically calls on us as providers to give a kind of self-pay price to the patient. And given that other information is great too, the law is self-pay price. So, technically, an in-network insured patient can ask to pay cash and opt out of their insurance benefit. And so, that person would need to be supplied a good faith estimate as opposed to an estimate of their charges based on their co-pays and their insurance plan and whatnot. So, they're kind of two different things, although very similar, and they kind of serve the same purpose. Patients know better what their costs are. You do this in a simple manner. You know, one example here, where if you bundled and priced, then you can have tools, various software tools that'll help you create these in kind of an automated fashion. So, it takes a lot of work off your staff's plate, storing them. They need to be stored for six years and all kinds of fun stuff. But one of the things I like to say about this is if you're providing people good faith estimates, a lot of people end up then purchasing. And so, what I've seen in my practice and others who are doing this is the good faith estimate ends up being kind of actually a sales tool. You give the patient the estimate, you give them the ability to click a button and buy, pay in advance and things like that. And actually, it gets you new patients. So, how can we do this? And I'll try to be relatively brief. As you can tell, I would probably talk here all day about this if allowed to. So, I'll try and leave plenty of time for questions. I think we have a full hour and we're maybe a half hour in here, but we'll go through this and I'll leave plenty of time for questions at the end. But how do you do it? We'll talk about this step-by-step. And each of these can be their own talk, but how can you do this in your practice? I think some people, the mistake they make is they look at everything they do and they're just overwhelmed, right? Like, I mean, what if the doctor does this? What if the doctor does that? Like, where do I start, right? And the answer is you just have to start somewhere. So, what I like to tell people is look at the top five to 10 diagnoses in your practice, right? I mean, orthopedics, you know, let's say a top 10 orthopedics. Why do people come to your office? Knee pain, wrist and hand pain, hip pain, right? Great. Bundle that, right? So, it's a visit with a doctor, maybe an x-ray. A lot of times we'll tell people x-ray if needed, and patients seem to accept that. If you offer to include an x-ray, then you don't do it. People ask for refunds. If you have two packages, one with x-ray, one without, people buy the without, then they need one. So, one thing that I've done in my practice is we include an x-ray if needed because we do an x-ray, honestly, with a new patient the vast majority of the time. And patients actually get it. They don't ask for refunds if you don't do an x-ray. And then with surgeries, you know, you have to bundle things. Some of these are multi-CPT code bundles. And again, happy to talk to anybody afterwards about details. We really don't have enough time today. Single CPT code surgeries are easy, like a total knee replacement or something. I do sports medicine. I do a lot of knee and shoulder arthroscopy. And so, a Ritcheter cup bundle could be up to five CPT codes. I mean, there's implant variability, you know, all these things. So, but I make it sound really difficult. It is difficult. But if you look at it kind of from a different perspective of, let's look at our charges for, let's look at the last 25 Rotator Cuffs we did, whether they were bicep tenodesis, decompression, this, that, and the other thing. And let's, what's our average payment? What's Medicare's payment for that bundle among our five doctors who do this at our surgery center? What's the average number of implants used? I mean, if you break it down that way, it actually starts to become a little more reasonable and easier. So, so the key is starting somewhere, office visits, adding surgeries. Physical therapy can be challenging because it's built in various units depending on what's done. Again, take a step back, look at it from a different angle. So, what I'll tell people about physical therapy is, what's your average reimbursement for a new patient therapy visit, right? Just run those numbers. Those are pretty easy. We saw 100 new patients last month and our average reimbursement was X, $150, let's say. Medicare paid us 110, our best payer was 180. Now you have a range of, like, what you're going to do there. And it kind of goes back to, like, with the physician office visits and physical therapy more so. Like, you talk to your physical therapist, any of the employee therapists, their, their worst nightmare is the same as my worst nightmare as a physician. It's entering data into the EMR in order to get paid. And they spend an inordinate amount of time doing that while they're trying to take care of patients. And if you've bundled this stuff, you just say, look, new patient visit, you're going to spend an hour with them. Do whatever you need to do to take care of the patient because you're going to get paid. You don't have to