You should now see my updated screen, so again, this is understanding orthopedic practice models. It's a webinar series. The first of three sessions, independent practices and joint ventures. Our next session is coming up on Thursday, February 22nd, and that again is at 2.30 PM. We're going to be discussing mergers and mega groups and hospitals, and the following session will be March 20th, again at 2.30, and discussing private equity and PSA. We've partnered with Ziegler to moderate this series, but all the panelists are going to be members just like today, so definitely sign up for those at aoe.net slash events. If you are considering any of these, want to hear experiences from other members on any of those models, and then again, this will be culminating in a conference session on Sunday, April 28th at 2 PM, and there will also be a meetup after at the end of the day in the Hive at conference at 5 PM. So if you are planning conference, definitely plan to attend this session. Today we are joined with Andy Colbert with Ziegler. He's going to be moderating the session with panelists. We also have Alyssa Ashley High, who is with Orthopedic Associates of Marlboro, Andrew Wade with OrthoSC, and oh my gosh, I'm sorry, Chris. That is Chris Greenman, not Alyssa, and he is CEO with Bale Summit. All right, so with that being said, I'm going to pause my share and turn it over to Andy to get us started. Excellent. Yeah, thank you so much, Jessica. I appreciate everyone tuning in today. So my name is Andy. I'm one of the partners here at Ziegler, a 20-year career in advising private practice physician groups on various strategic initiatives and strategic alternatives. Have worked on over $5.5 billion worth of transactions over my career, helping groups navigate things such as joint ventures, PSAs, affiliations, mergers and acquisitions, private equity transactions, do a lot of work across all different specialties, but with a specific expertise in orthopedics. And Ziegler, 100-year-old firm, we're an employee-owned firm, so very much understand the importance of independence and partnership, and being around for 100 years, we certainly appreciate the importance of culture and continuity, and about half of our firm actually has been with us for over 10 years, so really, really bring a lot of these to bear. So today, we're going to start off with just having everyone do really quick intros on their group and just kind of the makeup of their practice, as well as just some of the dynamics in their local market. The goal for today is really to compare and contrast three groups of differing sizes. Chris kind of represents a group that has some joint venture and hospital external party relationships on the ASCs, Andrew's group is also kind of a larger group that is kind of fully independent, and then Alyssa represents kind of more of the smaller group side. So really excited, all three of you to join, and maybe with that, Alyssa, we'll kind of start with you, since you're first on my screen, and you want to just kind of give the quick makeup and background of your group and what's going on in your situation. Sure. So I work for an independent practice, currently we are two surgeons, both owners, so we are one of the only people within our market area. We have an affiliation with a local hospital, and in the next city over from us, we're in central Massachusetts, and the next largest city outside of Boston is called Worcester, and so we are affiliated with that large hospital system. So we, but they have a small community hospital in our town called Marlborough. So they really do help us, we do surgeries there, they are also part of a joint venture with a local MRI company, so they have the surgery center, but Massachusetts has some really interesting rules and regulations where we are not allowed to own our own ancillaries, so our market's very limited of what we can do, we don't have therapy, we're just surgeons at this point. So our struggles are definitely with recruiting and retention, and just, you know, as we'll discuss later of, you know, planning that next step, and, you know, but staying viable because we want to stay independent to provide the best level of service for our community. That's great. Andrew? Hey, good afternoon, I'm Andrew Wade, I'm CEO of OrthoSC, we're a primarily orthopedics multi-specialty group in the northeastern counties of South Carolina, 34 physicians, about 92 billing providers in total with our mid-level folks and our therapy folks across the entirety of the company, six different locations, several MRIs, two ASCs, full range of what you would typically see in most groups today from ancillary services perspective. Our market's unique in that it's a really, really rapidly growing market, if you search for us online, you'll find that the area that we're in is one of the fastest growing, particularly on the eastern coast and in the southeast. And we have a, we have four different hospital, I'm going to call them partners that are in the market with us that are also providing orthopedic services around us. And so one of the things that's super unique for us is that we really have to compete and have to hold our stake in the ground, if you will, just based on service and access and making sure that we out take care of the patients that choose to come and trust their care to us, because there are so many other options around us for patients. So younger group, we've been around for about five years, we were the culmination of three separate sister groups that were in the geographic area that had been around since 1980s, came together in 2018, been growing ever since, and just like Alyssa, same challenges, different zip code. How do you recruit? How do you grow? How do you, how do you maintain great staff and, you know, that really drive that experience for your patients? So excited to have that conversation with you guys today. Excellent. Chris? Thank you. Sorry about that. Yeah. Chris Greenman, CEO of Vail Summit Orthopedic and Neurosurgery. I've been in this position about a year. I was previously at Tahoe Fracture for nearly 25 years. And you know, some of our unique situations that we deal with, I mean, the recruitment, obviously, as everyone else, we deal with the mountain living, which the cost of living, you know, access, you know, getting qualified staff can be quite a challenge. Although it has been a challenge, I'm very pleased that, you know, the staff we've been able to maintain and recruit here. You know, our independence is important. And as Andrew mentioned previously, we do have a good relationship with one of the local hospitals and we have a joint venture with three ASCs, which, you know, keeps us busy. We're also in, and that's primarily in Eagle County. We're also in Summit County and do have a relationship with the local hospital in the Summit County as well with inpatient