So welcome everybody and thank you for joining us for orthopedic practice ancillary services and practice diversification. It's presented by Steve Fiore. He's a chief executive officer of Orthopedic Specialty Group in Fairfield, Connecticut. Steve's also a past president of AAOE in 1996 and 1997. So a few housekeeping notes to get us started. All attendees will be in listen only mode. We will be using a Q&A function today to gather questions for our speaker so feel free to submit those and I will pose them of our speaker as they come. We will not be using the raise hand function. Please do submit your questions to the Q&A and you can interact with other attendees by posting comments to the chat. When using the chat function just be sure to select all panelists and attendees from the drop-down above the message box before submitting your chat so that everyone can see it. 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What I wanted to talk a little bit about today is is how ancillary services have worked in our practice and what we can take away both in the traditional sense as well as less traditional more innovative opportunities. Next slide please. So we look at ancillary services as a clinical services performed within the practice and most of the time these are provided by a mid-level or a licensed technologist or therapist. This provides additional revenue to help support the physician's hands. They don't generally are not involved in in most of the ancillary services and some of the stuff usually carries a significant capital equipment either either physical equipment or human capital to provide the services such as you know imaging equipment or or physical plant layouts with therapy equipment and so forth which is what most practices need to assess when they want to develop additional ancillary services. Next please. So in years past you know what I've always used is the traditional ancillary services contributes about 35% to physician comp and we all know today that as the physicians hands that are generating the work are realizing less dollars per event and it requires additional sources of service such as imaging therapy DME injections other other opportunities that will need to support some of the gaps than physician physician compensation. Due to Stark you know the other impact is we also need to address the designated health services which are you know mainly an x-ray DME MRI therapy and predominantly Medicare driven Medicare advantage is no longer part of this but the rationale behind this is a physician can't be credited directly with the revenue for services they did not directly provide and since they don't do the x-rays they don't do any of the things listed here they can't realize any of the direct revenue directly other than the x-ray they could get the 20% for the reading fee because they generally do the professional reading in the office so you've got to figure out in this whole process what do you want to do with this DHS you know we have chosen to spread it equally as an overhead offset to the shareholders so I collected from all the docs return it back to the shareholders equally which is in one of the safe harbors there's some various methodologies to consider orthopedic revenue in a practice you know we've always kind of used the benchmark that 60% of the revenue will come from the office and 40% from the operating room so however the 40% in the operating room although it's where the doctors like to play and it's where they enjoy their time it takes more man hours for them to generate that hours that revenue than it does in the office in the office it's it's it's their office visits it's the injections it's the ancillaries it's all the things they do in the office which will generate you know more revenue that's how we what we do it is we calculate the revenue per patient visit that's all included including post-op visits so we can understand that for every patient we see we have a revenue expectation that'll help us monitor increased visits or increased access to within the practice all that plays it plays a role next please so you know each ancillary service that you know when depending upon how you allocate these services everybody's got a comp plan and I will tell you if you've seen one comp plan you've seen exactly one comp plan everybody wants to approach it differently but in our organization you know we we have we directly apply the ancillaries to the physicians production and we apply the individual overheads x-ray for example is 60% and that's high to the high increased cost of technologists so I'm sure you all realize trying to find x-ray text is becoming an increasingly difficult challenge and that word should be technologists not therapists but the problem is you can't run an orthopedic practice without it so I've got one of my walk-in centers that we have run open but I can't get an x-ray tech and it's had a severe impact on the volume in that office obviously our MRI we have two MRI machines we've got you know a pretty good level of technologists that you again should be technologists but that but the cost of MRI is 75% and it's mainly due to the high cost of the technologists we're pushing close to $50 an hour hospitals are paying higher