document for this or that. Or, you know, do this because you get reimbursed more or that because you don't. Or, anyway, it just makes it really simple. And, and the clinicians actually love it. Do the same thing with MRI labs and whatnot. So, bundling services, number one step. Then how do you price those bundles? A number of things come in here. You don't want to undercut your commercial contracts. You certainly don't want to undercut Medicare, right? Because then you get in trouble. Your commercial contracts, generally what we tell people is, you know, look at your best high volume commercial insurance contracts, your BUCAs. And if you're happy with those reimbursements, then there's your price. Pretty simple. If you're not happy with them, I mean, you know, interestingly, you know, a lot of my friends and colleagues around the country who are orthopedic surgeons and just working with a lot of folks on the bundling aspect, it's amazing the variability in people's insurance contracts. Honestly, like I won't go into it, but, you know, living in Florida, Florida's not the greatest market, generally. There's other states that are better, other states that are worse. There's pretty significant variability nationally. So if you have great commercial insurance contracts, that becomes your price. If you're getting paid 105% of Medicare or something, that's probably not a good price, right? And so on average, people tend to price these things at roughly 200% of Medicare, give or take, 50%, let's say. That's a wide variability, but that seems to be a price that's well accepted in the market. I often tell people, it's counterintuitive, but a lot of practices tend to underprice their services. They look at it as charity care. Oh, for charity, we just do Medicare rates. Well, that's great. Are you happy with that rate? No. Well, this is direct pay. You can still do charity at Medicare rates. That's a different thing. And when people do that, they find that these are really, again, kind of their best payers. The other thing people have a hard time wrapping their heads around is, well, what if it's a hour visit versus a half hour visit? It really doesn't matter. You kind of take the good with the bad and you bundle it in. And generally, again, you're setting your own price. It's not someone else dictating your price. You can set your price at a level that pays you for the higher level visits, and you make a little more money if it's a lower level visit. But the patients, everyone thinks there's pricing sensitivity in the market, and there is up to a certain point. Like, our chargemaster prices are generally ridiculous. That's not the price you want to charge. But I said this this morning in my consumerism talk, and I always say this. My brother's a veterinary surgeon, and as I said, he gets paid more for two dogs ACL than I do humans, quite honestly, by a multi-time factor. But if you look at what, those of you who have pets, I have two big labs. When I take those dogs to the vet, I don't get out of there for less than three, four, 500 bucks, honestly. And people come to see us, and if we charge 300 bucks for an office visit x-ray bundle, I mean, that's very reasonable. It's less than a vet visit a long time. Dental is the other thing to look at. Last time we went to the dentist, I can't get out of the dentist for less than 250 bucks, even for a routine clinic. Cleaning, if they have to do anything else, oh, we're doing x-rays again. Now it's 400 bucks. And so these pricing, I think we have to, we want to be fair to the patients, certainly. We don't want to give our charge master a price. But the bundled pricing can be something that's reasonable that pays you what you're worth, honestly. I don't think Medicare reimburses us fairly for the work we're doing. It just doesn't. And so to set your prices at Medicare levels is probably not the best thing to do. So we bundled, we priced. This is great, this is a good FAQ. People ask this all the time. Well, does this become my charge master price, right? So people are concerned, I've got this price out there. When I got to renegotiate with my insurer, is this a problem? And number one, we've already talked about this, you're gonna price these similar to or better than your commercial rates. So you got that, check that box. For office visits especially, you're generally not gonna have contracts for bundled care packages. So basically, they're not tied directly to, there's CPD codes in the background of all these, but you're charging the same price for a level two visit or a level five visit. And so it depends on what, I mean, you've taken it, bundled it, and you've priced it. So it's hard for an insurer to tie back to like, well, you treated this patient, you're charging 300 bucks, but our patient, you know, you charge 310, well, your patient was a level five visit or whatever we reimbursed you. So anyway, it hasn't been an issue. I've been doing this a long time. We have a lot of folks that I've advised about this. It's just not an issue. The insurers don't really care, but you're covered if someone did come and say, well, you know, you're charge master's 1,000. We see that you're charging 