PT, which we provide. We have a couple of MRIs. And really, I think our main focus is accessibility and allowing patients to get into our system and get the healthcare, the great healthcare that they, you know, they need and they seek. And we have a lot of tourists that come through as well. And so it's accommodating them at the same time, you know, in this process. So I'm happy to be here today and provide whatever experience, you know, that we have had and whatnot, if in hopes that it can help anyone else. That's great. That's great. And so, you know, piggybacking off this, you know, I do want to introduce folks to the chat feature. You know, please do use the chat feature to ask your specific questions. You know, we want to make this session as interactive as possible. We're going to do a series of polls to kick things off. Jessica, I don't know if it's possible to load those up. And then we've got three quick questions. So the first is, in your opinion, what's the biggest challenge faced by independently owned orthopedic groups? So it's financial constraints, resources for technology, competition with health systems or other. The second question is, how much is market competition on your mind as you look at the next five years? On a scale of zero to five, five being most concerned about competition, zero being least concerned. And then lastly, which attributes do you consider most important to your practice success? Leadership, value based care, data analytics, benchmarking, culture. So maybe we'll give folks just a just a minute to fill these out. I think it'll be super informative as we move through the discussion today. While that's going and while folks are filling out the survey, I'm going to kick off with kind of the first question. And I'm going to start with you, Chris, because, you know, this isn't your first rodeo. You've got a bunch of experienced leading groups in multiple markets, experience also with groups that have taken capital and groups have been independent. Chris, give us a flavor for kind of just the level of kind of awareness your group has as to the various market strategies, and then particularly, you know, how deep has your group gone in terms of evaluating various partnerships and affiliations? And, you know, kind of where are you on that curve, if you will? Yeah, no, great question. You know, prior to me arriving, our main competition, another orthopedic group in the area, had gone with private equity. And so our group had looked into this about two or three times. And in that evaluation, although I was not here at the time in that evaluation, and they basically have come up with a decision that they want to remain independent. They feel they can do that. And so I would say the local environment is such that, you know, we are able to do it currently. But it's something that, you know, at the end of the day, we've got to become even more efficient to have that independence, to maintain it. And so, yeah, they are committed and they've gone down that road a couple of times. Have you guys thought about bringing on other, you know, smaller independent groups or joining forces with other like minded groups or what kind of what's been the evaluation there? So in our initial main service area, there are no other orthopedists aside from the main competition, which is has gone private equity. So we have reached out to other communities. We do have an agreement with a we employ two physicians at a hospital that's in the next county. And so they have our name, but the hospital reimburses us for those physicians. It is, though, that can be that can be difficult because we might have two to three hours travel distance between offices. And so things can get pretty spread out. And it's important to I think in any of these situations for us in these mountain communities, if you do not have the hospital, at least cooperation and partnership in some way, shape or form, it is extremely difficult to make this work. Yeah, that's that's certainly interesting. And you're you're you're in a market that is relatively isolated in some regards. Right. So it kind of brings it brings its own challenges. Andrew, talk to us a little bit about your your practice. I mean, you guys are a pretty sizable group. You know what? Close to thirty five physicians, 100 staff. Have you guys thought about various affiliations and partnerships? I mean, you guys are in a market where there are a number of other independent groups in surrounding vicinities. Yeah, so we definitely have a lot of time and energy spent over the last couple of years trying to think through what does that look like and what do we want to what do we want to be? We looked at private equity previously, never gone through a full evaluation of that, but looked at it previously. And our physicians just came back to the realization that it just wasn't the pathway for them. Now, I don't want to completely trash you because I know some groups that seem like they've had great success there. And that's awesome for them. It just isn't where our guys want to go. From a partnership perspective, we are the only independent group within about an hour and a half of our geography. So we have some incredible practices to the north of us, some great folks to the south of us, some great folks to the west of us. We have the Atlantic Ocean to the east of us. So there's nobody that we know about there. But we've got people around, but there's nobody right here in the backyard with us. And so from our perspective, it really comes into, you know, do we do we try to build a larger organization that's geographically distributed? Do we attempt to partner with the hospital systems that are here in the community with us and work through the competing goals and objectives that they have in the community versus what we have in the community? And so we've certainly landed on remaining private, independent. Our folks are dead set that that's the future of where they want to go. And so we're we're continually looking for how do we maintain that independence? But how do we also do that while, you know, creating good partnerships, being good partners to the folks in the community and finding ways to create mutual wins? That's great. Alyssa, how about you? Have you guys ever thought about joining up with with something larger? Obviously, a lot a lot of complexity leading the helm of a two dock group and, you know, all the headwinds racing your direction. Yeah, it's it's a challenge. We have talked about it behind closed doors, and there's been some kind of gentleman conversations between my two surgeons and some other private surgeons that are near us. The problem is that there's a couple of other groups within an hour of us that work also for the same affiliated hospital system. But they do surgeries at a different hospital. So our problem is if we join with other people, how