than that they're getting higher rates than per diems so we're trying to find creative ways to keep our technologists happy DME which is our probably our most profitable ancillary has a 40% overhead we happen to be in a group purchasing arrangement through Blackrock which is an orthopedic driven group purchasing arrangement where we get pretty good discounted pricing for all of our DME I believe osers in it DJOs and it breaks in it so we can we can we can pretty much get pretty good pricing on our DME and then PT and OT obviously that is the therapist is the right word there that's an 80% because our therapists are starting to tip a hundred and ten hundred and fifteen thousand dollars so the high cost of therapy in days of your when I was a young man in this business we used to recognize about 25% margin in therapy if we pull 10% now that's that's great but it really is you can't run a big orthopedic practice without it but it is costing more to do it and then visco supplementation we've all seen this over the years there's been many conversations that we've had at a AOE and I know a number of practices of the club to stop doing it all together but right now it's a dead push you know between trying to we have chosen to limit our inventory to one or two products the doctors don't think there's a big difference in the atoms and the molecules which the sales reps happen to hate but they're all the same they all do the same thing so we try to find the right strike point on price the least a number of specialty pharmacies I got to use control inventory but basically right now it really is limited reimbursement it's really very very low next please so ancillary services and compensation I think again it goes back to my comment if you've seen one complaint you've seen one we've chosen to make it a direct to provider allocations can be one of two things direct to the provider or shared in our organization it goes direct to the provider the question comes down when you do it shared it's the impact of non-users and years ago when we try to do an equal share model many many years ago there were providers who would not use any of the services yet they were realizing part of the revenue so that's how we ended up shifting away to a direct to the provider it also has an impact of outside referral by the group providers you know and what's the monitoring process we let a lot of our Medicare PT go outside because you as the rules are for Medicare it's going to be one-on-one it's just not feasible to tie up therapists that way so we do have some relationships on the outside but we let the Medicare volume drift out to some outside therapy services that way it keeps our therapists and therapy assistants more productive they can see more patients in the course our target in therapy is about is about 12 per day is what we try to see and our managers in therapy do a very good job of monitoring that to ensure that the schedules are you know pretty full you minimize no-shows you minimize cancellations as best you can and that's the impact of mid-level mid-level referrals so you know as the surgeons are functioning with what they do and the mid-levels are doing a lot of follow-up visits there's a lot of the referrals by our mid-levels into the into the ancillaries whether it's follow-up x-rays or it's therapy or follow-up DME post-surgery so our mid-levels very very integral in this whole process and the other part of this is really assessing the capital investment you know I think when you look at DME imaging advanced imaging for example you know I've got two I've got a 3t MR and I got a 1 5 MR you know and the physical plant requirements for both of those were substantial I had to add about 3,000 square feet onto one of my main buildings so I could get it on grade on lower level the machine weighs 18 tons so we had to do a lot of reinforcement in the ground and then the floor to be able to sort to support the machine well with all the infrastructure for cooling and ventilation and so forth for the space we the one five machine we had to modify the building a little bit which was which was okay because it was already anticipated for getting the certificate of need for it and that machine only weighs about nine tons so it was a little less endeavor but the machine alone cost us a million so you know I think as you look at it it's how many how many exams can you do we we generate probably 14,000 MRS a year we have the capability of doing about 10,000 so there are some based on payer based on contracts that we send out patients that have implantable patients that have pacemakers we all send out and you know we do a pretty good job of evaluating which patients we can see what you can't we we are a team doctors for three universities so patients are from all over the country sometimes they want to their their their children to go to their home state but you know it's a it's a challenge and it's a part of the monitoring process you have to do but they are very capital intensive service contracts the the ancillary equipment that goes with with MR is very expensive so you really have to stay on top of the maintenance agreements that go with those next please so you know we've talked about traditional ancillaries