300 for an office visit. It's like, yeah, you pay me 290, right? It's just, you know, conversation's over basically. Prompt pay discounts exist in almost every state, if not all states. And so patients with these bundles are paying you day of service. And so you can offer discount because you can just say, look, the cost to collect is X. And so we've discounted that. And then finally, a fair number of insured patients do participate. Most of these people are out of network or sharing ministries or small business owners like my high school friends I alluded to. The patients, in-network patients, particularly for services like physical therapy when they've exhausted their benefit, VSCO supplementation if they're BCBS patients where that's not covered, things like platelet-rich plasma, those kinds of things. The other place we see this a lot is in pain management. Someone's hurting, they need an epidural, they don't want to wait for it to be approved. Imaging, hey, I don't want to wait. The MRI got rejected. Well, I don't care, I just want to pay for it, right? And so they can sign a waiver out of their benefit and then kind of sign back in for a surgery or a more expensive item if they'd like. Marketing. Basically, this provides a great marketing opportunity for your practice, very consumer-centric messaging. We want you to be concerned about getting better, not the cost of your care. I mean, things like this. It's very, very, very popular in your communities that you're taking care of these folks and giving them a great option. Along the self-funded insurance side, once you've bundled in price, now you have an opportunity to go out to employers, right? So a lot of times we talk to people about going and talking to the municipalities. A lot of times your doctors are friends with the county commissioners. They know the school board, they know the mayor, they know the sheriff, they're patients of yours, they're already seen you in the practice. And you go to them with transparent pricing and have them connect you with their TPA and you can start doing some direct contracting, right? And we've seen that, and that's been very successful. Press releases, all that we talked about, and I've covered the local ones in self-insured small businesses. Billion collection. How do you do this? One of the reasons I alluded to in the earlier self-pay equals no-pay, part of that is the fact that it's hard to collect that money, right? To have that conversation. A lot of our staff are really good at it, so when I say it's hard, but having conversations with patients in the waiting room about their bills and things like that with these self-insured people and self-funded folks, if they're paying in advance, kind of nice. Having a process to disperse payments to everyone in the bundle, if it's a surgery bundle. And there's various software platforms that can help do this. And so how can you do this in your practice? Show you a couple examples here. And so you can create a pricing tab on your website. Staff can refer patients to the website to purchase if they call in. Staff can find you, your marketing efforts, bring people to your website. If they're able to purchase care and find pricing transparency, it drives some significant business. Other workflow tools where the staff just send a link, the patient purchases, makes it really easy. I talked about good faith estimates. You can create solutions where the patients can actually request their own good faith estimates and generate those where your staff literally does not have to lift a finger. Well, they do, technically, they have to lift a finger to push the button to send the link. But then everything else is done. Consumer-friendly landing page for pricing. So on your website, some of this messaging you see here, patient employers want to pay directly for their care. We offer transparent bundled payments. These are the folks we're serving. Here's our locations. Click to buy. Most people are transacting on their iPhones. So same thing, very simple packages, back or neck, shoulder, both shoulders. These are things patients understand. You don't see any CPT or ICD-10 codes. You don't see knee internal derangement unspecified. Patients don't know what that is, right? So it's like they understand what their knee hurts, but that's something that sometimes people have a hard time wrapping their head around. Marketplace pages for various services. So there was an example of some marketplaces for office visits, which I kind of showed a little bit on the last slide, but very simple, easy to understand for patients. Surgery packages, same thing. Various bundles and descriptions. And patients understand this, employers understand it. They have the ability to access your practice like they access any other good or service, which is digitally, right? I can learn about it, this is what I need, my knee hurts, I can buy it, I'm done, great. The last thing is, earlier in that slide, when I talked about what the McKinsey study showed, people want Google, Apple, and Amazon. This is what I'm trying to give my patients, right? And other folks too, obviously. Patients understand the service, they buy it. Generally, with