Hello everyone. Thank you for joining us for the Maintaining Patient Care and Clinical Excellence in the Consultating Physician Market webinar. A few housekeeping notes to get us started. All attendees are in listen-only mode. We'll be using the Q&A function today to gather questions for our speaker. We will not be using the raise hand function. Please submit questions through the Q&A and interact with other attendees by posting comments in the chat. When using chat, just be sure to select all panelists and attendees from the drop-down above the message box before submitting your chat so everyone can see it. This webinar is being recorded. Please know we will be sending all registrants the webinar recording and PowerPoint slides via email in the next couple of days. Our speakers for today are Rich Blan, Managing Director at DC Advisory, and Peter McCann, CEO at Growth Ortho. Now I'll turn it over to Pete to get us started. Thank you, Joe Young. Good afternoon, everyone. Thanks for joining our conversation really on maintaining clinical independence in this consolidating physician marketplace. It's a topic that I know comes up a lot in my world. Just to preface it, neither Richard or I are clinicians, so we're approaching this from the investment standpoint and the operations of healthcare on the physician side. We want to have a conversation about one of probably the most important topics to physicians in the marketplaces. How do you maintain that clinical autonomy, that clinical excellence as the markets are changing dramatically in the physician space? So a little background on myself. My name is Peter McCann. I've been about 35 years in healthcare operations, mostly on the physician space. So I started as a young teenager in physician offices in a medical supply company and worked with physician offices in all different realms from the health system side to private practice, to now what is some of the private equity-backed groups, to some of the larger groups that aren't private equity-backed, just large physician groups throughout the country. Worked on the Pioneer ACO program when that came out many years ago, plus or minus success on that, but really understand what physicians and the markets look like from the operations, the healthcare side. Again, I'm not going to be a physician or a clinician, but the perspective that I bring to the table for that is just, what does the market look like? What is it going to look like? We can never predict healthcare, as we all found out through COVID, but there are certain trends that we've seen over the last 40 years in the physician space that could kind of give us clues specifically for the physicians that are out there making decisions coming out of residency or coming out of fellowship as to what type of employment model that they'll go into. So currently, I am the CEO of Growth Orthopedics. We're a national MSO in the orthopedic space backed by a private equity, Tribest Partners. My disclaimer is I am not a private equity person in this deal. I just bring my healthcare operations experience to it so that we can build practices and a group around physicians and patients. Because I think in the marketplace today, a lot of times, physicians are caught up in the consolidating model, and in that, patients sometimes get forgotten. So the patients are the center of healthcare, and our goal is to maintain that kind of autonomy and clinical excellence. But how do you do that? And so that's what we're going to talk to. I'll introduce my friend, Rich Bland, for his introduction, and then we'll kind of go into our conversation about this topic. Rich? Great. Thanks, Pete. Good morning and good afternoon, everybody, and thanks for joining the webinar. My name is Rich Bland. I'm a managing director with DC Advisory, a global investment bank that is owned by Daiwa Corporation. We're one of the largest international investment banks serving the middle market across a variety of sectors. I lead our firm's efforts across a number of different subspecialties within healthcare, and in particular, I spend 100% of my time working with a variety of different physician groups, all shapes and sizes, different ownership models, independent, private equity-backed, partnered, et cetera. I have about 25 years of investment banking background and expertise. I've closed over 75 transactions during that time, representing over $75 billion in value. And today, I spend all my time working with physicians and physician groups. It's a passion of mine. I come from a family of physicians. I'm being the lone black sheep, not being a physician myself, but hopefully the work that I do to partner with my doctor clients and physician groups helps position them not just for today, but to maintain the legacy that they've built over many, many years and continue to grow, expand, and frankly, deliver better care to their patients in the future. I work across all physician specialties, everything from very retail-centric services like dental and med spa, all the way through to higher acuity and surgical practices like orthopedics and cardiology, GI, urology, as well as multi-specialty practices. And I have a passion for what I do, and I love working with doctors and helping to find solutions, whatever they are, because there's a variety of different options that are available to physician groups today. And I think that they benefit from having the ability to choose their path on a go-forward basis, and we help our physician clients achieve those goals. Right. And thanks, Rich. And I know a lot of times when we're talking to physicians, when we talk about investment bankers or private equity, people who are involved in healthcare, there could be a negative connotation to that because we aren't clinicians. But I can tell you people like Rich in this industry and the people that are in this space who are doing it correctly understand what the physicians are about. And we try to take that stigma out of it because there is a general partnership that can provide better quality care, keep the private practice really operating the way it should have, and the way it was kind of meant to be when physicians came out of school. And taking that stereotype away, we're investors, we're