All right, y'all want to get started early, how's everybody doing this morning? All right So as uplifting as my talk was yesterday during the massive rotator cuff session Yeah, medicine's changing. The healthcare world is changing. We all know that it's been going on for years, but hopefully this morning We can give you guys a little hope that there are alternative measures to Productivity right as I like to say When I got into medicine and over the last couple years You would hear people old-timers like couple the gray hairs up here. You'd hear them say You'd hear him say Don't go into medicine this it's brutal. Don't go into medicine anymore. You can't make a living and I don't agree with that All right change is not a bad thing changes an opportunity and what you're gonna hear up here this morning are Doctors getting creative opportunities to create this revenue stream Different than what we've done 30 or 40 years in the past. So with that we're gonna start this morning with one of our past presidents Dr. Beach on tricks with coding Morning, thanks Where do I find me Beach There you go. So coding tips, tricks, what you need to say in 10 minutes. So we'll get going. So here, hopefully everybody has access to the slides. This is a website, the Medicare website, where you can check things that are bundled, okay? So when somebody says it's bundled in NCCI, National Correct Coding Initiative, basically you can know whether that's true or not. And anything that's not listed is assumed to be not bundled, okay? So that's a really good website. So new age in AI and medicine, keywords. You gotta use the keywords, because you don't get paid for history and physical anymore. That doesn't have anything to do with your coding, but you got to make the argument that somebody's getting worse or not doing well. So use the keywords. So McMurray's test, positive Lachman's, empty can, all those things that Jorgensen's test, all that stuff are in the websites. So here, if you take a few minutes, this is Carillon, which is owned by Anthem. This is all their stuff on their website that you need to say in the history to get yourself an MRI, okay? So if you get yourself an MRI, or if you want to get an MRI, this is the way to do it, okay? Specific, so coding quirks, 29877. People have asked me, well, why did they bundle 29877 with 29881 when 77 has a higher RVU? Usually you bundle lesser RVUs. That was a deal we made with Medicare and the insurers probably about 10 years ago, because they were going to cut meniscectomy in half. So we, the Academy, maybe wrongfully so, made a deal where they could bundle 77 and 74 with 881 and 880 if they left the values alone, okay? So that's why, it's not fair. It doesn't make any coding sense, but that's the rationale. My interpretation, here's the procedures. Don't list things that you don't expect to get paid for, because it gets in that denial loop. So if you do 881 or 880, don't list 74, don't list 77. That's just going to make you get denied for a longer period of time. So be a smart surgical coder. Cinevectomy, 29876 is an underutilized code. So if you do a plaque excision and actually do a cinevectomy in two compartments, then you can get paid for a cinevectomy. Now you can't get paid for cinevectomy if you do 880, because you've done medial and lateral meniscectomies, then you don't have two isolated compartments to do the cinevectomy in. So if you do 881, you can do 29876. Your coders are gonna want you to say it's pathologic, even though that is not in the descriptor. I wrote the vignette and the descriptor, pathologic cinevitis is not in the descriptor. But if you listen to the coders, they'll say it's gotta be pathologic cinevitis. So they want you to have PVNS or rheumatoid, which is not the case. 29879, abrasion arthroplasty. It's abrasion arthroplasty, it's not abrasion chondroplasty. That's gonna get confused, and they're gonna deny your code. Arthroplasty, abrasion arthroplasty. So you gotta do microfracture or abrasion arthroplasty, but you have to say the bone was abraded to bleeding bone, and this was visualized by decreasing the fluid inflow. They want you to say that you saw the bone bleed before they're gonna pay you, okay? Bundle with 7-7. The academy's gonna fight that though, 7-7, because you should be able to do 7-7 in a separate compartment, okay, than the 7-9, all right? So hopefully that might change. I wouldn't hold my breath on that though. Shoulder codes, you know, there was a time when Medicare wanted to do shoulders as a single anatomic site, and they were only gonna pay you one code. That has gone by the wayside, but somebody last night at the coding meeting said, where's he from, Eric, was he? Wisconsin. Wisconsin, that United in Wisconsin has bundled everything down to one code. So we, Anna, hopefully the academy, are gonna start writing letters to United. So here are the possibilities. None of these are bundled together, okay? These are pretty good RVUs if you look at them. 29827, 15.9 RVUs. So people were asking, why don't we have a code for remplisage? We don't have a code for remplisage because if we go and get a code for remplisage, they're gonna ask us how we've been coding it. How do you expect to code it? I can almost guarantee you, if we have to do a resurvey of rotator cuff repair, that number's gonna go down by, what do you think, Eric, two RVUs-ish? Probably 15%. Yeah, so we haven't done remplisage, not because they don't believe in remplisage or that it shouldn't have a code, but it's a big risk for our rotator cuff repair code. All right? The other thing is you must... Hello, hey, do y'all know what he means by re-evaluate it? So if they go up there, they're going to re-evaluate all the codes and they'll say, you're doing a lot of rotator cuffs. It's not as a valuable code anymore. So then all rotator cuffs will lose 15% value. That's why they haven't gone for remplisage. They'll make us find 30 guys who do rotator cuff repairs. They will audit your times, audit the intensity, and re-value the codes. So that's a loser. All right? So that's why we have not... It's not like