this program, people pay in advance. The money's held in escrow, they present a redemption code, you enter that, you're paid. The time of service, so it decreases your revenue cycle to zero, basically, and you get paid a fee that you named. So there's a lot of advantages to embracing this basically digital movement, this consumerism movement, this price and transparency movement. And we'll talk about some of those benefits here, and then we'll wrap up, happy to answer questions. So increasing workflow efficiency. We talked a little bit, I mentioned that study I did, that presented AOS, Notes of Florida Orthopedic Society. Basically, average time on the phone was 14 minutes, 37 seconds to answer questions with a direct payer. We call these practices and post as a self-paid patient. And like I said, by 90% of the time, it was either a no or it was this 15-minute, almost, phone call that ended up without a clear answer. Patients can do it online, no more negotiating. Compliance. So the government, when they pass a law, I just learned this, actually. So when they pass a law that costs money, they have to do an analysis and show how much this is gonna cost, right? So what's the time it's gonna take to do this? We have to show that it's not too onerous. And with this analysis, I'm not sure why they didn't think that was onerous. But the government said it takes 1.3 hours to manually create a good faith estimate at a cost of $207. You know, if you look at attorney fees and all this stuff and building it, and it's just like, it's like, really? And then you still pass the law. But so people don't read these laws when they vote on them. We all know that, we've heard that a bunch, the 1,000-page law, and they just vote anyway. But that's our system, unfortunately. And on the practice management, the billing collection thing, you're not having this conversation at a desk, which those two ladies look very happy. Usually, you're asking people for money. They're not very happy. So maybe that's not an accurate photo for this talk. But basically, if patients are paying for these services in advance, it virtually eliminates no-shows. And then the revenue cycle we talked about, which is really quick. And then we talked about self-insured employers. So I started doing this really just to kind of accommodate local small business owners, which we do a lot of. Actually, it turned out to be more business than I ever thought it would be for our practice. But here's the real thing. I mean, self-insured employers started reaching out to me, not necessarily the employers, but the TPAs and navigator companies and the people that navigate this care. And they saw we're offering transparent pricing. And so they wanted to work with us. And the delta we're really working here with our practices is the cost between doing a service in your office or surgery center versus the hospital. So I think when people look at this, a lot of folks ask me, well, if I put a price out, then someone's gonna be lower and someone else is gonna be lower and it's gonna be this race to the bottom. And a couple answers to that. Number one, it doesn't have to be. I tell people, pick a reasonable price that's data-driven and plant your flag on that price, right? Because the hospital will never be able to compete with you. And so if you look at the cost of care, I have a son who a college student graduated last year. He went to Wake Forest University and he broke his wrist, unfortunately, very bad wrist fracture. As a parent, when you see that you're just, and especially if you're an orthopedic surgeon, it's like, oh my God, like powdered his wrist. And so we had surgery in the university health system there. And it was cost of care. And I have a high deductible, which I knew I'd hit my deductible, but the hospital got reimbursed a little bit over $40,000 for a facility fee for an outpatient ORIF for the wrist. Like, and how crazy is that? And the total, you know, it was like a 50, $60,000 thing. And I've worked with practices. You know, we sell that, our group sells that operation all in our surgery center for I think a little over $8,000, which pays us a very fair rate, right? So this is what employers are looking to avoid, that surgery at the hospital. You know, you have cancer, you need expensive care at the hospital or cancer, yeah. That needs to be done, but you need, you break your wrist or need your ACL fixed. It's kind of crazy what hospitals actually get reimbursed for this. So I think as independent practices, we have the ability to really, really, you know, work that to our advantage. So these folks want an alternative, the TPAs, the brokers, navigators, the employers. The other thing I mentioned in my talk this morning, which I'm not going to go into here really, but the digital therapy companies, Sword, Hinge, Kaya, these folks have positioned themselves as an inexpensive alternative to an orthopedic practices. So you see musculoskeletal, digital musculoskeletal care, and these companies are growing rapidly. They're actually able to poach a patient from you after you've seen them. They have deals with the employers, where they get notified that a patient saw an