bankers, we're private equity, we're not. I mean, I know from my experience and have worked with Rich for many years, we are truly invested in healthcare operations. So we try to separate the two because there's a distinction there that sometimes gets lost. But together, we spent over 50 years understanding how physician offices work, how can they be better and how can we help enhance them, knowing that the entire time, all of those decisions and all of that, all of the practices up to the clinicians themselves. So I want to start here. We're going to talk a little bit after introductions about just the consolidating the changing landscape of the physician market. And I won't bore everybody, but I'll go back about 40 years on this. And I'll be quick because I think it's an important framing of where we're going and where it's gone for the private practice. We'll take a look at physician options currently for employment models and what that looks like in the marketplace, because I know that drives a lot of decision making. And then we'll start the clinical autonomy discussion. What does that mean? It means many different things to many different people. And how do we make sure that the physicians have that voice that they want to have in their own private practice or in the health system environment that they work? The bottom line is that I know, as Rich has come from a line of physicians, my original mission as a teenager was to become a surgeon. And the one quality that I enjoyed about it was I wanted to help people. And I know from working with the thousands of doctors that I work with, that's the mission of the physicians and the staff around there is to help patients. How can we, Rich, people like myself and I, help you do that? And we'll have that discussion. And then really, how do you decide on a path to ensure that you can have that patient care and clinical excellence? How is that maintained? The landscape is changing dramatically. So how do we maintain that on a go-forward basis, whether it's in the health system, in a private practice setting or a retail setting, any of those settings that are out there? And that's kind of how we'll end the discussion. And feel free at the end, if you'd like to ask questions along the way, just put them in the chat, but it's really an open dialogue. So I'll give you a little history from my experience in the physician consolidation marketplace. So everyone always asks me, where is this going? What does the next five or 10 years look like? And I'll always tell them, no one knows that for sure, but there are certain trends that if you look back over the last 40 years of the physician consolidation space, that can give us clues or give us a kind of a little more roadmap to what may happen in the future. So back in the 80s, private practice physician offices were being consolidated, mostly in the primary care and internal medicine groups were being purchased by local hospitals. So the hospitals realized that they needed the physicians in their area to capture those patients that are there. And that really was a big model for the primary care and internal medicine physicians for about a decade. That kind of fell apart. Physicians sold their practices. It wasn't what they wanted. They didn't get what they were promised in the healthcare system relationship for the most part. Also local hospitals were not well-capitalized. They didn't have a plan to do this, but they realized that they needed to be able to capture patients. So many of those relationships went back to private practice. There was a non-compete. A lot of those private practice physicians, I'd say 50% are great. It went back to private practice. So there they were back in private practice. So we had a consolidation to local hospitals. It went back to private practice, about 50% of them. And now these physician offices were out in the marketplace again. Well, then you have the creation I call it of the large health systems, the IDNs, the integrated delivery networks, the bigger systems that had better plans. They had more resources and little better relationships with payers. So starting to understand that they still needed to capture those patients in the marketplace. So they needed to build a physician network around them. And that kind of where the health system started buying the physicians offices. So there was a second wave of that. And again, mostly it was primary internal medicine. Most of the cardiologists went there. We had the OBs and GYN started to go there just because of insurance reasons. So you had this subset, which left a lot of the other high processing specialties kind of independent. So that was about until 2000, right around 2004, you had the pioneer ACO trying to change it from the government standpoint of the value of care of physician offices, how would they relate to health systems? That was changing the dynamics. But then you had a lot of interest with large groups forming, not investment bank or private equity bank, but just large groups forming for scale, knowing that if they can get together in a local area with five, 50, a hundred physicians, they could have some economies of scale. They did that fairly successfully. But then what we started to see was the large systems, again, looking to buy those large groups and also the introduction of investors like the private equity marketplace in the early 2000s. And that's really taken us for the last 15, almost 20 years of that consolidation that goes on. Now, negative or positive in terms of what has happened and transpired there, but there was a large scale consolidation of private practice physicians of all subspecialties into kind of investment or private equity back models. They're all different. And I know Rich can speak to a little bit of that on the specialties he's worked with. I believe that every specialty is different. Every group is different. Every private equity is different. But when we come back to it, that whole journey that I just outlined is how does that affect patients and how does that affect physicians? And that's kind of the second half of the conversation we'll get into because there is, it does. In all of those decades, the 80s, 90s, 2000s, and today's, there's