to be sort of interactive, because practice management issues are sort of singular to each one of us. We all practice in different environments, whether you're a hospital employee, or solo practice, or you're a midsize orthopedic group. And I've been all three. So I have that perspective. My obvious is that I felt that I thought that I delivered care best in that midsize orthopedic group where I controlled my MRI, my PT, and my surgery center. So we had a real community of patients. So Thomas Carlisle, he was a philosopher in the 19th century. He was also an economist, and he coined the term the physical science for economics, because a lot of these things we talk about are not necessarily to our advantage, especially when you think about how we're reimbursed and what's happening with that at the time. So I became very interested in the practice management side of things, sort of in charge of, for better or for worse, a midsize orthopedic group that was generated about $12 million in revenue and had aid for orthopedic surgeons. And we were stressed. We were stressed with decreasing reimbursement, increasing costs, increasing consolidation in the neighborhood of hospitals and most especially groups applying that practice. And so, by necessity, I really had to drill down and leave some of the clinical stuff behind and sort of take up the mantle of becoming an expert on the financial side. We did some really kind of cool things in regards to he did all things sort of siloed with the practice. We also put it in an electronic medical record in 2002. That was nine years before the pandemic. The reason for that was this. I was looking at my practice in a line-by-line way, a line-by-line manner. And I was saying, how are we going to cut costs? I mean, I'm looking like, I can't cut my malpractice, which in New York was $110 a month a year. I can't cut my staff. I can't cut the rent. I can't cut the homes. And all of a sudden, I get down to transcription. We're spending $100,000 a year on transcription. I'm like, we've got to cut that out. So we started looking at ways to digitize our medical record. And that's when we made the decision to purchase an electronic medical record. And lo and behold, we saved that $100,000 a year. And I actually wrote a paper on what was the economic impact of implementing an electronic medical record and how it would allow us to save some money. And guess what? We saved some money. We saved us about $8,000 to $10,000 per guy per year. So that was sort of the way to call me. And we continued to run that through and to try to do other things like that. But eventually, what happened was the consolidative process just kind of ran us over. And we eventually sold it, possibly. So once again, I'd like to have you ask me some questions. But after this little preface, if that's OK, just as Brian asked before, if that's OK with you, I can continue to talk about other things. But I would suggest that I don't care what practice environment you're in, whether you choose a solo practice, whether you're in a mid-size OP group, or whether you work for a surgeon who has 99 or 50 surgeons, or whether you work for Northrop, which has, I don't know, I think it has about 450 now. 22 hospitals, $12 billion operation, largest private employer in the United States is a hospital system. But I don't care what environment you're practicing, you need to understand the economics of the business that you're in. Because if not, there's an old saying, no money, no mission. So you need to understand the economics of your environment, whether it's R and U-based production or it's collection production, it doesn't matter. But the economics drive everything. That's how you really, in some ways, not in all ways, but in some ways, that's how you're going to measure your success. I mean, everybody talks about growth, right? How am I going to grow my practice? I'm a young person, how am I going to grow my practice? To grow my practice in what regard? It's an economic equation, right? More patients, more surgery, better income. These are all things we need to pay attention to. A lot of people don't want to do that. It's like the research that JT talks about. You need to diversify yourself as an educated person to have a more robust and enjoyable and rewarding experience in life. So yeah, you've got to become more cognizant of the economic environment that you practice. Do some research, do some pro bono stuff, whatever, whatever. Be diverse, right? So even if you don't think you know anything about economics or how to read a spreadsheet or whatever, well, guess what? You're going to keep searching for advanced marketers, how am I going to do it, right? Become familiar with the CFO of your organization or your business manager or patient manager or whoever it is that runs the place. Have a good relationship with them. Establish a two-way discussion where you can go to that person and get any information you want about the economic health of your organization. And when that health becomes, when you're assessing that, and you should do this on a monthly basis, then you'll know when things need to be changed. And you don't freak out after one bad month. But after three bad months, well, then it's time to think about how you're going to change it. So those would be my suggestions. And at this point, I'll just ask some questions that we have. We have some other experts in the room on this. We have other people who have got an unbelievable handle on how we're doing this. So Don runs his own show, a solo practitioner. And I can tell you, I've been doing that for four years in a competitive environment. Anybody who's successful with that, you're going to want to ask him questions on how to do it. Don has a far better niche for himself. It's really unique. And it's really interesting to see how he accomplished that. So what's everybody's most pressing practice management issue? And just think about it. What is it? And let's hear about it and how can you take care of it? Is there a resource? Like, how do you backtrack here, right? If I was coming out, I went to the military, so I didn't have to learn any of this stuff. If I was coming out and going to private practice, I know that each time. Is there a resource that you do? Is there one place, a book, a podcast? You know, unfortunately, the resources for this are few and far between. The academy has some pretty decent stuff on the website. MGMA, if you become a member of that, which is about $500, that's a really good source for information like this. The web, the web is sketchy sometimes. But those are where I go, the academy, MGMA. And to the, who's ever running the finances of your organization, most orthopedic practices right now are pretty sophisticated. Right now, I work for a company that purchases orthopedic practices. And we purchase practices anywhere from 9 to, say, 26 orthopedic surgeons. The systems that they have in place and the financial sophistication of these organizations are pretty significant. So if you go to the CFO of who's ever running an organization, you're going to learn how to be a human being. So that, the academy, MGMA, that's where I go to learn this stuff. There's no bulk on this for orthopedics. Perhaps that's not true. But those are the places I go now. So it's a lot of matters in this particular place that you're not that involved in. And of course, it doesn't happen immediately. You know, you can look at it. You can just question it. That's an opportunity. Four years in, they're telling me it's the real assistant center. So that's a potential resource. Absolutely. We talk a lot about leadership. It's an