does call work? Because our doctors, you know, they tend to live closer to Boston, whereas the other doctors live closer to like the West Western part of the state. Massachusetts is a fairly small state, but, you know, no one wants to drive an hour, you know, beyond the hour that they already drive. So we kind of looked at, you know, how how would that work? And we've started seeing, again, some of the other groups that are within an hour of us. You know, there's a super group that just formed. There's a couple of joint ventures that just happened and we're just not really sure. And then the conversation of because we do have support agreements with the hospitals, there's almost this nervousness of talking to the hospitals about, well, what does our future look like? Because if they feel that we're the fear is that if we look weak, maybe they'll just come in and decide to do their own thing or not want to support us anymore. And it's it's not the case. It's just more of, you know, we need to have some sort of plan for the future. And right now we just don't have anything. That's great. That's great. Well, certainly a lot of strategic thinking. So the results from the polls have come in and certainly pretty interesting. There seems to be kind of an overwhelming theme here of awareness of competition. You know, the first question looks like about 70 percent. The group's biggest challenge is competition with health systems. You know, on a scale of one to five, it looks like, you know, almost, you know, all of folks are at least a three, three or higher. And, you know, about 60 percent is four or higher. So definitely high on people's mind. And then I think the last question is, is is kind of interesting, which, you know, 80 percent of the respondents have answered that leadership is the single biggest element to the practice's success. So certainly bodes well for the three of you here, the importance of AOE and what we're all doing together. So I think it's great. A lot we can we can hit on. So maybe I'll start with you, Andrew. You know, given competition seems to be very top of mind here. Talk to us about some real tangible examples of what you guys have done specifically to really drive market share and increase competitive positioning and kind of, you know, keep keep your market share and protect your turf, if you will. Sure. I'm not surprised by the competition. I'm surprised that the financial pressure is not higher on the list there with it. But the competition definitely makes sense. So from our perspective in our market, I said earlier, you know, we're we're attempting to out serve our competition. Right. And that's not because our competition's dumb or incapable. It's just that they have a lot more to focus on than we do. Right. They've got every specialty under the sun. All we do is MSK. And so we really have the ability to be a focus factory. We really have the ability to just hyper focus in on making that process as easy as it can be. So easy to access your information, easy to talk to one of our team members, easy to get an appointment, same day access, same day access for MRIs, trying to get procedures done as quickly and as efficiently as we can. Pushing our way into direct pay and direct to employer type contracting agreements so that the concept of price transparency as that continues to be a big issue that's out there in front of us is there. You know, we have really centered and focused on making great use of technology so that it's easy to book an appointment. And I think that's gonna become more and more prevalent and important for all of us as we consider the fact that with consolidation happening across our hospitals, you know, there really is something to say for working with a health network, if you will, in a community and having literally every specialist that you see and take care of available to you in one mobile app. You know, think the major market players out there in the EHR industry and what it means to have your kid's pediatrician's info in one place and your primary care in one place and your specialty care in one place and your labs or imaging all in one place. So it just comes down to people are busy. Their lives are busy. They've got a lot going on. And the easier that we can make it for folks to be able to access care, the easier it's going to be for them to get on with this and get done with this. I think the important thing for us to remember is that most people don't wake up in the morning thinking, man, I really want to go see the orthopedist. Something's broken or hurt, right? Or in a lot of cases, they didn't plan to see us today and something's happened. So it's, you know, this is not one of those, this isn't Apple where we, you know, have this shiny fun experience. This is a, they need care, they need service. Something's come up in their life and now the opportunity to come alongside of them and to get them back to health or to get their kid or their parent or whoever it is back to health as easily and quickly and efficiently as they can is really where we're going to win. Because at the end of the day, it's not that they don't love us, but they're not waking up excited to come do this today, right? They want to get back to their life. They want to get back to being able to provide for their family at work or play with their grandkids on the weekend or play golf or whatever it is that they do. And so focusing on the ultimate desire of the customer and trying to reinvent and rebuild our system or how do we connect to that and how do we deliver that for them at every step of the way has been critical and key for us. So that's- So Andrew, maybe to drill a little deeper into that, cause you don't want to be as tangible as possible. What specific tools are you guys using on the technology side? Is it stuff that you guys have had to kind of home grow or customize or off the shelf tools? I wish that we were smart enough to home grow this stuff, but we're not. So it's online appointment scheduling. It's making good use of a patient portal. It's making good use of an EHR's patient application, which is not as good as I want it to be yet, but it's getting better, right? It's having online chat available for folks. It's looking into how do I create an opportunity for patients to be able to just work with me via text message? Cause I mean, I'm like this close to being a millennial. You could just totally turn the phone service off from my cell phone entirely. And I'd completely communicate with you via email and text message. There's a whole lot of people out there, right? I mean, there's just opportunities to make it easier for people who are there and taking advantage of them, dropping that into our workflow so that people can interact with us is really going to be a key part of what drives us in the future. Yeah, yeah, no, that's great. Chris, maybe a great opportunity