which most practices look at the point behind this this slide here is what other opportunities could you explore that can add value to the income of the shareholders and part of this is the ability to manage risk tolerance with predictable outcome and then manages the impact on practices balance sheet and P&L so as you look at opportunities you know how is it going to add value and how can you manage its impact on the on the on the organization's finances next please so we have walk-in centers we looked at walk-in centers as another ancillary service it's we have four of them we staff them with primary care sports non-operative sports medicine doctors we run them Monday through Saturday Monday through Friday 8 to 8 and then Saturdays 8 to 4 and then we run one of our locations on Sundays from 9 to 1 we do probably 20,000 visits a year and and what we have learned is I'm less worried about the profit in the in this particular answer is I am more about the downstream revenue what I now know what we've been able to measure because we will track the patients through it for every dollar I see in my ortho fast I'll realize $4 downstream surgery imaging therapy different services within the practice so it's and I can place them about 15 miles away from the two main locations we have 250,000 square foot buildings and I can place them about 10-15 miles away and those patients will come back into the main locations for their advanced imaging or see to see the orthopedic surgeon so it's a real good way to draw to capture volume and because it's it's you know it's full service it makes it makes a big big push down into the practice the the the ortho fast they buy the management from the practice and it offsets the overhead we treat it we treat it as a as a revenue center so we treat the all the docs and staff in the revenue center and we'll share profit at the end of the year with them but they do contribute quite a bit to the overhead their direct overhead plus they pick up you know a contribution of GNA from the rest of the practice so it's a it's a it's a pretty good opportunity for us next please other things that we have found bring good value and this is a little nontraditional but but when we need to finance a project like we did our new buildings and we had to buy equipment and furniture and fixtures we form leasing companies and basically I form an LLC and then the doctors or whomever you know senior management there they can participate and they put the funds up and then the LLC will then buy the assets we turn around and create an operating lease operating lease back to the practice the practice is the guarantor so you know the the the assets get flown into the practice they get deployed the practice through its general operating money will pay the monthly fee back to the leasing company the members of the LLC realize a significant interest rate you know you usually generate usually you can generate probably four or five six points above prime you know we use between anywhere between 10 to 12 so that's the the dot why it makes the docs want to do it is they're getting a better return on their money the the members of the LLC get to realize the tax the appreciation tax credit on the on their personal 1040s from the from the LLC the beauty of this is there's no practice you cease to file there's nothing on the balance sheet or there's debt service so it's you know it's pretty clean to the practice it keeps the practice's balance sheet very healthy also the practice we allow the practice's executive team to participate which is a good opportunity for them and so it's a you know it's a it's a it's a nice way to bind everybody together you want me to answer any of those questions you want me to keep going or no I was just gonna ask you if you wanted to do that can you see those in the chat there where do I do that so if you go up to your bar and hit chat I can read them to you that's fine sure so the first question is what are some KPIs that you track for ancillary services to help ensure it's helping overall revenue I'm thinking PT and DME specifically PT we look at it on its on its number of visits and the revenue per visit and then we we kind of each quarter we'll do a P&L on PT and kind of see what the return is because what we have built into our overall PT P&L is if I'm getting 12 visits per therapist per day that's my that's my target and we have built in a incentive program that the Pete the therapist will share 5% of the net profit out of therapy so at the end of the year I'll send 30 or $50,000 over the therapy for them to split amongst the therapist and in some format which has been very very well received so it gets them to hit their targets so we that that's our big measurement is the 12 visits per day and and to try to minimize the no-show cancellation rate because as we all know you know if it's at the last minute it's hard to refill how to refill those visits DME it's it's it's it's kind of the volume it's the number of units that go out and there there used to be a great little value that our athletic trainers could go in and do in room exercises that the physician could bill for as part of the visit a lot of that's kind of gone by the wayside you can do crutch teaching