important thing to have in this country. We have a lot of this. We want to have it in our community. Yes? So I was wondering if you've heard about this with the other surgeons that you're part of. Can you answer that? We're like, when I go in, you know, when I move in, what question do I ask when I see your partner about what do I want to look at? What do I want to know? One, how long have you been in operation? Two, are they growing? You know, they're female. They're proper to law students for the last three years, right? If they're growing, that's good. If they're not growing, that's not good. That's a real red flag. Have them describe to you why they want to hire you in regards to need. There's going to be a need for your services, right? Are you coming in as someone with a skill set that they don't have? What's the referral? Are they out? Are they referring out those patients? How are they going to promote you, right? And I think most important, what's the need in the neighborhood? I mean, you need to explore the demographics of the place where you're going. Is the city growing? Is it, I don't know, in Las Vegas, is it still growing now or not? I mean, places where you want to go are growth, like Nashville, right, or Houston, or, you know, places where there's even a lot of population shrinking. So that's fine. And it's overclouded. I mean, what's the percentage of work for the exurgants in the neighborhood? You know, there's a statistic that the academy has regarding the percentage of work for the exurgants. I'm confident you can look at that, too. Very high in the northeast, very high in the northwest, relatively low, much lower in the southeast. So there's a lower penetration of work for the exurgants. Obviously, you're more likely to be able to carve out that third population, carve out a niche for yourself where you can get kids here soon, right? I mean, who wants to take 10 years to build a practice? That's crazy, right? It could be 10 years to build a reasonable practice in the suburbs of New York, right? Because you've lost 15% of our CPP code search volumes in New York City in positive perceptions. So who's your competition, right? That's another thing you want to know. Who's your competition, and how strong are you? Wherever patients go, they don't go to your new partners. And then, you know, of course, then you're told all the things about, what's the contractor going to do? What's the time of partnership? Do they have any ancillary services? Do they have MRI? Do they have PT? Do they have a surgery center? Those are things that are applied to practice for the long-term health of practice. You need to have access to those in an insurance-driven service market. I guess my question is a little bit more specific. Because I know most of that stuff as far as looking at the book system. I know you said the profit and loss. Right, you're going to need to look at their P&Ls. You're going to need to look at the insurance mix. I mean, are they seeing 20% Medicaid patients? What's the insurance mix? So the insurance mix is, what's the percentage of Medicaid? What's the percentage of Medicare? What's the percentage of private payers? You're going to want to look at what's their contractual rates? How much are you going to get paid? Okay, you're going to do HIPAA processing, right? What are they getting paid for HIPAA processing? So those are things you're going to want to drill down on. There are some other things when you get the P&L, you're going to be able to calculate the estimate of the total. There's some range of private practices outside. And if they're blocking at a 60% overhead, that practice needs to get covered. If they're immediately at a 30% overhead, then that's something that could be a factor. And capping it at overhead, there's a lot of fudge factors going on for that overhead factor. So you really have to scrutinize the way that they account for things in the P&L. You see a $12,000 sling inside a drug market, who's letting somebody drive? And if you're not sophisticated looking at P&L, there are countless situations where you have to do that. But I would ask them for that for three years, going back three years. And all the financial data would be helpful. And if they're reluctant to give it to you, that's a better time to give it to them. Now that you're basically evaluating these practices, obviously, no matter what your findings are unusual or problematic, all of a sudden, you're going to go blind. What are the commonalities that you're seeing between best practices and worst practices? I think the number one thing is the attitude of the surgeons in the groups. We've been looking at some groups that have some guys that really, they are just workhorses. They work all the time. And they're in an environment where there's not as much competition. So I'm not saying that makes it easier. But they have an incredible drive to work. They don't say no. They see a lot. They build their facilities so that they can see fine. So one of the practices we look at, for example, has a non-operative sports medicine component that really sees the patients first. So in other words, they see the ankle sprains, the ACL tears when they first come in. Appropriately treated non-operatively. And when in it, they need to be indicated for surgery. And then they go see the surgeons. You can't build that in every neighborhood. But that goes to the type of things that these guys are doing to drive volume. So that's an incredible surgical volume that's driving them. Think about the FTP value of a surgeon. If you're seeing an ankle sprain, you're not generating pain from it. You should be able to generate if you do an ACL reconstruction. You should be doing ACL reconstruction. So that's number one. Four. Number two is advertising. Is marketing. There's got to be some kind of... You can't hide your love under a basket. There's a lot of very sophisticated marketing tools now that are mostly digital. I mean, they have these tools now. It's not necessarily outreach in regards to Facebook or social media. It's digital. For a price point. We figured out that we can bring a new patient to some of our platforms for $80 based on our social media and and digital marketing. And each new patient is worth about $2,000. So marketing. Work. Practice. How is it set up? So what happened in my practice is that a lot of the patients all got sucked up by hospital systems. So there were fewer patients coming into my practice. You're at Northwell. How is Northwell going to make sure that all patients that come into the system see you for their orthopedic problem? That's a big issue. That's a big issue. So how is the practice that you're going to join and how are you going to make sure that you garner as much patient volume as you can? Certainly work, advertising, but at the bottom some of the employees have these issues. How are the people that manage your organization, how are they driving the patient volume and the crews into that organization to see your orthopedic? They have to have coding. I think those are the most important things. I think those are the most important things. So I think we could probably go along with this for an hour. I know it's fast. Does anybody else have any other quick questions? It's been a busy, very busy few days. I really appreciate everybody participating this afternoon. I'd just like to say one last thing about Anna. Matthew chapter 22 14 says, Many are called, you are chosen. Anna is sort of the opposite of that. You're all called.

practice management

economics of healthcare business

electronic medical record system

healthcare consolidation

patient volume