for you to chime in. You're in, as you mentioned, a market where you got a relatively well-capitalized competitor, not too far from you. What are some of the initiatives that you guys have done as specific as possible just to give folks some real tangible takeaways to help with market competition? Yeah, yeah. And I really liked Andrew's response. At the end of the day, it is about access and it's about taking down all those barriers to entry. Every phone call represents an unresolved concern. And how do we minimize all those? So some of the things that we've done, and frankly, I agree, we have to be mindful of our competition, but I have found the more emphasis I put on what we're doing as opposed to the competition, I think the better we do. Because at the end of the day, it's just ourselves providing a better service. And so some of the things that we've done, we've taken a look at our schedules, for example, and going back to the access of care, we see a lot of situations, a lot of areas of improvement, which we've implemented because of this, where the types of appointments, we have so many different types of appointments. So we've narrowed that down. A lot of appointments go unfilled because it's not the right type of patient. And so then also we've taken a look at utilization throughout the day. How do we maximize the day? Are we taking these hour and a half long lunches? Can we work through lunches? Can we be a bit more efficient and fill more patients in during the day and give them that greater access? And so those are some of the things that we have really kind of focused on, but a lot of it's been more internal and focusing on our own efficiencies or inefficiencies as we've seen them. And I don't know, through the years, I've been doing this a while, I think focusing more on ourselves than our competition, we end up doing a far better job. I'm not saying being blind to it, but all groups, we all have struggles and issues and everything else. And so we've really kind of looked inward on how we can provide a better service. That's great. And anything that you'd like specifically changed or altered to make that service better? Yeah, we've had a kind of a slash urgent care kind of modified, we've changed it to a walk-in. Based on some of those needs, we have weakened MRI at certain times of the year because our demand fluctuates throughout the year. And again, some of those changes of how we utilize the efficiencies of the clinic in the scheduling and whatnot. That's great, that's great. Alyssa, give us your perspective on running a smaller operation in a market that's got a lot of big health systems, right? With a lot of deep pockets, how do you guys stay healthy relative to all the competition in your market? And what are some of the strategies you guys have done to retain patients? It's definitely about that small community feel. And we're generalists, so we don't subspecialize. So my surgeons, they deal with everything and all ages. So our goal is to be the practice of choice for the family. And we've been around for 50 years. And so we are seeing generation after generation of the kids come in with something when they're little or get cast on their feet for things. And then they're moving up and then they're seeing them get married and have kids in their own families. And our staff has been very consistent over the years as well. My longest staff member has been here for 28 years. I have one of my older, no longer practicing surgeon, he's been here since the seventies. And so we know the patients, they call, we know them personally. We send them congratulation cards or we will go to a funeral. So we have that personal touch. So it's not just about being able to get them an appointment, but it's really actually that we know these people and they are like family and they care about us. My providers are, one of them does live in the town. And then the other one, they do things for the local schools or senior centers. They're out at the hockey games, supporting things. They're at the senior centers just to make sure that they're there, they're present. They also will give all the local doctor's offices, urgent cares, they go down, they have their cell phone numbers. So they'll just call them on their cell phone and just say, hey, I've got a patient in the clinic right now. Can you just take a look at this X-ray? What would you suggest? And then we'll get them in either that day or the next day because it's something we can do for our community. And I think that's, again, unique because you can't get that with the bigger hospital system. You don't even have their phone number. You have a general central scheduling line. And I get it, you need that for efficiency, but because we don't need that, we're able to, I answer phones and it being the practice administrator, I'm in every aspect of it, but I know the patients as well. And I think that's important. So when they're calling to schedule, they're getting somebody who they're gonna actually know the face of and see them and care about them. And we can just talk to them as well versus someone who's gonna follow a script to try to get them someone that they never seen before, they don't know, and they may never see again after they've had that short little encounter. That's great. That's great. So it sounds like a big key to your success has been really that patient relationship continuity and really being that trusted resource for the patient generation after generation. That's great to hear. So I wanna hit on one of the topics on the poll around leadership. Clearly that's an important element here and leadership is tough. It's something that often you can't really learn in a textbook or in an academic setting. Andrew, talk to us a little bit about maybe two things. First, what's the biggest challenge you face in terms of leading your group? And then secondly, what are some things that you're most proud of as you think about some of your leadership accomplishments? Sure. So I think one of the biggest challenges that we face is helping our organization think at the rate and the scale that it needs to think to take its next step, right? Whatever that is. I mean, I think we always have to be building systems and reinventing systems and structures and processes and the things that make work happen that allow us to deliver care in our practice every day. We have to be rebuilding and evolving those things so that they're ready for the next stage of growth. And I think one of the challenges that we all face is we see this continual reimbursement decline and inflationary pressure on cost of doing business and this kind of perfect storm of stuff that's coming at us right now is that our physicians, our staff, they often have a picture in their mind when they think about what a successful job or a successful practice looks like. And so part of the art