we're not paying attention. We just don't want to lose the value. CMS will pay for 29826, which is an add-on code, a chromioplasty 29826. It's only three RVUs. Medicare is the only one who pays for it, but you can use that as a structure to be debrided, okay? So your coders are going to say you can't use Bursa. That's not true. We intensely didn't include the Bursa in the subacromial space. So that can be a structure. The labrum can be a structure. If you don't do a tenodesis, the biceps can be a structure. If you don't do a rotator cuff repair, the rotator cuff can be a structure. And the acromial osteophyte is also a structure, okay? So if you can't get paid for an acromioplasty, use the acromion as a separate debridable structure. Fab five, yeah. There you go. So again, 29826 is an add-on code. If you just do 29826, you can't use that code. You have to use 22 or 23, okay? 29826 cannot be listed by itself. Specific dictation, as I said, I use that as one of my debridable structures. So say I did an extensive debridement of the acromial osteophyte, okay? Make sure you lead them on the way. So that's for the surgical stuff. I know it's quick, but here, be an educated office coder too. You know, we're gonna make more and more money in the office compared to the operating room. So you gotta be a good office coder too. So here would be my suggestion. I rarely do peer-to-peers. Why do I rarely do peer-to-peers? Because I never list anything in my operative plan to get pre-certed that's not in the MRI. So it's not in the MRI, don't list it. Why list it? All you gotta do is get the patient to the operating room, and then you can do whatever you want for the most part. United may be fighting that in the future. So if I list somebody for a 29827 rotator cuff repair, and I do a distal clavicle resection, I do a biceps tenodesis, I do extensive debridement, I can list all those things after the surgery. What I have to do is quick, I gotta do the dictation relatively right away, right after the case. I have to go and go back to the pre-certer and do what we call post-cert. She or he's gotta call the insurance company and say, hey, we actually did this, not just 29827, and you can get paid for all those ones that you didn't do. So who cares what you got pre-certed? It doesn't matter. All you gotta do is get one code pre-certed, and you can get that patient to the operating room. But you have to be timely, getting your stuff done post-op, and do a post-cert, okay? Questions on that? Post-cert. Sometimes you only got 48 hours. They only give you two or three days. Yep. Going back one step is the REM plasage, so what's your recommendation to do the extensive improvement with that? The Academy says that's supposed to be listed as an unlisted procedure. In Massachusetts, they don't pay unlisted procedures. No, no. So that's why, yeah. So what, I'll be honest with you. You didn't hear that here. If the infraspinatus has any ding in it whatsoever, I'm gonna repair the infraspinatus. Is what I did anyway. That's what we should do. And that's what we wanted, that the code we want to get is similar to a rotator cuff repair, be a limited rotator cuff repair. But we haven't got it yet. So if there's a ding in the infraspinatus, say that. Okay. Knee MRI, yeah. So this is a little trick. I don't know how I learned this, but if you really need to get an MRI, you can bypass the algorithm that says they gotta do four to six weeks of PT by saying they're afraid they're gonna fall. Fear of falling will get you there. But you gotta tell the patient, ask the patient, are you afraid you're gonna fall? And then if they say no, then you say, are you sure you're not afraid of anything? But make a big deal. But you gotta let the patient know because they're gonna go back and read their note now on MyChart and say, oh yeah, hey, I really wasn't afraid I was gonna fall. Here's the thing, here's the key. Interested, be a savvy coder, okay? Know what you need to put in your note to get 99213. The goal is to get 99214s, okay? If you look at that, it's an increase of one RVU or 0.62 RVUs, and all you need, any undiagnosed problem is a new visit in terms of the data, okay? If they've got an outside x-ray, MRI, CT scan, ultrasound, anything, that will count as in the data section. You only need two of these three sections. Easy to do, though, and if you, I mean, don't game the system, but if you write somebody a script, you're over the hump, you're over the top. That's a four, that is not a three, and that's a new four. So if somebody comes in, automatically, they got a new problem, okay? I've checked one box. If I write a script for Meloxicam, I'm done. That's a level four new patient visit. If I give them a shot, even easier. There, I just included this so you guys will have this. I would say be an educated coder, especially in the office. Don't be afraid. If you got an option, get a scribe. I have a scribe. Best thing I've ever done. Saves me at least an hour and a half a day just talking to that dumb machine. Hate it, but he can do it, and the notes that they write are gonna be increasingly, exceedingly better than what you write. I'm not gonna read that to you, but that's the conclusion for somebody who's got a distal biceps rupture. Thanks. Great job. Thank you. Thanks Dr. Beach. There's some seats up here. If you want to sit up here, you don't have to, but if you're looking for a seat, there's some seats up here. All right, next we have one of our current health policy fellow. Right, Ian, you're up. He's going to give you a talk on his current research project. Thanks Dr. Joyner, and thanks to the anti-advocacy committee for the opportunity to be here. Oh my God, you're a great girl. Great. So picking up on some of the things mentioned by Dr. Beach just a moment ago, the title of my talk is Code Red, RVU Differences Between Institutional versus Individual Coding in an Employed Hospital Setting. I have no disclosures related to this talk other than the fact that I'm the current AntiHealth Policy Fellow. And we're actually looking for a new fellow for this year. We got some additional