always an effect it has on physicians and an effect it has on patients. And again, the heart of what we want to talk about today is that effect, but I'm going to turn it over to Rich and maybe add some color commentary from the last kind of 20 years of he's seen the consolidation mostly on the investment side of the different subspecialties and really what that's meant for physicians. Yeah, thanks Pete. And you know, it's been a fascinating journey for the last 15 or 20 years. A lot of lessons learned, a lot of successes along the way. And I think the model continues to evolve over time. What we first saw maybe back in the early 2000s was a model that was more geared towards consolidating practices and having doctors effectively sell their partnership shares to the consolidating group and become employees. And that model worked and it worked well because the consolidator, the aggregator of smaller practices was better capitalized and it offered the physicians not just an opportunity for them to monetize what otherwise would be a very illiquid investment, which is their partnership shares. But with size and scale, they now had a cloud with payers to get better rates. They have the ability to invest in systems and technology and people in order to better position their businesses to deliver better care. We've seen a massive change in the reimbursement landscape. We've seen a massive change in compliance. And a lot of the independent practices, frankly, did not have the capital available to invest appropriately in systems and technology and people to keep up with those necessary changes. And so we've seen the benefits now of what size and scale means to a lot of the smaller practices. And as we continue along this journey over the last 15 or 20 years, we've now evolved that model, which was originally founded as an employed doc model to one where there's a variety of different solutions that are available to the physicians. It's not just selling your practice and becoming an employee. You can sell to a hospital, you could sell to a group and become an employee. But there are now models available to physicians where they can continue to own equity and continue to have that appreciation and value of that equity ownership so that it gives the docs an opportunity to monetize upon their retirement in ways that, frankly, were not available 25 years ago. When a physician retired, they basically collected their AR and maybe got a gold watch and a pat on the back. But now we're talking about substantial financial benefits for the physicians that marry nicely with what the overall goal is, which is better capitalize the healthcare system, better position physician groups, alleviate the administrative burdens so that physicians can focus on what's most important, deliver better care to their client patients and do it in a more efficient and a more convenient manner. And Rich, you bring up a great point because I think part of what the mystery around the consolidation or the investment that comes into this is how it's perceived is a point that you made when you first started talking was that the smaller groups, the independent groups, so maybe five or less doctors, there was going to be a challenge for them moving forward to stay that independent, which in turn would affect their ability to deliver patient care to patients. I mean, up on the slide here, kind of growing up in that 80s and 90s, the private practice physician in your local area was just part of the community. He or she was the person that people counted on to help them get healthier, whether it was house visits or just general preventative care. They were looked at that the kind of the gold standard in patient care. It was that personal touch. So the consolidation model, even before the 2000s, was taking that and bringing that to the health systems. But along the way, even in the 2000s, those independent groups, the smaller practices that we kind of grew up with were challenged to be able to continue that level of care because reimbursement pressures, technology pressures, and as we all know, regulations can drown a three or four-member group because of the expense of it all. So I think there was a need to help them with investment, but also that need has helped keep patient care up. So I don't know if you have any thoughts on, you know, if investors didn't get involved with this kind of marketplace in healthcare for private practices, what do you think those small groups would have looked like or would they have survived? No, that's a great question. You know, it would have been a big struggle. You know, just thinking about the capital need. And if you think about a partnership group, right, where you've got five or 10 docs and it's a democratic practice where each physician owns, you know, his or her representative share in the group, and you have to make difficult decisions. You can either, you know, take your partner distributions, you know, and put those dollars in your pocket, or you can bypass paying yourself and using those cash flows to reinvest in the business. And it's a very difficult decision when you have physician groups that have, you know, young doctors in the group, and you have docs who are mid-career, and you have docs that are close to retirement. And, you know, I've been, you know, party to many conversations where there are very different opinions around how to spend capital. And, you know, if you just think about the physician that, you know, is maybe a year away from retirement, why should he or she want to bypass putting money into their pocket in order to invest in new, you know, MRI equipment, or, you know, a new EMR system? It's not going to benefit them because they're retiring next year. Right. You have a lot of these challenges that I think the groups were struggling with, which led them down this path of how do we better position the group as one that can continue to deliver better care, and one that is going to allow us the opportunity to invest, because we have better ability to generate, you know, profits for the group that can help support that reinvestment in the practice for continued growth. No, and I agree. And when you look at the term that independent group, some of the