and the science and the weird middle between the two of leadership is helping challenge that picture that people have in their mind because we've got, I have some partners that they really love the small partner, small practice feel like they wanna be at the table for every decision that we make down to the brand of pens that we're sticking in the nurse's station drawers. And you just can't do it as an organization grows, there's no way that you can move things forward. And so one of the things that I think I'm most proudest of is just teaching and leading and working with our physicians to help them see that they can let go, right? They can focus on their patient, they can go to that exam room and do what they're best at doing. And with time and repeated application over and over and over proving that they can trust us that we're going to make decisions that are in their best interest and their patient's best interest that we're gonna keep transparency and communication open with them as it happens. But I think that's just one of those ongoing growing things for us is that the future of this is gonna require all of us to operate, I think at levels and layers that we've never had to operate before. And that's gonna be a challenge for a lot of our physicians and a lot of us as leaders and a lot of our staff to be able to not see that as something to run from, but to see that as something to lean into and to figure out as we move this stuff forward. That's great, that's great. Chris, what would you add to that in terms of what you've felt are the biggest challenges but also accomplishments from a leadership standpoint that's made your group successful? Yeah, I would say there's a constant analysis, right? Of why are we here? What are we doing and what's our purpose? And what we thought maybe three years ago might not be the same because of the dynamic nature of our industry and field and region and whatever it may be. And so some of the things that we've really been focusing on this year is, are the incentives correct? For expense, for example, direct expense, mid-levels, how do we deal with them? And having the discussion with the doctors because there's this constant balance, right? If some docs want to micromanage and others are so hands-off, it's finding that middle ground of engagement, right? Where just like what Andrew said of, hey, trust us that we can do this but then also to those docs who don't participate as much of, hey, your voice counts here and we wanna hear what you have to say. So it's kind of really finding that balance but we've been able to make a lot of changes internally as far as the structure goes that changes the incentives to a more efficient clinic and operation and utilization of the existing staff. Part of that is having staff working to the top of their license. Do you want a doctor? Do you want a PA? Do you want them doing stuff that can really be done by other staff members? Because at the end of the day, we wanna be seeing as many patients as we possibly can that need to be seen. And if the docs are more efficient, if all the providers are more efficient because they're seeing patients and that's what they're focused on, then the community is better off, frankly. And so, you know, that, and something that I really, I think a real highlight of my job and position is watching employees particularly realize their potential and to see them grow and to, you know, able to hand off more responsibility to them. And you know what? Part of that's gonna be making missteps, falling down but that's how we learn and that's how we grow. So create an environment where it's okay to make a mistake but we're gonna be transparent about it. We're gonna talk about it and then better off because the more empowered my, you know, the employees are that I work with, the better capable, more capable they are of addressing needs of upset patients, doctors and everything else and anything it adds to their ownership. Yeah, yeah, that's helpful. Alyssa, anything you would add to that? Just to get involved that just because we're small doesn't mean that we don't have a voice. And I have been blessed with the opportunity. I mean, part of my job requirement was I had to become an AOE member when I started and joined some other, you know, state professional medical groups. And it has given us a voice. So if there's a problem, I, you know, we're able to talk about it. We're able to get buy-in. We're able to advocate to, you know, to see what's going on. One of my surgeons is on, you know, the Mass Ortho Association. He's also on the board for the Academy of Orthopedic Surgeons. And so we're able to, you know, spread some knowledge of what we're seeing and actually make change happen, which is great for being, you know, a small company with few employees. But in the converse, it can be difficult because, you know, you definitely have to, as a leader, prove ROI on everything because, you know, we don't have the bandwidth or the things to necessarily outsource everything. Or, you know, we kept on hearing the term during COVID and now is like, do more with less. You get to a point where you can't do any more with any less. And so what do you do? And again, it's that valuing of those employees and really, you know, showing them and investing in them and letting them know why they're important. And that if you can, you know, elevate them so that they're, you know, marketable if they ever need to leave and let them know that, like, you know, we don't want them to be, we want them here, but we want them to succeed in life. And to give them avenues that, you know what, we have some people, we've got them connections through the larger hospital systems to help get them into PA school or med school or nursing school or whatever it may be. And that's great. And that's, you know, another reason why people do want to be with us or stay with us is that, you know, our employees are just as valuable as our patients. That's great. That's great, really helpful. And I think good lessons learned in kind of everyone just learning how to wear multiple hats, right? So, you know, I'd love to take it to the next step here and, you know, really push the envelope on critical investments, right? I think at the end of the day, if you're going to stay independent, you've got to come to terms with the fact that any business that's going to be independent for the longterm has got to be retaining earnings and making investments in growth, right? And fundamentally you can't just squeeze every dollar out of the piggy bank every year. Yeah, I don't think any of us would invest in a public company, you know, that's going to have no retained earnings, right? And just completely drain the coffers every year, right? So I want to push on the topic of, you know, A, how do you engage with your physician owners around the topic of retained earnings