funding. So if any of you guys are interested, please see me or any of the committee members after. And you too could be up here. So if you're like me when you just heard Dr. Beach's talk, it's like drinking a Mountain Dew Code Red. And it turns you from normal into looking like this after hearing about all that information. So, but have no fear. So we know that the rate of employed physicians is increasing, that's in medicine as a whole and particularly in orthopedics. And many of these physicians are compensated based on RVU metrics. However, there's a dearth of research on coding techniques for sports medicine procedures. And this affects you whether you're RVU based or collections based. So we know that this basically becomes a patient care issue at the end of the day, right? So if physicians are not compensated appropriately, there's evidence that, you know, in struggling health insurance models or patients with Medicaid, they have less access to care. They don't get the orthopedic procedures that they need. So this really is a patient care issue. Obviously, we all want to be reimbursed appropriately. But at the end of the day, it's about taking care of patients. So the purpose of this study was to compare what is being coded and billed for by the hospital versus what fellowship trained orthopedic surgeons would have billed independently assessing the operative note. And our hypothesis was that there would be a discrepancy between the two groups with the orthopedic surgeons over coding and the coders under coding. So an IRB review is completed and we did a retrospective chart review of three fellowship trained orthopedic sports medicine physicians. We looked at their orthopedic sports medicine cases only and excluded non-cases, HEMIs, trauma, et cetera. And then two other orthopedic surgeons with experience coding their own procedures reviewed those charts independently looking at the operative notes and wrote down what they would have coded. We then cross-referenced this against what the hospital coders coded and what we got paid for in the employed hospital setting and compared the discrepancy. And then we recorded or disputed the cases where we found a significant difference between the two groups and differences between the two orthopedic surgeons individually looking at the codes independently were resolved by discussion. So the average number of cases for the three surgeons over the three-month period was 80 sports cases, range 70 to 90, and roughly one-third of these codes ended up with disputes. So the average amount of RVUs that were disputed monthly was almost 50 RVUs, so that's almost 600 RVUs per year, and it was an average of about eight and a half RVUs per case. And there were two instances in the three months of over-coding according to the two independent reviewers. So the disputed codes were a lot of the same things that Dr. Beach just talked about. In the shoulder was extensive debridement, subacromial decompression, and then an open biceps tenodesis probably in conjunction with an arthroplasty. And then in the knee it was the abrasion arthroplasty code, the synovectomy major code, the two ones he just mentioned for the reasons he just mentioned, and then also manipulation under anesthesia. There were some higher RVU disputed codes which kind of get into that unlisted code realm of something like a humeral head, osteochondral allograft, or the slap repair. So for discussion, remember coders can only code what we put in the operative note, and you need to be very thorough not only with your procedures that you write, but your procedures in detail. So for example, this case was only coded as an arthroscopy of the knee with a loose body, despite all those other procedures. And I think, remember, we have an appeals process for some of these high-risk codes, and so you need to be aware of that information through AOS and ANA. And finally, have a process where you independently meet with your coders monthly, and this is exactly what me and my coders look like when we're all getting together to discuss the coding. So I think that was the most valuable thing to come out of the study. It was limited, obviously, retrospective one institution, limited time period, and did not differentiate by insurance types. So obviously, orthopedic surgeons and coders view these areas differently, and it's important for us as ANA and as the Advocacy Committee to educate our surgeons to get them paid, but also to help take care of patients. So thanks very much to the Advocacy Committee for the opportunity to be here. Good job, Ian, and good job, guys, staying on time so we have time for discussion. All right, who's next? Ravi, you're up. Let's talk about the difference between surgical and clinical productivity. All right, hi, everyone. My name is Ravi Viswani. I am the past and health policy fellow before Ian, and I echo what he says. Definitely a great experience. If anyone's interested in this type of work, it's a great experience. All right. So, as we all know, physician reimbursement has steadily declined over the past three decades. Office visits have increased in value with recent E&M coding changes, but there has been no reciprocal increase in surgical code values. This devaluation of surgery may disincentivize some surgeons from indicating elective surgeries. This is occurring while the need for orthopedic surgery in the Medicare population is rising. So the objectives of this study were to determine the real-world surgery versus office value difference in orthopedic surgery and to assess the opportunity cost to surgeons. So we included four sports medicine fellowship-trained orthopedic surgeons. Two were early in practice and two were in more established practices. Time data was tracked using a smartphone app. When the timer was started each day when the surgeon arrived to work and then stopped when they were leaving for work, each timer was named either office or surgery, and data was tracked over a three-month period. We collected WorkRVU data for each surgeon, and this allowed us to calculate a WorkRVU per hour value for each