factors that play into the marketplace is this massive position shortage that we're experiencing now and beyond. So, some of the talk I give about the consolidation of the industry, I say it was a necessity that, done right, will maintain, you know, patient care, but the shortage of physicians is real. So, back in the 60s, you know, 97% of all medical students in 1962 were men. That demographic has changed dramatically into the point where now over 50% of medical students are women. I bring up that stat because that is a demographic shift to what, who are coming out of medical school and what their needs and wants and expectations are. Back in the 60s, 97% of those, you know, the men who came out or the graduates that came out, male or female, 70% of them started their own private practice. With the shift in the demographics and a better quality of life and a better balance that comes from having a better mix of medical students, there was also this dramatic drop in number of medical students. So, where you had 70 plus percent opening private practices, that number has just dwindled and you have less physicians coming out of practice. So, the long-term effect of the group, as we call it, was in jeopardy because they couldn't attract a new physician. There was less of them and how do you survive in that world? So, and I think that's when we talk about employment options, it's why the health system certainly offers different and unique employment options for those physicians that are attractive. Balance of life, work life, kind of guaranteed salaries, a little higher salary. So, we'll talk about that, but any thoughts on the kind of that dramatic decrease in physicians in the marketplace and the shortage that's out there and how that affects patients and care? It is one of the most talked about issues that groups face. Big, small, mid-sized, PE-backed, independent, everyone struggling with labor shortage, physician shortage, and frankly, you know, to the point around the economics of it, you know, you think about the debt burden that graduating physicians have when they exit, you know, the education system. They don't have the ability to build and invest in their own private practices the way that you could have maybe 40, 50 years ago. They come out with hundreds of thousands of dollars of debt and they absolutely do not have the desire to double or triple that debt just to have the opportunity to build their own practice. So, most, you know, kind of move in the direction of joining a partnership track, independent practice, or going to a large multi-specialty group or a health system in order to have that ability to generate some, you know, personal wealth to pay down that debt over time with the hopes of potentially, you know, maybe mid-career making a pivot to having an opportunity to build their own practice through an independent approach. But it's a challenge, and I think one from an economic perspective has led, unfortunately, led people a little bit away from the medical profession given how hard it is to make a living there economically compared to what it was 50 years ago. Right, right. I mean, and mix that with what I see from the standpoint of just different generations of non-physicians, just the makeup of the American population, those under 30, for the most part, the majority of them do not have a primary care physician or a primary physician, whereas people in their 60s and 70s, that was just a normal routine that we went out and we found a private practice physician in your local community who would help deliver care. And that's where the relationship built. So there is a shift away from having a primary care physician. COVID certainly escalated telehealth and that strategy. Retail health has certainly helped with that with urgent cares and retail health clinics where you kind of stop in when you need something and you get healthcare administered. So there has been a shift in what the private practice was, but to me, it's still the most effective way to deliver healthcare to the local community. But we've got to realize that the options for that are changing from everything that you mentioned, from just getting people to invest in their own private practices because of the debt burden, and also just the lack of physicians that are coming out. And I think the country overall, and I think the shift in healthcare with the addition of tremendous amount more of PAs and nurse practitioners, I think it's helping fill some of that gap, but that is changing what the private practice looks like. But again, as we get into the latter half of this conversation is how do all these factors relate to making sure that patients are cared for and we maintain the clinical excellence? Absolutely. And the one thing I'll add to that, Pete, is what we saw in COVID, I think exacerbated what was already a big challenge in the industry with labor constraints and labor shortage. The strain that was put on our providers in the US and global healthcare system was absolutely unparalleled in terms of the challenges it created. And frankly, the level of doctor and provider burnout increased exponentially, and it's only put further strain on the system. No, I totally agree, totally agree. So just to backtrack a little bit in terms of overall what the physician employment options are, when you've got someone coming out of residency, medical school, or fellowship, some of the general paths that they may take. And we've talked a little bit about why the shift is in terms of the demographics and not starting private practices. But there are a couple of basic routes that physicians take. And that also, again, once we've finished this slide conversation, leads us into wrapping that all up to how does that affect the clinical decisions and also how does that affect patients? So some basic employment options for physicians are go to work in the health system. And we've seen that. We've seen these really capitalized, well-run, I'll call it well-run, or large systems recruiting physicians because they need to. They administer much of the healthcare that goes out there. They've got physician clinic groups that surround their hospitals. They've got urgent cares. They've got surgery centers. They've