and the importance of that relative to compensation, right? And kind of the trade-off on that. And then B, when you do stand up, you know, in front of the room and make the case for investments, what have those investments been and how significant have those been? And what areas do you think require more investment as you see the horizon going forward? So maybe Andrew, we'll start with you on this one. Sure, so I think I would say I hit it head on, you know, and I think that the, maybe one of the most dangerous things that we can do is assume that all of our physicians understand what you just said. I think some of our guys totally get that. They're numbers minded, they've been around long enough, they maybe have a background that they've seen some of this stuff academically and they can run with it and they can just total sleep through that part of the meetings, right? But then there's some of our guys who are exceptionally gifted clinicians. I mean, it still blows my mind that they can put a pair of loops on and do what they do because I just, I don't have that, right? But those same guys who are so insanely brilliant in one area, they don't have the same background that we have and in our areas of training and so those concepts are just not, they're not just going to pop up in their mind or you know be absorbed by osmosis and so it really is up to us to paint a very real picture of where we are, what the very real pressures on our business are and what it requires for the machinery of an organization to not just exist but to thrive and so part of what we do on a regular and ongoing basis is look at you know what's happening with the with reimbursements, where are we from a production standpoint, what is it, what is coming up that's you know how how much longer is that 15 year old MRI gonna keep on chugging along, there's a big big check to write associated with that kind of stuff right, if we're gonna provide a great experience for our patients they can't be showing up to a building that looks like it's an old storage unit you know I mean if our if we want our staff to stay with us and if we want our staff to be proud of the organization that we work in, making them deal with a computer that's 700 years old and you know they click it and come back next week to see it finally advance, that's not gonna fly you know, so being straightforward with our physicians about what it's gonna take and what that's gonna look like that's part of why a budget is so important, you know monitoring your production is so important and having solid regular intervals where we're representing that information to say all right this is how we're doing, this is where we've got to get to to be able to continue just to stand still, but if we don't want to just stand still because that really doesn't benefit us either right, this is what we need to accomplish to really grow, to really be able to produce the margins that we need to run our business well, but also the margins that we need to continue making it worth it for physicians who are coming out of school to come bank on us as a bet versus the other opportunities that are out there are available to them. That's great, so Andrew what are some specific examples of areas where you guys have made some sizable investments and then what areas are on the docket for a future investment? So we could talk for a really long time on that because it feels like that's all I do today is like just spend money on trying to find ways to make systems and stuff like this better. One major investment that we made in 2023 that's really just now I'd say hitting cruising altitude is a platform to help automate the process of prior authorization. You know we realize that being able to keep up is we're just we're beyond that you know the sheer volume and the complexity of the stuff that's coming at us even if I had unlimited resources I can't hire enough or train fast enough to be able to keep up with that and so putting a tool in place that gives us the ability to manage that really rapidly growing volume and complexity has been huge for us. I think one of the things that's on my docket just and maybe even harkening back to our conversation earlier you know if you guys listen to me for for any amount of time I'm a technophile so I'm I'm always gonna look for a piece of technology to solve a problem sometimes that's good sometimes that's bad but one of the things that I'm chasing is how do we how do we make this a better place to give care and that's not a brand new statement or argument right I mean I think we've been a great place to receive care for a long time but Alyssa said it so well just a few minutes ago you really get to a point where you just you can't do a whole lot more with any less you're gonna have to have more access to resources or time or people or whatever it is and so one of the things that I'm chasing is how are we going to make it possible for our clinicians to be able to continue seeing more patients and still be able to get home to their families still be able to get to their kids ballgame or whatever that is right because I mean the thing is is our surgeons are somewhat inhuman in a lot of ways right and none of all of my surgeons would they growl at me for even insinuating they have emotions or need to sleep or eat or use the restroom or take a personal moment because they're they're rock stars and they're just gonna go go go but they're human right and they can only do so much in a day and so looking for ways to support them so that they can maintain the ability to do this for the long haul I think it's gonna be a big big part of what keeps us successful for the long term so I think one of the things that looked that's gonna be on our docket is looking for AI driven clinical documentation solutions I'm really excited by some of the products that are out on the market today I think we still have a lot of room for growth and a lot of room for improvement but I think there's some real substantial benefit coming in the waves if you will from being able to take some of that administrative burden away that that sucks the life out of them and give them the ability to just sit eye to eye with their patient and talk about how we're gonna help them get well that's great that's great Chris you're up next what what are some of the investments that you guys have made and then what are areas that you see as critical investments going forward yeah you know technology is a huge huge area prior to me arriving they invested into a nice phone system that really streamlined a whole whole lot of processes I mean it can forward an email voicemail or a phone call to your cell phone it could you know you can get it an email form it just really makes things a whole lot easier and you know as Andrew said it's it's leveraging the technology you know to our advantage so that that that is extremely