practice setting, and we also did an analysis excluding post-operative visits. And you can see the breakdown of each surgeon's practice here. So here are the results for Surgeon 1. You can see the time that was spent in the office as well as the productivity in the office, and this generated a WorkRVU per hour value of 3.3, and then when we excluded post-operative visits it went up to 3.6. You can see the time spent in surgery and the surgical production as well, and this led to a surgical work RVU per hour value of 4.5. So we calculated that this surgeon would have to see about eight patients in the office to equal the productivity that they had for one surgical case, and we extrapolated that to show that if this surgeon had a purely office-based practice, they would actually generate more RVUs than they actually did in this three-month period. Here's a graph that shows average RVUs per day by the number of patients seen in clinic. The horizontal dashed line represents the average RVUs generated in a surgical day, and the diagonal lines represent the RVUs generated in a clinic day by the number of patients seen. And as you can see, the current production of this surgeon, if they increase that by 10 to 15 patients in the clinic each day, then they would equal or exceed the amount of productivity that they're doing in surgery. Here's the results for surgeon two. So again, you can see that for this surgeon, the office RVU per hour value was 3.2, which again increased to 3.9 without post-operative visits. In surgery, it was 4.4, and this surgeon would also have to see about eight patients in the office to equal the productivity for one surgical case, and this surgeon would also potentially be able to generate more RVUs in the office versus what they actually did. Here's a graph for surgeon two. So you can see that for this surgeon, they would only have to see about five extra patients in the office in order to equal their surgical production. And here's the results for surgeon three, who's in a more established practice. So here you can see the work RVU per hour value is 4.8, and that increases to 5.8 without post-ops. In surgery, this surgeon was generating 7.9 RVUs per hour, and this surgeon would have to see about 10 patients in the office to equal one surgical case. So this surgeon was actually producing more currently than what they would if they had a purely office-based practice, but you can see that the results are pretty close. It's within about 10% of each other. And here's the graph for surgeon three. So this surgeon would have to see about 10 to 20 more patients in the office to equal their surgical production. And then here's results for surgeon four, also a more experienced surgeon. So this surgeon is generating about 11.9 RVUs per hour in the office versus 8.4 in surgery. This surgeon would have to see about 13 patients in the office to equal productivity for one surgical case. We didn't have post-operative visit data available for this surgeon, so we weren't able to do the more advanced analysis. And here's the graph for surgeon four, and you can see that this surgeon is actually already producing more in the office than they are on surgical days. So in conclusion, office encounters have increased in value, and the office work RVU per hour value was higher for three out of four surgeons and was similar for the fourth surgeon when accounting for post-operative visits. Higher operative volume does increase the value of surgery, and as reimbursements decline, large and lower volume surgeons may be disincentivized to schedule operative cases. This may jeopardize the access to orthopedic surgery, and in the future, we would like to look at collections data as well. That talk really changed, so I do my practice. I'll tell you real quickly, if you don't have two rooms, your OR day is unproductive. If you're only operating in one room, you might as well be in clinic. And I've gone to two OR days, three clinic days, and like I said, my profit went up 19% last year, profit. So for you young surgeons, I'd recommend you only operate one day a week, be in the clinic four days a week. And I'll tell you right now, I actually love clinic, because when I walk in the clinic, I know how productive I'm being. All right, next is Eric. He's going to give you a talk on some ancillary revenue, some alternative streams. Yeah, but really quickly, just tell them how you do clinic, because you have multiple PAs. I do have three PAs, but we see roughly 80 people a day. So for me, if it's 12, because I do about 600 surgeries a year, so that's 12 patients a day. 12 patients equal one total joint, so I have to be doing equivalent of five to six total joints per OR day for me to equal a clinic. So I look at my schedule, and if three weeks down the road, like I just looked at my schedule this morning, or yesterday, and I texted my team, three weeks from now, I have two patients on one day. And I said, cancel that OR day, move them to another day, and open a clinic, because I'm going to make more money on that clinic day than I will doing two surgeries. And that's how I run my office. Every three or four weeks, I'm looking at my schedule, and I'm canceling OR days. It's very much like an airline in my clinic. I want to have an overbooked OR and an overbooked clinic. I never want to have a day where I go home early. Times have changed. We can't do two surgeries and have a productive day anymore, right? It's OK. We can still make a very good living. We just have to understand how to do it. Yeah, that's a great point. So I was involved in that study in the data collection, and I would also echo a lot of those sentiments. But I think we also lose track of the time that we spend in the operating room. My OR days were much longer. My clinic days were consistent on start and stop times, oftentimes with a lunch break. So the intensity of work done in the operating room needs to be efficient. Two rooms matter in a lot of cases, as opposed to spreading them out over the front of this. Eric, real quick, I want to tell them the most least efficient, least productive way of