orthopedist. I just had this recently, a patient asked about it. I saw a patient tore their ACL, I ordered an MRI. They got an email saying, oh, you really probably don't need that MRI, just do some at-home physical therapy. And the patient like knew his knee was screwed up. He was kind of upset about it. But at any rate, these companies have these ways to kind of try and pry our patients away, because they're presenting us as a very expensive alternative. They're lumping us in with some of that hospital care. They're saying everyone we see gets surgery, which is far from the truth, and whatnot. So we need to be able to compete with these folks and show that we're really adding not just great care for our patients, but care that's kind of reasonably priced and worth it, right? You're getting their employees back to work and whatnot. So at any rate, that's just something that's pretty new. And we can talk about that for a whole talk probably too. But really, I feel this transparent pricing is kind of this foundation for the direct to employer contracting. And then finally, I'll wrap up here. I think I have one or two more slides and we'll do questions. I like to say it's not a burden. I think most people look at pricing transparency as a necessary evil that the government's now, you know, pushed on all of us. It's really a benefit for all these reasons. Just in summary, you're attracting new patients who are paying a price that you've set, not an insurance company. You're paid quickly. It's a new revenue stream. Most of us are missing this. And this will generate the kind of revenue for your practice that you'll see from an ancillary opening a physical therapy center or surgery center. It's showing more than most people think. Minimize no-shows. Patients want this. And they're going to these digital first companies instead of our practices. So we need to accommodate that. And then the direct contracting. And, you know, you guys see these things in the news probably all the time. I mean, there's Los Angeles Times. Yeah, a model for healthcare reform. It's called amazon.com. And there's people that are, you know, doing this that are out, they're not orthopedic surgeons. They're health coaches offering this care on these digital platforms and trying to keep these people out of our office. So we kind of have to get in the game there to compete. Finally, last slide. So the numbers here, when I started doing this, I did it, like I said, just kind of serve this need in my practice. I didn't realize how much money it would generate for the practice and how popular the program would be. And not everybody does this, but this is what a lot of our groups do. So this was a group that onboarded and started doing this in their first year on the platform. That's the numbers they saw. And so it really kind of does move the bar. Most people I work with on this, when I'm talking to them about how to do a program, they're kind of doing it for the regulatory side maybe, or just because they think it's the right thing, but they don't really think it's going to generate revenue. But it does, like I said, on the scale of what you'd add, building a new therapy center maybe, or things like that, right? And so with that, I'll kind of wind up and field questions. The checkout code's up here. 27, for those of you in maybe the back room, 279508. So 279508, if you need to enter that to get CME and things like that. But with that, it looks like we still have, I don't know, 10 or 15 minutes. I didn't see the time. Maybe 15 minutes, it looks like. So happy to answer any questions right here. I've got a hand surgeon who just wants to get away from the hospital, don't have an ASC. And so he wants to start doing hand surgery in the office. Perhaps I should just tell him, let me just local price your hand surgery, market to patients who aren't insured, and maybe we can start there. Because he's got a charging question. Find out how we can set up in-office hand surgery. Yeah, well, I mean, apart from the location, certainly doing it in an office or an ASC would be a lot cheaper for the patient, as opposed to a hospital. But one interesting thing on surgery bundles, you can actually, your practice, or that doctor can actually own the bundle, right? So let's say it's a carpal tunnel surgery and you want to charge $3,500 for the carpal tunnel. You go to the surgery center, the facility, or if you want to do it in your office, that's fine too. You don't really have to. You go to the surgery center where you work or the hospital. Well, you go to the hospital and you say, look, Medicare reimburses you X, whatever. I don't know what the hospital reimbursement for carpal tunnel is off the top of my head, but I know at surgery center, it's around 500 bucks, give or take. And the surgeon's reimbursement is probably similar or less. I'm not a hand surgeon, so I don't know those numbers. Right off the top of my head. But let's say the surgery center's, say the hospital's getting 1,000 bucks from insurance if the surgery center's getting 500. The surgeon gets paid, anesthesia gets paid. Medicare reimbursement for carpal tunnel and anesthesia, I know is roughly 250 bucks or