important we recently have put in an additional MRI which you know we have a far better utilization now in that area and you know we are looking a big thing that we've just implemented is I've really struggled to have access to information and so putting a position in place that kind of more the analytic side on the financial side has been it's just starting off but it's something that's badly needed to know exactly where we sit with you know our numbers and with budgets and projecting you know what what amounts are we anticipating to have this year what you know what are our goals with this what how are we performing in accordance to that and frankly in my experience in a lot of groups the bigger you get the more likely probably gonna have some sort of budget but I think the budgets are needed for all the groups and all the sizes it's not it's not so much as oh we've you know reached our max of you know expense for IT this quarter we can't spend anymore it's more knowing and anticipating not just expenses but production you know with that so we are constantly looking for new areas and new new ways to really in our situation is utilization of technology something that we've done with the employees is we have more of a hybrid because some of the employees it's hard to find people and that is outsourcing it's not outsourcing to get rid of the locals by any means but really because you know we get more phone calls on Mondays than we do on Fridays we get more phone calls in the winter maybe than we do in the spring and so by by having a outsource company that has a greater capacity to flex and be more dynamic and scalable to our needs then we run into less issues of people getting burned out and overwhelmed and everything else and so we're doing on a number of counts it really it's to kind of ease the flow of you know the operations of the entire clinic that's great do you have a rough ballpark of like what percentage of the profits you think should be reinvested back into the business oh yeah yeah great point I forgot about that that is that is extremely important I'm so glad you brought it up I heard an AOE conference it must have been about a year ago a consultant talking about who deals with private equity deals with all sorts of mergers acquisitions and everything else and he said something interesting he said you know what for those docs who actually do you know have retained earnings and invest in the future he thought his opinion was there's really no need for all these other entities to come in to infuse with cash and everything else so our situation is unique in the sense that there's a lot of money to that they make from the ASC and so they're not so tied to the fact that all that money's mine you know from the clinic and have to ink out every little last penny when at the same time we need to reinvest in the future for the next year the next month and so that is absolutely key I think for the independence and the survival of the independent clinic is to implement retained earnings and to put money away for the future and get the docs out of this mindset that that is their money that they have to take home they have to you know that they deserve and everything else because once if they cannot get past that I can almost guarantee you that clinic probably its chances of survival is far less yeah I mean I always like to say it should be at least 10 to 15 percent of earnings but you're curious if you have a different view there I don't I don't have a you know specific I think so you know when you go back to the budgeting and everything else we're looking to the future and saying okay you know this year we need to increase the network we need to bolster it we need to you know do that MRI or whatever it may be and so really play that's why that budgeting that planning ahead so we can tell docs hey we're gonna have this expense next year let's set aside the money now and prepare for it I think that's a good I Andrew I think that's good like rule of thumb that amount I think is he have to you have to you do have to set that aside and consider it yeah yeah Alyssa how about from your perspective any key areas of investment that you guys have made or areas that you've identified that need investment since I've been at the company for about seven years and I've probably touched absolutely everything in here it I was the like the fourth administrator in 50 like 50 years so they it's always worked well so it never really changed and that was one of the reasons why I was hired was just be instrumental in changing everything and our biggest thing was you know getting a new EHR to be integrated with our hospitals EHR so we are part of their hospital part of their system so we have you know all that and that came with all new technology you know so again all new computers that they had never invested in and things like that so that's been really you know instrumental and part of our success of doing that and that's always a big scary investment because EHRs are just their beast and no one likes change and you know unfortunately we did lose some some people just for because of a fear factor of learning something new but we've you know the benefits of far outweighed any of the the negatives the places where we have we've struggled in which we're you know getting more or just like the basic things of reputation management and really because we've always just had that really good word of mouth but I don't think that's going to sustain us forever and you know so we're we're really working into you know how do we get more online presence and and have that better you know skill there and then you know again with the AI you know what do we need to do with prior offs again being a small practice the same kind of thing I can't tie up one one staff member for an hour and a half working on a prior off when I only have two or three ma's so you know again showing what's the return on investment how does that work you know do you stop doing some of these things because of the prior loss or are you able to do that and then we're looking at AI for really looking at our billing we just recently outsourced our billing but now we want to really compare our you know what's charged and then what you know are the insurance companies actually paying or you know what we're what we're supposed to be get getting paid and that's a big thing that you know you can always have these spot audits but you really need to like look at it in bulk and some of these technologies out there can you analyze it within seconds whereas it would take a you know a full-time person all week long to do things so that's where our next big thing is is looking at how AI can help us you know recoup some of that money that's that was ours that's just lost them we've been aware of that's great that's good well these are really great topics and I think we've accomplished