got imaging centers, kind of that holistic one-stop approach. The problem is the health systems tend to be one of the most inefficient deliveries of healthcare finances in terms of being able to do this for the affordable price. But there is an option for physicians coming out of school to sign up and join the health system, which there is a majority that do this. And there's reasons for it. There's flexibility in the schedule. There's nice guaranteed salaries. Some of them will even take over some of the student debt. They can work in a teamwork, collaborative environment. There's a lot of good reasons to go to work in the health systems. Historically, depending on the subspecialty, physicians are usually very independent and always wanted to go into independent practice, but hospitals are a good option. So the ones that do go into independent practices, they've got challenges as well. First of all, competition from the hospitals and also other competition. You've got insurance-based providers who are offering healthcare. In the Optum model, in the UnitedHealthcare and all the local, the CVS Caremark, all of those groups that are now offering healthcare, which is a competitive to the independent practice. So those independent physicians coming out of school wanted to start a practice, have new competition that they didn't have 25 years ago. And then you've got practices that may have some ancillaries like an ASC or an imaging group that help them to kind of scale themselves a little better. But there's challenges in all three of these models. And that's some of the options that physicians have coming out of fellowship, including looking at some of the kind of insurance-based providers of care, like the Optum model. They're recruiting, they've got 60,000 current physicians owned or affiliated with their group. So that's what's changed dramatically in the last 20 years too. So part of that is in all these models, what's the best way to treat patients? And I don't know if we have the answer to that question, but these are some of the factors in that. Rich, do you have any kind of thoughts on kind of their employment models and what the shift looks like out in the marketplace? Yeah, look, no, I think it's an exciting time to be coming out of fellowship and having, frankly, the most variety of opportunities available. And I think that it's worth each individual understanding the pros and cons of each of the models to figure out what works best for the individual. And it's gonna be different from person to person. You're gonna have certain physicians that they wanna come in, they wanna deliver their clinical care, and they wanna go home and not worry about or think about work until they arrive the next day to see their first patient. That could be very positive for people that wanna have more of a work-life balance, that don't want the administrative non-clinical burdens of being an independent practice. But then you have individuals where they wanna drive and deliver care in their own customized way and working in a large employee doc model might not necessarily align with them individually. They wanna create more of a legacy for themselves and their partners, and they might choose the independent practice to do that. And then you have people that might have gone that route and formed an independent practice or joined an independent practice that is now seeing consolidation around them, mostly driven by private equity investment and partnership with some of these physician groups. And now that becomes another option for them as well. So I think for each individual, what makes the most sense is get educated, talk to people, understand what life is like today, what life looks like going forward, what is not just the clinical experience, but the economic experience, and then the personal experience, working in teams, working with others, so that you can, as an individual, make the most informed decision as to which of these variety of alternatives that are available might work best for you. And it could change over time. You might start out working in a health system and decide, you know what, I wanna go join an independent practice, or you might join an independent practice and say, you know what, that might not be for me. It wasn't as what I thought it was gonna be. I'd rather go work for a large multi-specialty or a health system group. Right, right. And again, part of what we're talking about today as we get to this next part of the conversation is with all of this that's going on, and the next slide is one that, here are some of the challenges from why these private practices, which to me, again, back in the 80s and 90s, early 2000s, they were your main point of contact for healthcare. They were the delivery method that was referred method just about every American at that point. They were embedded in the communities. They had control over their clinical decisions. Obviously, they either had admitting rights or affiliated with a local health system. So there was that continuum of care created by private practices to the hospital system. Hospital systems have kind of reversed that now. They are kind of the front door and they control the network around it. But the physician practices, there's a lot of different challenges that they have that are out there. Some of them that are listed here on this, which Rich and I have talked about, but the bottom line is with that shift, with going from the 80s and 90s where the private practice was the main point of healthcare to where we are today with all the challenges, I think what we talk about is, how do we maintain that clinical excellence for the patient care? Because in all of our conversations, and I know I always start with in my world is, you gotta start with the patient. Like, who are the patients? What are they looking for? And how do we best deliver the best care to them? And unfortunately, as systems have become big and insurance models have changed, sometimes the patients are the last to be thought about. And we try to put that first. And I know that's a concern of physicians, whether no matter what model they're going into is, how do I do what I went to school to do is to help people? And based on all the different