something. We just were looking at this for practice, so I don't have the numbers right at the top of my head. But so that bundle, so the Medicare reimbursement, let's say at the surgery center, it'd be 500 bucks to the center. Let's say 500 bucks for the doctor, just to make it easy. Anesthesia, 250, so 1,250 bucks. Maybe the hospital's getting reimbursed a little more. But if you sell that bundle for around 3,000 bucks, 3,500 bucks, which it seems to be a, if you look at national pricing data, that seems to be what's out there. I don't know if people are doing this directly. If you go to that surgery center and say, instead of 500 bucks, I'm gonna pay you 800 bucks or 1,000 bucks, 200% of Medicare. You tell anesthesia you're gonna pay them 200% of Medicare. So now you're at, you know, from 500 to 1,000, you had 500 for anesthesia, which would be 200% of Medicare. So your cost is $1,500. If you're charged $3,500 for that bundle, your surgeon's made two grand, right? And so it's very appealing from a surgeon's standpoint, I can tell you, to own the bundle. And so what I personally do in my practice is our practice owns the bundles. So me or my partners, when we do surgery, we've negotiated with the surgery center. And I'm, our group doesn't own our own surgery center, but we all are part owners of surgery centers and multi-specialty groups. So, but we're very fair to the surgery center. They're making a better pay on our self-pay bundles than they are in almost any commercial bundle or commercial payer, not bundles. And so we're bringing them good money. But I think as a surgeon, I should capture more of that revenue as opposed to the surgery center. Why should the surgery center make $2,000 profit that I make 500 bucks? Like I want 1,500 bucks and I'll give them 1,000 bucks, right? And so I think that you can kind of flip, flip the equation there a little bit. So if you, so hospital may be a little more difficult because they may just be ridiculously expensive anyway. Like my son's $50,000 or whatever, $40,000 wrist ORIF. But I think if you work with them at the hospital's outpatient department, the HOPD reimbursements aren't the same as the inpatient certainly. And so that is something you can certainly do as opposed to bring it into your office. And I think you just have to show them the value too, that they're gonna make money, right? And so you're bringing them a new revenue stream and we've had a lot of success doing that actually. Own the bundle, yeah. Yeah, if you wanna, I gave a talk at this meeting two years ago in Dallas that was called Own the Bundle. So I can send you a copy of that at some point. Let's go this way and we'll come back over there. Go ahead. Yeah. Yeah, that's a great question. Pretty commonly asked. So a lot of states do have very generous work on fee schedules. Others don't. But if you're one of those states where their work comp pays very well, if it's still an in-market price, like let's say it's 300% of Medicare, that's not unreasonable to charge for a self-pay bundle. It's a little high market, but you could come in at a similar price. The other thing is, I think with work comp, if they said, okay, well, you're charging 200% of Medicare here, we're paying you 400% of Medicare, what gives? I mean, and we've not had this happen. No one's really pushed back in some of these work comp states that pay well. But you could say, okay, fine. You pay me in advance or on the day of service. You don't make my doctors fill out a bunch of paperwork. I don't have to do all this stuff. We'll honor that price. And they won't do it. And you know, in the state laws, the state laws are kind of funny on that anyway, but it's a great question. I get asked it frequently, and it just hasn't been an issue, right? And I think that is the one exception. Sometimes people ask about kind of PI work, personal injury. Again, they're getting paid. You know, they're charge masters sometimes. But again, that might take three to five years to get paid and this, that, and the other thing. And it's just a different thing. And we haven't really seen an issue with that either, where, you know, if an attorney says, well, you want me to pay you $10,000 for this, but you're charging 6,000 here, you say, well, okay, fine. Yeah, pay me today instead of me waiting and signing a letter of protection, all this other stuff. And it just hasn't really been an issue, but it's a great question. And I wish I had a little bit better answer, but all I can say, it hasn't been an issue. And there's kind of some of the answers I gave about the commercial insurance concerns, I think are valid for the work comp too. Your bundling care, you know, and all this other stuff. Someone over here had a question, yeah. Yeah, I mean, there's no legal reason you can't own the bundle. You can let them own the bundle. You just have to dictate what you want to be paid, right? And so, you don't have to own it. If you own the bundle, it's easier to set the prices with them. But as long as you're paying everybody fairly, like I didn't go to my surgery center and say, you know, hey, I'm going to pay you Medicare rates and I'm going to charge this and pocket a bunch