making money. On call. So the hours spent on call, there's a lot of downtime. And the only time you're generating any revenue is when you're physically in the OR doing a surgical procedure. So the opportunity cost of on call, the opportunity cost of hour-long turnovers is a real and big thing with your productivity. In the clinic, you can generate two to four RVUs every 15 minutes, right, with your visits. So be efficient in clinic, be efficient in the OR. If you've got two days and you're running one room, try to work something out with your hospital for one day in two rooms. So with that, we'll get into ancillaries. Just a quick survey, who has ancillaries services? And then how many private practice and how many hospital-employee private practice? Okay, all right. All right, so ancillaries, you guys probably know a lot about this, but what I wanted to do was provide kind of an updated 2024 number estimates of where you should be in benchmarks. So we're going to go through the big three. So ancillaries are designed to enhance patient care, improve efficiency, and obviously generate revenue. You guys know what they are. They're diagnostic therapeutic services, surgical and procedural service. But an ancillary really is anything we do that's extra, that generates income without generation of additional work. Now we all know about the Stark Laws and what is called the in-office ancillary exceptions. Just as review 1989, Stark prohibited self-referral of Medicare patients to services where the physician had financial interest. There were two exceptions, Stark 1 and 89 had the exception for in-office laboratories, and Stark 2 included designated health services, imaging, DME, MRI, and physical therapy. So what do we know about ancillaries? Physicians with ancillaries earn 20% to 50% more than those without. In fact, a 2017 survey that looked at this specifically showed orthopedic surgeons reporting greater than $750,000 in total compensation versus less than $6,000. So we know that each ancillary should produce about $50,000 to $100,000. Let's talk about margins. What should we expect to receive? Well, in general business terms, a 5% to 10% margin is expected for high volume, low margin industries like retails and restaurants. 10 to 15 is not bad for manufacturing. And 15 to 20 margins, we begin to think of luxury technology. These are high margin industry sectors. You are much better off owning an MRI than you are investing in a restaurant, okay? So these ancillary services are highly productive. So the data on MRIs, orthopedic surgeons order an estimated 150 to 300, that's 15 to 30% of all medical encounters result in an MRI, 350,000 of them were done last year, more than 350,000. Let's talk about break-even point. If you have an MRI, you should talk to your office manager and figure out what your break-even point is for your machine. Here's the formula how you do it. This is an example. So we got fixed overhead, average reimbursement per scan, variable cost. You plug it into the formula and you see what your break-even point is. Why does this matter? Because we look at graduated profit as we go beyond the break-even point for the machine, our profit margin increases. So these numbers are very important to understand. MRI profitability, risk analysis, orthopedic practices can easily hit these target numbers to get this 25 to 50% margin, which is fantastic when considered in general business terms. Volume matters. Looked at our results during COVID-19, 18% drop as expected, caused a 24% total revenue loss that year. What are we looking at now in our office? Wider boards, AI-powered programs can result in a 50% reduction in time. If you have a machine that is 5 to 10 years old, consider updating your software. Right now we run our machine, the last office appointment is around 8.30 at night, which is pretty common. But we can cut our variable cost in half by improving the efficiency of the machine. Again, you're going to have to plug the numbers in. Does your volume support it? Bottom line, for the younger guys, if you don't have an MRI, here's kind of the numbers. This is basic consideration points, target volumes, 10 per scan, a group of 5 to 6 providers should be able to support one machine. Let's talk physical therapy. 20 to 45% of all ambulatory patient encounters result in a physical therapy referral. In fact, orthopedic surgeons are responsible for nearly 60% of all PT referrals. Potential revenue, $100,000 to $300,000 per therapist. This is a good number. In 2023, mean compensation, $85,000. Mean collections, $220,000. What are your targets? What are your benchmarks for an efficient practice? 15 to 30 referrals per provider per week. That's based on a 30% referral rate. Referral to patient conversion rate should be 75%. That's a good number to hit. So how many are you referring? How many are actually showing up? Practices should target 50 billable visits per week per therapist. And if you're between volumes, consider a PTA. However, in 2022, remember PTAs make 15% less for billing their services to Medicare. Physical therapy, 25 to 30% is a good margin. Here's your ratio, PT to MD ratio. Look at your practice. One to one, anywhere between one to one and one to four. Finally, nurse practitioners, physician extenders. Everybody knows they work, but what are the actual numbers? What should the targets be? Financial benefits, high return on investment, 250 to 400 in annual gross revenue. Increased patient volume. Physician extenders can handle about 80 to 90% of what we do in the clinic. So they can help support those high clinic volumes that drive revenue. Physician-owned practices with a one to one MD to PT ratio generate an average $100,000 per year more per physician. Hospital-owned practices with that same formula, about 130. Median salary for PTs in contemporary numbers, 130 to 160. Assuming revenue generation, 200 plus 30 to 50% margin. So key takeaways, ancillaries boost revenue. Earnings, 20 to 50% more than those without them. Remember your compliance with your Stark laws and know your profitability of your ancillaries. Two