models to make sure that I am making the decisions that help my patients. And if we start with that, my line is if we start with helping patients, we can always create the model that works on the business side or on the delivery side. So, but I think the employment models play a lot into that. So, I know Rich, you've traversed many acquisitions, talked to thousands of physicians, what's on their mindset when you talk about kind of patient care and delivery of care? Yeah, it's again, in a very highly regulated industry like healthcare, there are constant changes. Some are good, some create challenges for groups. And what the physicians now care about is, how can I continue to stay up with those changes and be able to stay compliant and continue to deliver the best care to my patients in this ever-changing world, with all of these pressures that are forced upon us from labor shortage, physician burnout, to all the way down to all of the administrative challenges of having documentation and the appropriateness of compliance, not just in delivering care, but recording it and then getting reimbursed for it. These are massive business challenges that physicians are not going to school to have to deal with. And many times they come out, wanting to focus on delivering clinical care and they wind up spending hours after their clinical day is over, just trying to play catch up on all of the non-clinical administrative aspects of what they have to do as clinicians today to stay compliant and to get paid for the service that they've already given to their patients. And I would agree with that. Probably the most enjoyable part of what I do on a day-to-day basis is when I'm in one of our physician clinics, working with the doc and watching them kind of navigate their exam rooms with their patients. That's what they want. That's why they get up in the morning. That's why they go to work. They're helping people. Orthopedics, and I've worked in all the different subspecialties, orthopedics is one of those, they can help somebody walk again. They could take away pain. Having gone through on the oncology world, they can cure cancer. That's what they wanna do. And that's what individuals like myself and you understand because we spend a lot of time, and I know I spent a lot of time in that office, but then to your point at five o'clock when the patients are done, the amount of work and compliance and billing that needs to be done to close the loop on that is a giant challenge for everyone in the office, including the physician, because they spend eight hours trying to help people and then another four hours trying to do all the back and office stuff that has to be done. So regulation, compliance, payers don't make it easy in that aspect, but it's part of it. So part of them is keeping them focused on that first eight hours, which they really enjoy and they're helping people. But how do we make proper investments for the other four hours of the day that needs to be done? Yeah. And I think that, look, not every model and every platform and every private equity backed group is 100% successful in achieving all of these aspects, but with the right investment, the right leadership, the right business acumen, it certainly can alleviate a substantial amount of that burden that frankly is overburdening our physicians and distracting them from what their value and focus should really be. And that's on the patient. And then we haven't talked about it yet, but we've talked about the challenges. We haven't talked about the opportunities and value-based care. I know we've been talking about that for a number of years, but we are starting to really see groups that are large, that are data-driven and that have great investment in technology and systems and people to create a value-based care solution that benefits not just them economically, but frankly, it benefits the patients because they're receiving better care that's now being scored for outcomes. And that's a huge opportunity that comes with, frankly, only the largest of the groups that are practicing because you need to have substantial amount of information and data to analyze and then validate that the care that you're giving is actually resulting in better outcomes for your patients. And that's where a lot of the focus is looking into the future in terms of opportunity. No, I would agree. And to your point, there are so many opportunities that come out of this. So part of it is how do you take the investment and solve the operational concerns that we just talked about and let them focus on that eight hours of patients? And I think to your point, value-based care was almost like an anomaly. We were trying to figure this out and it was difficult as a group, but it takes a lot of investment. A single, one or two practice, doc practice group couldn't make the investment to figure out value-based care. And it's not a knock on them. It's just, you need a lot of systems information and resources behind the scenes to go ahead and do that. And I always look at it, I call it from symptom to outcome. How do you take the patient who has their first symptom, treat them, cure them, get them back on, and that their outcome is that they have their quality of life back. The continuum in that model is what gives you success. The decentralized kind of specialty group, and you go here to get this, you go here to get that, you go here to get that. Patients don't have the, most patients don't have the ability to understand that continuum and advocate for themselves because healthcare is complicated. So if you get, you make the proper investments, whether it's private practice or larger groups, to be able to serve that model where they can handhold them through every stage from symptom to outcome, you're gonna have healthier patients and you're gonna have better patient satisfaction, but that all takes investment dollars and operational know-how behind the scenes. And I think that's part of what, some of these models can help with. Yeah, no, it's a great point. And you hit on probably one of the most important phrases, and that's the continuum. And we talk about the continuum of care. And now with some groups that are specifically being established, designed, invested