a lot I want to close with with one last question for all of you we're really kind of a two-part question first is you know what what is it that that keeps you up at night and then secondly what advice if you could leave with with one piece of advice what would it be for someone that is kind of following in your footsteps so maybe Andrew will start with you I think one of the things that keeps me up at night is the the continual concern for seeing private practice just continue to be choked by congressional lack of motion on dealing with some of the payment cuts that we're seeing and some of the complexity that we're seeing you know I've spent a lot of time digging through like why is the system here the way it is today and I get a lot of why that we are here today today I mean I think you can you know you could take a look at the False Claims Act activity out there and see that there are unfortunately people who do dishonest stuff it's real but I think the overwhelming majority of clinicians went into what they did because they wanted to help take care of people right and I feel like a lot of this complexity and a lot of the pressure that we face today has kind of come as a you know an over response if you will and I'm concerned about what does that look like for us in 10 20 and 30 years from the health system perspective if we don't see some positive motion to at least balance this stuff out not saying though you know the caution to the wind and you know throw away all the controls that are in place but I just think we need a more balanced approach and then I think the thing that I would say from advice to someone who's following in my footsteps is find a way to control the noise around you and focus on the stuff that's actually gonna drive value and gonna matter right I mean you can you can be completely overrun by the never-ending inbox the never never ending voicemail and phone ringing the never-ending people knocking on your door and and all that's important right I mean that that chaos is why that we have a job it's why that we're here is to help navigate that stuff but you still have to find time to think and to work through some of these real complex problems that your organization faces and help lead your team by creating real applicable drivable tools and systems and processes that they can deploy to help solve those problems so that they can stay focused on taking care of those patients that are gonna walk through our door and entrust their care to us Alyssa what keeps you up at night and what's the one piece of advice for someone that you know is following in your footsteps so similar to Andrew and some of these aspects of just the fear of the unknown again because we don't have a great succession plan you know what if you know life happens and one of my surgeons is not here tomorrow how do we how do we sustain that and you know how do I make sure my employees are okay and secure and so you know you know how aggressive am I to make sure that they have a plan for their future I mean it's not at the end of the day I it's their their dollar there this is their company but I feel again like they're my family and I want to make sure that they have something set out so they're both protected my biggest suggestion or advice would be to get involved I think joining AOE was probably the number one best thing I've ever done in my career because I didn't feel like I was alone I came from the urgent care world which had you know had several c-suite executives it had several locations it was all over the place and I didn't you know I don't have to really think I had someone else to do it for me or that was there and a team I came to this practice it's just me and I felt like I didn't know where to go and I had so many resources there's so many people that you can just reach out to and talk to that are gonna give you guidance we're not in competition with each other and so you know you're not alone there's somebody guaranteed that is going through something very similar to what you're going through and you can have that support out there so you know join the collaborate join a committee go to conference and talk to people because it will save not only you but it can help save your practice. And Chris to close us out here. Yeah you know I totally appreciate both what Andrew and Alyssa have said I'm gonna take a little bit different stance because of my past job at nearly 25 years I worried about a lot of things and then I ended up at a new job and realized life goes on and so my advice would be be mindful of what you can actually control and influence and I have found that is very little and thus any any advice to anybody coming I'm not saying this is the best thing but for me get to a spot you don't worry about this stuff because at the end of the day there's not much I can do to fix a lot of this I'm not saying it's not important but you deserve at the same time I think we all deserve to take a step back and you know enjoy life and not get bogged down with all these details because they're always gonna be there so what it's worth. That is some great sage advice really appreciate that Chris Andrew Alyssa real pleasure having you guys join me today and thrilled to have you part of this webinar series really excited for the next three parts in this series you know two more webinars and then the in-person so it's a it's a four-part continuing series of direct conversations from AOE members unfettered content and excited to see where this all culminates at the in-person event with it with an in-person networking discussion as well so I think the next event Jessica keep me honest but I think it's Thursday February 22nd at 2.30 is that right? Yep that's correct and I've dropped the links to register for everything upcoming into the chat so grab those and if for some reason you miss that of course it's all on the AOE website if anyone has any questions for this group feel free to let us know or you know drop it in collaborate email us and we can always get questions to panelists after the fact if you've been you know thinking about what they've talked about and something comes up I'd be happy to pass that along and connect that so thank you all so much for your participation thanks Andy for moderating this discussion and thank you Chris Andrew and Alyssa for joining us for this I think it was a great conversation a lot of good things to think about and advice provided and we'll look forward to seeing everyone the next time around thank you all

orthopedic practices

investments

leadership

competition

health systems

technology

EHR integration

physician owners

AI-driven solutions

work-life balance

orthopedic practice leaders

key challenges

strategies for success

retaining earnings

investments in technology

communication with physician owners

patient relationships

EHR implementation

budgeting