crutch teaching that the trainers can go in and teach the patients how to use crutches you can bill for that service but generally with the with the the measurement for DME is the overall number of units that that's going out now the other upside for us as part of that BlackRock one of their components is called CompSmart and they buy all of my workers comp claims and they pay me a rate for those claims that I now can turn I realized the return and that company CompSmart then they hate the risk on getting paid for those claims and it's been very it's been very positive for us that I don't have to go chase workers comp with all the silent PPOs and all of the repricing that happens in work comp it's been it's been a great return for us and then there is a follow-up question to that how do you determine whether to expand or phase out an ancillary service based on performance metrics if I can find something to expand you know but one of the things I would like to expand is our ambulatory surgery center but I'm landlocked at the moment in this building we're thinking about adding a second one because we the number of surgeries we're doing the number of things that are being allowed in an ambulatory surgery center particularly the outpatient joints so we're looking to add more rooms and we're trying to do it in a in one of our other locations that's that's one of our goals I've got two MRs we've talked about going after a third I don't think I would be successful in Connecticut getting a CON to support a third room a third MRR we've talked about cry cryotherapy we've talked about using ice machines we already do ice machines that we buy from OSER cost me a hundred charge a patient 200 but these are the compression units a lot of a lot of a lot of challenges with them but we're trying to look at anything you know we're starting to evaluate collagen dressings there is some money in that a lot of the guys looking at me kind of cross-eyed whether they think it's real real or valuable but you know we have an in-house dispensary that we have had for years which is the workers comp only but we probably now generate probably a million and a half our pain guys that use that are just killing it with patches and some other foot and ankle surgeon has generated a fair amount of effort for it so we we do do that we don't do any narcotics, we don't do any Schedule II. We have now learned that we can do self-pay patients. So we're gonna start evaluating the formulary for self-pay patients. So as things occur, you know, we look at the opportunity and what it will take to go do that. I'm not as bullish on the self-pay dispensary. I just think it's gonna be more of a, pardon my expression, more of a pain in the ass that it's worth. But, you know, the guys whose name on the door, they wanna take a look at it. So we'll go down the pathway. Okay, and we've got another question that just popped up. Are you incorporating athletic trainers in the clinic as physician extenders for ancillary service other than to do crutch training? Yep, they do all of the splinting and casting. They take a lot of the phone calls in and triage phone calls and distribute them either to the dispensary coordinator to refill prescriptions. They'll take a lot of the medical reports in and review MRs for normals or whatever, report back to patients. They support the physician assistants by taking messages in and pulling notes together and giving them to the PAs. What else? They work in our orthofast. So generally speaking, we staff our orthofast with trainers because they do a lot to help the doctors there with splinting and casting and taking care of the patients. They probably are at the point now where they cost me just a little bit more than our medical assistants. So they're a pretty good resource to utilize within the practice. I have probably 10 of them. And what about billable services for athletic trainers? It's the casting and splinting that's billable services. The rest of it is it releases the PAs from phone calls and allows the PAs to, it's cost avoidance, right? So if I'm not having a PA sit there, read through phone calls, I have the trainer do it. And then the PA only does the things that they need to do. And the PA then can add patients into their schedule. That's all the questions we had at the moment. Okay. Okay, go to the next one. So we also built another one of our ancillary thought processes is we built a trauma company. It's called OSG Trauma LLC. And what we did with this is we, OSG is the sole member of it, but we took it outside of the practice so it doesn't get subjected to the overhead and the control of the practice. But all of our call, we take it outside of the practice. All of our call, we take call at three hospitals. We have all these medical directorships that we have. We have co-management and we also staff one of the hospital's underserved clinic. And we provide a orthopedic surgeon a day a week with a PA and they'll, and they pay us quite a bit of money to staff those. So all those funds go into the trauma company and we hold it outside of the practice so it's not subject to overhead. At the end of the day, we use it. So if a particular provider comes up short in any fiscal year, their share of that