additional ancillaries, joint ventures with hospitals. These are options for co-owning ancillary service lines. Hospitals can provide infrastructure and payment contacts while physicians share in revenue and operation efficiencies. These agreements have to be fair market value and I recommend a third party evaluation from legal representation when you're considering these. What's the difference between a joint venture and a co-management agreement? Co-management is a direct payment for managers of services at fair market value. These can be quality initiatives. These can be shared savings like cost reductions for negotiating with third parties and implants. Again, Stark laws apply. So these are some hypotheticals of what you could do with co-management agreements with your hospital. Here's fair market value arrangement for management of ER call schedules with per DM reimbursement. We negotiated this. It resulted in about a $500 per day increase in call pay. Quality management and performance metric standards, base participation of 150,000, 250,000 for quality metrics and then a shared savings with implant reduction initiative. 22% capped at 250 for three years. So you have to have a sunset to these types of agreements. Here's kind of an example of quality metrics and performance. This is dated. This is about five years old, but this was our, you know, first exposure to this. And you can see we had a base participation rate and then hit quality metrics and received reimbursement for helping the hospital hit these targets. Thank you. Um, my goal during this talk is, uh, during this, uh, ICL is during the discussion. I think some of us, I'm willing to be very candid about some of the numbers. You know, I have no problem sharing. It's not about being braggadocious about helping all you guys out. I know their ancillary, um, Eric and I talked about last night is concierge. It's real. I do it. It's an 80% profit margin. So it's huge compared to the numbers he just showed. Um, and, uh, I'll tell you my numbers. I made 300 K last year, so I'll be more than happy to tell you guys how we do that. Um, next will be Dr. Bert. He's going to be talking about direct to employer, uh, contracts and how to maximize those benefits. Okay. Here we go. So I'm going to talk to you a little bit. This is going to be a little bit different than what you've heard in the past. Um, my background is past president of the organization, past chair of the AOS practice management committee. Um, I've been a consultant for practice management projects with groups around the country for gosh, 15, 18 years. And I brought Sam Moen with me. Um, Sam's got his carrying conceal on him today. Um, he, uh, used to work for Optum United Health Group. Actually, he's got a relative now that, uh, has a security guard that works at United Health Group that, uh, they actually have these guys walk out to their cars and, uh, with security guards. It's gotten pretty interesting in Minneapolis since, since the shooting, but he's been a consultant, healthcare systems, over a hundred hospitals. Uh, he's had a history of process improvement, uh, training and currently works with a company that deals with brokers, third party administrators, employers to decrease MSK insurance expenses. So, what we're going to talk about is the concept of getting rid of the damn insurance companies. And that's basically the, uh, context of this next 10 minutes because nearly half of Americans receive health insurance through an employer. The average cost, and believe that this is an actual factual statement for US employers that pay for employees healthcare will increase 8.5% in 2025 to more than $23,600 per employee. The annual premium for family coverage in 2024, believe it or not, averaged $22,463 with the worker contributing $6,000 annually. It's been an increase of 20% over the previous five years and 43% over the previous 10 years. So, you can see why employers are really having issues with healthcare costs. Now, what's also fascinating is that you'd think that the top costs for an employer would be things like cancer, CV, diabetes, MSK is either one or two for every single employer in the United States. And you can see in this number as well that Medicare and commercial employers are the top two largest payers of MSK. And again, you can see here that MSK is number two in this particular example. 47% of total expense in orthopedic claims is elective orthopedic surgery. And the most important strategies when you look at some of this data for the next three to five years for employers is managing high cost claims. If you saw some of the stuff that Sam has brought up, for example, for, uh, um, uh, United Airlines. They spent about a million dollars for nine back cases last year. Their average cost for a knee procedure was $47,000. And so what happens, and you heard about ancillary services, when we look at these claims, we'll see 15 to 20 weeks of physical therapy for somebody with knee osteoarthritis or patients that have rotator cuff tears that have, that are acute, that have had six months of physical therapy prior to surgery. And that's the kind of stuff that we see on literally a daily basis. So they want to enhance benefits to improve attraction retention and manage these high cost claimants. Their goal is to improve quality and outcomes, lowering overall health care costs. And you can see 91% of employers nationally are self-funded. So there's, there's the switch and that's what we're going to talk about. And if you have 500 employees, 73% are self-funded, 1,075% are self-funded, and 5,100% are self-funded. So the conclusions upon review of this data from the employer's perspective is pretty simple. Health care spending is out of control. Brokers control the employer's health care decisions. Employers have an appetite for direct contracting. And MSK costs are the number one and two health care expenses. And almost all employers are moving to a self-funded model. So this is huge opportunity for us because in 2025, they want to reduce costs and they're seeking providers that will initiate value-based programs, which