in, and expanding, to be able to deliver that full continuum of care from symptom to outcome. And just in orthopedics alone, you're talking about a group that could be, not just repairing a torn ACL, but all under the same umbrella from maybe some pre-op physical therapy to the actual surgery that's being done in the ASC that's also governed by the group practice, the physical therapy that occurs post-surgery, maybe there's DME associated with it, there could be pharmacy and other components to that continuum of care. And it's all done in a coordinated fashion. So you know that your surgeon and your therapist and all of the other folks that are involved in making sure that you have a successful outcome are speaking to each other and connected and understanding from start to finish how to best serve that patient so that they have a great outcome. No, agreed. And one of the questions we get from the Spectrum of Physicians, from the new physician coming out of school to a physician who's probably mid-career going, why would I need any kind of investment? I just wanna see patients. And I think that statement, I just wanna see patients is what they need. They don't need help with that. They need help with everything else. And that's where investments or different models that we have in the marketplace now can help with if done right. I don't think either one of us would say here that there's groups out there that have the best models around, all of them do, because they don't. And I think it's a very personal decision. And I think it's a matter of looking at what is the group focused on? I always say, make sure they're focused on patient care and physicians and then everything else we can build a model around. But those are the questions I get, questions of, where should I go? How do I best care for patients? That's a really simple, basic question with a really complex answer in today's marketplace. But if you have business operations and thought leaders in that space that aren't clinicians, they can help out with that. So I always say, just get educated to what's out there because there are groups and there are opportunities to be part of them, whether some really dynamic health system models that have that to some of the large groups, the independents, or even some of the insurance provider groups, they have that, but you've gotta make sure you're aligned with the right group. So to answer that question is, how do you best treat your patients in the way that you would train to is, there's a complicated answer to it, but there is an answer to it, so. Absolutely, yeah. And the beauty is, it's not singular. There are a variety of different available alternatives that physicians should definitely get educated on, pros and cons, good and bad, how does it evolve over time and who are the folks that are involved? And if you put the patient first and you build a network that focuses on provider success and patient outcomes, you will have a successful experience, both clinically and financially. I agree with that. And we've got about a minute or two left, but I would say to your point, we talked a lot about the challenges, we talked about the opportunities. My overall statement about healthcare in the US as it being kind of the largest business in America is that even though there's a lot of challenges and changes in that, the hope is, hope is there, that we will always put patients first and get to that level of clinical care. It's just that the models are changing, but there was plenty of opportunity within the United States being kind of a free market economy. That's why investors are involved with it. There's a way to do this right for everybody, for the investor, and make an investment in healthcare that helps the patient. So I think if you have a country or a world where people aren't willing to invest in healthcare, that's when you were in trouble. Here in the United States, there is no shortage of investment opportunities in healthcare, but that's a good thing because if we can keep the line of patients and physicians first, let the investors help you out with everything else, there's a lot of hope and opportunity for healthcare and positions in the US for the foreseeable future. Absolutely. And the one thing I would add to that, Pete, is we now have evolved the various types of models that allow the physicians to benefit from that financial value creation in the same manner that the non-clinician investors can participate. It's a partnership and there's great opportunities for investors to partner with physicians to create world-class clinically focused physician groups that focus on what's most important, and that's delivering care to the patients. 100%. So I think my parting words is that, we started with kind of the anomaly, maybe some of the fear of investors or bankers or equity involved with healthcare. We are here that, we're not here to work on clinical delivery or patient, we're here to help you continue to be able to deliver that care. So, and if you look at it from that standpoint, that again, the hope is that the investment that we make in healthcare will benefit the patient. We as investors and operations people around healthcare, if we stay focused on helping you with that, you're gonna deliver great patient care today and in the future. So that's where we are in healthcare today. I appreciate Rich's joining me on this discussion. It's a ever-changing and never-ending conversation, but we do have a great healthcare system in the United States. It's extremely complicated, but there are plenty of people in America who wanna invest in it, which means that there is an opportunity for this to continue to grow and continue to let physicians practice great medicine and provide great patient care. So we thank the AAOE and the entire organization for letting us take some time with all the participants today. We'll have this posted out there and we'll have our contact information if you wanna reach out to us for any questions or comments you have there. But we appreciate your time today and Rich, I appreciate your time and your partnership and we'll look forward to the next chapter of healthcare. Thank you.

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