entity, I can bring back into the practice and offset their losses so the doc doesn't have to write me a check back. Otherwise the money gets paid out to the docs as a 1099. Many of the docs have their own personal LLC for which they're doing IMEs or mental legal work and they can fund this outside entity through some of this money. And then they can take a second self-employed pension plan or they can offset other business expenses that I won't accept. So it gives them a lot of flexibility in their own personal finances. Next please. Another entity we formed is called University Health. Again, OSG is the sole member of this but we took it outside of the practice and it holds all of the contracts for the colleges and the high school sports coverage. So this money comes in from, we also take care of a professional hockey team which drops into this as well. We take the money in and that's how we pay our doctors to cover sports or our PAs to cover sports. We have a contract with some outside athletic trainers that support the schools. She has a rate, we charge the schools a rate plus. So we take a little bit of money and it's not subject to overhead. And then anybody who gets coverage, they get a 1099 for it. So it's not subject to payroll taxes and pension contribution. So what I try to do is on all of these entities, I try not to put any burden back in the practice. So other than payroll that I would have to pay, I avoid the payroll, payroll taxes and pension contribution which controls the overhead within the practice. And I talked a little bit about the dispensary before. So that's one of our other opportunities. Okay, next. Real estate. You know, this is one of those big issues that every physician thinks they're Warren Buffett and they should own real estate. I have never been a gigantic supporter of physicians owning real estate. However, it does work. We built two 50,000 square foot buildings. The physicians were the owners of it along with the real estate developer and some of the senior management was able to participate if they wished. It is a passive, it could be passive or active income. You know, you've just got to be able to, you know, control what you want in it. So we've got subleases within it because we have our ambulatory surgery center as a separate LLC. The sole tenant is OSG. So we've got to do some splitting of expenses particularly on utilities and the CAM charges. So you've got to pay attention to that. It relatively simple ease of entry for a physician. They don't really have to put up much money. The bank paid for a lot of it to do it. We did have the opportunity a couple of years after we built both buildings and we're up and running that the interest rates were so good and the cap rate was so good that we were able to sell both buildings to a medical REIT that was based out of Nashville. They paid a very handsome price. So the doctors, the investors all got a return. The beauty of this particular arrangement was there was a fund, they would call it a financing trust. So the docs could reinvest up to 30% back in the trust. So they could take their original capital investment back out and take their capital gains and reinvest it into the trust and they get distributions every year. In that they also, to make the deal proper allowed the practice to have an investment in the trust. And that returns money to me basically into the entity. And I can offset the rent increases every year from the dividends that come from that. So I don't have to absorb in my overhead the increase in rent. So it's helped me quite a bit and the money sits there, you know, and at some point in time they'll be able to return all that capital. So that's been a very positive thing. And as interest rates have gone up, one of my guys came to me recently and said, you know, our cost of the building has gone up. And I said, you're right. The taxes in this building alone went up $60,000. Electric has gone up $17,000. So cost of ownership has gone up. So the cam charges go up. So it's just something that you really gotta manage in the process. But it's been very positive. The beauty is we have a big sign out in our parking lot. It's up at the edge of the street. A few months ago, an impaired driver at three in the morning missed the, we call the rotaries here, the roundabout came up onto the property and took out our sign. Well, the real estate company in Nashville got a bill for $25,000 to fix our sign. And that's very good. Next, please. I think one of the issues that becomes more and more, we recently, when I first came here, our buy-in arrangement was you were an associate for three years. And during that three years, you had to generate a surplus of 500,000, which was kind of your buy-in. And then you were into the organization. As time went along, young physicians didn't, they wanted to be a shareholder faster. So we limited it to two years, and then we created a buy-in. And we went through some iterations of what the buy-in should be. And this past year or so, we finally have had to eliminate the buy-in altogether. So as you look at your buy-sell agreements, it's how you wanna create the value stream. So what we did, there'd be no buy-in, but you would have to vest in the ancillaries over