of money, even though it's not unreasonable to say that because they're willing to take Medicare right now, so why wouldn't they? But what I say is, look, I'll pay you, what's the fee, what do you want to be paid, 185% of Medicare, 200% of Medicare, and that's generally very generous pay and they love it. And I think it's, part of it's in how it's presented. I think a lot of people, when you ask at surgery, yeah, we're going to bring you bundles, we're going to do this. They're just like, no, right? Yeah, we're too busy. We got all this stuff going on. It sounds like a hassle. I think if you have kind of a pitch to them about the benefits for them, and I've done that for some groups I work with where like some, it's not that I'm any smarter than anybody or anything. It's just sometimes when a third party is doing it, it just takes away some of the, some of that antagonism. Maybe that you're trying to take advantage of me. It's like, look, here's the plan. We're bringing in direct payers. We're working with this group. They're going to bring you a lot of business. You're going to get paid a really fair fee. You know, what do you think? And most of them are like, oh yeah, you know, now, oh, I get it now. I didn't really understand it. Right. There's ways to do it. And some of it's just, you know, selling it to them and, and keeping everybody happy with the pricing and things. Back to the back there. So, those are both great questions. The second one I'll address first. Most people, so most of the people that are using this program, most of the patients are direct payers, right? They're people who are uninsured, you know, they're sharing ministry patients, they're people who are paying directly for their care. So, the insurance company isn't even involved. We do see a lot of insured patients buy certain things. So, what insured patients will buy, they'll often buy like physical therapy bundles because they've exhausted their therapy benefit. I mentioned like viscous supplementation, not covered anyway. So, a lot of times the insured patients are buying non-covered services, so that issue doesn't come up. As far as surgeries go, most insured patients, even with high deductibles, a lot of them will opt out to get the MRI done without waiting on pre-approval. Hey, my kid hurt their knee on Saturday, I want an MRI Monday, I don't care what it costs, whatever. But once surgery is needed, a lot of times, then they do want to utilize their insurance. So, you're going to get it pre-approved and all that, just like you would before the surgery. Anyway, and that person's probably going to use insurance. The exception to that on surgery is where I've seen people buy a surgery as opposed to use their insurance, are lower priced items. You know, maybe like a carpal tunnel release, or a knee arthroscopy, or things that are... Yeah, something you're doing at your surgery. Yeah, exactly. Yeah, exactly, yeah, so that's kind of the thing. So, we see people buy those lower ticket items that are, like, say you have a $10,000 deductible, you know, you can buy a knee scope for five grand. And if you went through your insurance, you're paying the five grand anyway. Now, that brings up the question, well, is it going to be counted towards my deductible? And the answer is, nobody knows, right? We're going to give you a HICPA form, we'll give you receipts, all that stuff. And when people pay for the HICPA form, they're going to pay for the deductible. We're going to give you receipts, all that stuff. And when patients do submit it to be counted to their deductible, honestly, most of the insurers will do it. But you can't really guarantee that to your patient. When they're opting out, you know, they're opting out. And they opt out, you know, there's a specific legal form that may vary a little state to state, but it's basically the same. It just says, hey, I understand the provider's not going to build my insurance company. And so they've opted out. Some of that's educating the patient ahead of time. In our case, we have, you know, FAQs and things like that where the patients, you know, it's very clear who can do this. For example, people, you know, Medicare, Medicaid, government beneficiaries, we don't like necessarily using the platform. Now the ones that need PRP or things like that can sign an ABN, so they can still use the platform. But yeah, it just hasn't been an issue. One other thing that I thought you might be getting to a little bit is like complication. You know, most of these are data surgery bundles. And so what if you do a knee scope on someone and they get an infection? Basically, one thing that a lot of groups will do or just starting to do, we just kind of been starting to recommend this is you can get complication insurance on the bundles. There's a number of companies that do that. And so you can insure these bundles and you can add that to the price of the bundles so that the payer's paying for that insurance. You're not paying for it in your group. And so that checks a lot of those boxes. And I'm sorry, what was the first part of your question? It's kind of a two-part question. Oh, malpractice. I'm sorry, what about malpractice? Like