is what we're going to talk about. So when employers were asked what types of initiatives would have the most impact, they require prior auth, but avoidance of delay and deny tactics by second opinion companies. So we try to get rid of the insurers in this model and utilize in disease management. So my conclusions are as follows. More employers are demanding cost-reduction strategies, brokers, third-party administrators, cost-management companies are seeking partners that can provide savings, MSK Care is the number one of the top two healthcare expenses for employers, and orthopedic surgeons, whether employed or private care, are positioned perfectly to provide efficient, cost-effective care if they're willing to take on risk, which can easily be managed with stop-loss policies and aggregate insurance. So determining an appropriate care pathway is critical to avoid the demand to produce to increase work-hour views and over-utilize ancillary services, which is extremely commonplace in both employed and private practice systems, as evidenced in claims, managements, and evaluations. So Sam's going to talk about, is it possible to develop relationships with employers directly for their musculoskeletal care? Sam? Thanks, Dr. Burt. As he said, I did used to work for Optum and United, and there's a reason why I'm not working for them anymore. The conversations with employers are similar to what you guys are feeling, which is very frustrated and not getting a lot of value out of those relationships. So I'm going to talk about book chapter four, and you can ask me for this after the talk. So the big thing to consider is where your volume comes from. The other patients that are very profitable and everybody's looking for, it's the commercial, it's your far left, much more profitable than government liability or self-pay. So for your practice, this is the number one area I would focus on. As Dr. Burt mentioned, the commercial funding breakdown for employers is you have the self-funded model or the fully-funded model. We're transitioning away from fully-funded to self-funded. What that means is the employers retain risk. So they win on the upside, and they lose on the downside. The inside baseball is seven years. There's only one bad year. So employers are starting to figure that out, saying, I want to get into this game, and I want to make the money and the returns of putting in this insurance policy. Big reason why insurance companies are going different directions. Network is something separate from the risk. That just means that it's a contract between you and the employer. So employers are buying or renting networks. So it's different from what the insurance company is. So what that means is control with their patients or their employees is with the employers, not with the insurance companies in the self-funded model. So the question is, how do we approach employers and attract them to your practice? So what employers want is high-quality care with appropriate indications. They want their people back at work healthy. And this is a lot different than the complication model that some of the insurance companies are selling. So what they want is price, so a good price, and high quality. So it's how you define quality that's really critical for these employers. Quality means outcomes over cost. So that's the big thing, is they're looking at how much does it cost, but also what outcomes are you getting me for my employers? That may mean doing the surgery a little earlier instead of delaying for a lot of conservative treatment. We'll talk a little bit about what numbers they're looking at. High quality also means using appropriate surgical indications and making sure that you don't exhaust conservative care, as I mentioned earlier. So to develop these relationships, you need to monitor your providers and make sure they're all providing care, appropriate utilization. But what is appropriate utilization? So I'm going to look at a case study, which this midsize orthopedic group that we worked with in a midsize metro area increased their market share by 30-plus percent. So they were a two-hour drive from a major market, and they had two large health systems they were competing against. What they did is they went from matching rates of health systems, which were 25% more expensive than the major market two hours away. They were unwilling previously to negotiate on price. They built their own surgery center outside of their non-compete, dropped their price to that of the major market, and employers in their area have lined up for contracts. So that's really the way to get these employers interested, is to say, we're going to match the rate of where they were all sending their patients, which was two hours away. And I'll talk about how they were sending those patients that way. So these are the metrics that employers are using to determine quality. They're looking at the number of orthopedic patients that were sent to your groups by your NPI number and the number of surgeries that were performed. So when your ratio is very high for some of these groups, if you group one, two, three, you can see one of them is at 90%, and the other one's at 27%. So if you're in the 90% region, they're going to be saying, why are we sending all our patients here? I'm trying to shift the volume. And I'll talk about how they shift the volume in just a second. They're also looking at the number of PT visits per patient. You can see 22, 12, or 4. They're starting to say, what's the difference between these three groups? These are metrics that are coming. Insurance companies are dealing with it, but some of these other groups are doing that. One of the things that we've seen are 42 visits of PT, 30 visits of PT with a low back pain and a negative MRI. So these are the things they're starting to look for in their data as they harvest it. Insurance companies or insurance brokers, employers, and TPAs are looking for what they call a cost containment solutions. They're also using what's called an incentive to make you the front of the line in your practice. So giving somebody $2,500 