some time. So for the MRI, you vested over three years to get into the MRI. X-ray and DME, we included it because that's what you're generating as part of your practice. Real estate, you'd have to invest in any real estate. You'd invest into the ambulatory surgery center, but there was still a buy-in to the ambulatory surgery center. And on the way out, it's not included any longer. So since there's no dollars in, now there's no dollars out. So ancillary was in some practices that I know, which created the issue. Some of the buyouts in some of these other practices that I know of, the departing shareholder had a lifetime participation in their ancillary. So we really had to do a lot of soul searching. And we decided, that's why I said, is the ancillary included? It's now not, it's out. So you don't get anything on the way out the door. I think you have to value your ancillary services to kind of determine what happens downstream. And I think impact of any debt. If you've got MRI machines, for example, and you're carrying debt, that's a significant impact. That's why we vested before you come in. And generally speaking, if you have debt and you get into become a shareholder, you have to assume liability and sign on to the debt instruments, which is always becomes an interesting topic for a young physician. Next please. So in summary, I think you define the impact of ancillary within your practice. I think what you need to look at is space, the number of physicians you have, what is it you think you can do to control it? I think you have to really understand the specifics of each ancillary service. Obviously everybody has x-ray. I think everybody probably has therapy to some degree or other. But I think you need to look at each ancillary service independently and understand the cost of the delivery of them in both human capital and physical capital, space management, so forth. I think you need to understand DHS, practices that don't do this, really, it's a stark issue. You get kind of surprised by it a little bit. A lot of my guys, particularly some of the younger physicians who had big Medicare practices were really shocked by the impact on DHS in their production. I do think you can get creative with your practices. And again, it goes back to the risk tolerance of your doctors. What other innovative opportunities can you do? I think once it's explained to them, and you can see that, I think it becomes a viable option, leasing companies, trauma companies. It's a different philosophy, but I think it works well, separates liabilities, separates exposure. You then can figure out how it fits into the compensation plan, where it fits into the compensation plan, if it goes into the compensation plan. My personal take in this is some of these innovative things can sit outside because they're not utilizing a lot of the organization's resources. It's me or my finance person that are taking care of it, and not a lot of other resources are consumed. So you just have to understand what's taking place in it. Don't try to make it do something it's not supposed to go do. Everybody will look at it as, oh, we can offset overhead. Well, it really doesn't, because it's not consuming much. And then again, it goes into, what is it in the buy sell? And as you, one of the things I did over the past year, as we were evaluating hours, I put on a list serve, who's modifying or doing something different in their buy sell and there was a fairly strong response that groups were having to eliminate the buy-ins to in order to recruit young physicians into their practices. Up here in New England, people only come here if they're from here or the spouse is from here. It's not an attractive place to be. Forget your political persuasion, but these Massachusetts, Rhode Island, Connecticut, highly taxed states, not attractive. I can say that now because I'm a resident of Florida. You know, when I commute back and forth from Florida, it's much nicer to live in Florida with no income tax than it is to live in, I used to live in Boston where it was a higher income tax. So all those have an impact on your ability to function. So I think you really gotta, as you progress and one of the things I would highly recommend is part of your strategic planning process is to really understand your manpower and the timeline that your current doctors have and the ability to function on recruitment. We all know that it takes, you know, five years for an orthopedic surgeon to ramp up to be self-sustaining. And if you've got aging physicians who are slowing down, sometimes they get in the way, what's your transition process for aging physicians and what's their timeline to depart so you know I gotta recruit because once you start making capital investments, someone's gotta pay the tab. And that becomes one of those risk factors that you really gotta plan for because you don't wanna be the last guy standing in a practice owning all the debt. Next, please. Any questions? Well, we did have one question. Can you please repeat the name of the company you mentioned that is handling your workers' comp payments? Well, CompSmart and it's part of BlackRock GPO. They're usually at the AAOE meeting, but if you go on and look up BlackRock GPO, Mark