what if... If you have not had to document... Oh, yeah, yeah, yeah. Are they going to say like, you know... Yeah. Oh yeah, no, no, no, that's great. No, you still have to document, right? You're still gonna dictate op note same as you would for everybody. When you see patients in the office, you know, the state requires us to create a medical record, right? Like, I mean, you lose your license if you see patients and don't document. So you have to do it, right? What I'm saying is the documentation can be more of a clinical documentation that's valid in the eyes of the state, but you're not asking the patient about smoking cessation, this, that, and trying to check MIPS boxes and... But you still have some doctors who can say, documentation, I want to be here. Well, it is, yeah. In your mind, that means... Oh. Well, yeah. I get where you're, totally. I totally understand where you're coming from, Dan, because I know some of those doctors myself. But yeah, you just have to... It's not me, but some of my partners, maybe. But yeah, you just have to tell them, look, it doesn't matter if they're self-pay or insured or anything. You gotta create a medical record. And if you really have to spell out for them, it's like, for the insured patients, your medical assistant and you and your PA have to check all these boxes if you want to build a level four visit. But for this, you're gonna get paid. You don't have to check all those boxes, but you still have to do a history, a physical exam, a diagnosis, and a treatment plan, right? And I think from a medical legal standpoint, most of what's in an EMR is data to be paid, right? It's not really clinical stuff. So it does simplify the note. So when I see one of these patients, just, I call it kind of like an old school note, right? Mr. Smith twists his knee playing tennis, you know, dah, dah, dah, dah, dah. It's swelled, it clicks, it locks, physical exam, you still do a past medical history, C intake, data on the charter. It's already in my EMR. Physical exam, they have medial joint line tendons, positive McMurray's and infusion. But I don't go into like their back and their neck and all this other stuff. And diagnosis and plan. Hey, we're gonna order an MRI. We think he's got a meniscal tear. She's got a meniscal tear. So, but great question, actually. That's one I haven't been asked before. So that's a great consideration. But good news, it doesn't really seem to be an issue. So, yeah, go ahead. back on what I've already done because we've had payers come to us and say they're contracted and we have to bill it. Yeah, well they don't actually. So the federal law allows patients to opt out of their benefit and opt back, they can also opt back in. So what we have seen is patients opt out to get that MRI in a timely manner or get an injection. Let's say someone has back pain or herniated disc, they're miserable, they won't pay for the MRI, they pay for an epidural, you know a month later it doesn't work and they're maybe needing surgery. Okay, now I want to put this on my insurance. They can opt back in. So there's actually on the waivers there's an opt out and an opt in. And you're covered legally there. Like now the patient, are they going to be upset? Is the insurer going to say, well we're not going to approve the surgery because, you know, it's like look, you still have a medical record as we just discussed, you show them the notes, look they've done therapy, they just bought six visits, you know, therapy's not a good example but it's not a bad one I guess. But the point is you still have documentation and we've not seen that insurers push back in a situation like that. I mean they should be happy because they don't have to write a check, right, so. Yeah, yeah maybe. But it hasn't really been an issue but another great question, yeah. I mean I think the thing about this is there's a lot of, you know, ways to think about it and there's a lot of potential pitfalls without a doubt. But most of the pitfalls can be avoided and they just don't seem to be a problem. And when I say that it sounds a little sketchy but I mean I can tell you, you know, I work with groups that did about 10,000 in total, over 10,000 clinical visits last year through programs like these and none of those issues existed and that's in one year or so, multiple years of that, tens of thousands of visits, it just doesn't seem to be an issue, so. But a great question. Anyone else? Everyone good? All right. Oh, yeah, sure. So here's the checkout code. Do you want the check-in code as well? Let me click back to the, I'll click back, sorry. Let me find it. Yeah, I think the AOE does all these. I think there was an option to opt in for the digital meeting. Yeah, they have all the slides for all the talks. What they're going to put up and what they're not, I'm not sure, but they say that the digital meeting is going to have access if you sign up for that, so. And if you would like the slides, come up, I'll give you my card, shoot me an email, I'm happy to do that for you. Okay. Hey, thanks a lot.

transparent pricing

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upfront prices

revenue cycles

patient documentation