Simmelman is the guy who runs it. It's part of that. He's always been at the AAOE meetings. Okay, and then we had another question. Not necessarily ancillary services, but have you considered implementing ABNs or financial waivers for assistant surgeons? We've looked at it. Most of the assistants at surgery are our own PAs and they're kind of going on the billing that are prior approved. In the hospital, other than some of the neurosurgical cases, most of the orthopedics use the hospital's PAs to do the assistance in surgery. It's not real economically viable for me to send one of my resources to the hospital. Thank you, Steve. Are there any other questions for our presenter? He's presented a lot of really good information. I imagine you have some follow-up questions, so please don't be shy and drop those into the chat. So we have another question here. What are some common pitfalls when integrating new ancillary services and how can they be avoided? Planning. As I said, I think part of the process is what's your expectation for this service to do? And I think you go through and try to figure out what's the demand for it. You know, I've got one guy who keeps coming to me about barometric services. And I go, where would you like me to put it? You know, it takes up a fair amount of space. He goes, well, there's this room. And I go, no, that's called the computer room. So they all, you know, they think outside, not necessarily correctly. So I just think you gotta plan properly. What's the volume? You know, every one of these guys goes to a meeting and they got a sales rep, you know, launches onto them. So I think it's planning, really understanding what the potential is, then really doing the research on what's the reimbursement. You know, every so often one of the guys says, well, it's cash. And I go, patients don't wanna reach into their pocket. They're not paying you the co-payments. So they're not gonna reach into their pocket for $1,000 for you to treat, to do something. You know, it's like PRP. No insurance pays for it. And you tell the patients $1,000, they kind of look at you sideways. In Connecticut, Blue Cross Blue Shield does not pay for VSCO supplements. So you gotta tell the patient that's cash and care. You gotta pay me up front so I can order the drug. They all look at you. Well, what else can you give me other than that? So I think in today's climate, you really have to understand what's the revenue stream? How's it gonna get paid? What's my capital investment? What's my physical plant demand? And then what's the reality that you're really gonna have the volume to support it? Okay, and then we have another question here. How did you transition to no buy-in and how did existing partners who had done the buy-in get handled? We transitioned because we were struggling with young doctors wanting to have a buy-in. We've been evaluating a couple of different capital arrangements. One, we almost did a PSA a couple of years back with Yellow Haven Health System and they would have acquired everything. So we kind of had to put buy-ins on a hold for a minute. We had a couple of guys coming in until we resolved that issue. As we have looked at, we've evaluated PE, we've evaluated a couple of platforms. It was becoming evident that young physicians could go work someplace else. We all understand that 65% of residents and fellows would rather be employed. So we needed to be able to make the environment more attractive. So taking away a $300,000 or $400,000 commitment to them, even though we had a number of ways to pay for it, was more attractive and it retained some of our younger doctors. Since most of the docs that were here came in under the old methodology where it was their surplus that funded it, they really didn't reach into their pocket. And the big change was all the existing shareholders had to agree that there'd be no buyout. And our buyout was two years of your accounts receivable, which wasn't a heck of a lot of money. So they agreed to that in order to make this work. So it was emotional. There was a lot of ranting and raving and stamping of the feet and crying, and that was mostly me during the presentations, but it got through. That's what we had to do to make this better. It was a big change, but it was doable and it kept three doctors into the organization. Thank you. That's great. Do we have any other questions for Steve? We've had some good ones so far, so don't be shy. Go ahead and drop that question into the webinar chat or the Q&A. Give everyone a minute to think about what they might need. No more questions? Everyone's overwhelmed. Okay. Yeah, so someone said, thank you. Okay, well, if there are no more questions for Steve, I'll say thank you for presenting this webinar. And again, I will be sending out the PowerPoints and the recording to everyone within a few days. And we'll see if we can get to everyone's questions. And again, within a few days, you're getting a lot of thank yous in the chat. So thank you, Steve, for this presentation. My pleasure. Thank you all. Have a great day. Okay, bye-bye. Bye, thank you.

orthopedic practices

ancillary services

diversification

revenue streams

Stark regulations

physician compensation

strategic planning

risk management