towards their $5,000 deductible moves volume significantly. And I think that's the biggest thing to take away is, how do you get your practice at the front of the line? So the take-home message in a five-step process you can use is build and evaluate your internal data, look for complications, get buy-in from your group, set a goal for the number of procedures you're going to perform over this next few years, produce a one-page marketing handout, including some of the things like complications to make sure your message gets to the front, target and interview and form partnerships with cost management companies, employers, and brokers and TPAs for these bundled arrangements, and then execute a marketing campaign, which oftentimes can get to these patients, their cell phones, their emails directly from their HR teams. A lot more effective than a billboard. And measure in performance the new cases that are coming in and continue to look at the new profitability. So the conclusions are MSK costs are a significant expense for both general health and workers' compensation. Groups can develop employer relationships and manage your care costs will differentiate yourself in your market. And commercial and Medicare reimbursement continues to decrease. So going to the employers is a new sustainable revenue stream. For some of you, that may seem like a little foreign, but it's true. Direct marketing to employers is a wonderful way to build your practice. Quick example before I move on to our final talk, we've been on time, great job panel. My group last year renegotiated with three workers' comp people, and we asked for eight times Medicare. And they said, no problem. They said, as long as you get our people in within 24 hours and you talk to our adjuster that day, we'll pay you eight times Medicare for every visit, for every surgery. And it's been great. And they do it. And so it's been a phenomenal increase in revenue for our group, and we've been helping out the workers' comp people because we're getting people in and out of the door for them. So you're absolutely right in what you're saying. It can be a wonderful thing for your practice. You just got to talk to your CEOs and business people. Next and final will be, where's Tim Burt? Oh, my bad. My bad. He's going to get up here and give us a final talk. Bring it home, man. All right. So we're going to switch gears here and talk about how to optimize hospital or large healthcare system employment. Based on the show of hands, it looks like about over half of you guys are hospital employed or part of a large healthcare system. So no financial disclosures. So more than 77% of US physicians are employed by hospitals, health systems, or corporate entities. And you look at the chart below, and you can see a big jump during COVID from 2020 to 2022 with about 73%, 74% of people are hospital employed. So issues with common hospital or large system employment issues. Physicians employed in hospital-owned practices are nearly three times more likely to report dissatisfaction than their peers in a physician-owned practice. Critical concerns include compensation, staffing, levels, workload, and autonomy. Among physicians in physician-led practices, 78% said their organizations have effective processes and workflows compared to just 59% in those that are hospital-led organizations. So these are the issues. So less autonomy. When you go from a private practice model to a hospital-based system, I think you feel that you have difficulty affecting any sort of change. So staffing typically is decided amongst your administrators, including quantity and quality. And then many physicians feel that they have a limited potential for compensation when they get a hospital-based model. And then workload, which is decided at the time of contract negotiations, and that includes call, number of clinic hours, and clinic flow. So I think with less autonomy, difficulty affecting any change by far is the hardest to deal with. And they did a survey where they saw 81% of private practice physicians reported satisfaction with their involvement in strategic decision-making compared to just 50% in hospital-led practices. So these are the solutions. Physician leadership. So you need to establish a joint committee, which includes both clinical manager and physician leaders. And it's ideal to have that practice manager from a previous private practice group so they're pro-physician. You know, they make joint decisions on the direction of the group, and that includes growth strategy for clinical expansion as well as physician recruitment. And when you hire new physicians, you need to have all physicians in the group approve that physician so that you can control both the quantity and the quality of the physicians. So compensation. 29% of surveyed hospital-employed physicians cited compensation as their primary reason for seeking new job opportunities. And many physicians in a hospital-based model find it difficult to relate their value to the system. In 2022, the average employed orthopedic surgeon generated about $3.3 million net for his hospital. And this included facility fees, professional fees, MRI, PT, and DME, with an average salary of $552,000. And that's 6X their salary. So these are the solutions. You know, if you come from another practice and you're high volume, attempt to negotiate a higher RV reimbursement. There is some limitation with the MGMA, which dictates your salary regionally, but you typically start out with a guaranteed salary your first two years in practice and then become productivity-based once you become established. Make sure, though, that when you are productivity-based, that your payment productivity is based regardless of reimbursement so you can see all different types of insurance and you don't have to worry about the reimbursement. You know, the benefit is you do not have to worry about overhead expenses. In the private practice model, these overhead expenses can vary anywhere from 45% to 85%. And then be able to get busy quicker with an automatic referral pattern from the hospital PCPs is beneficial to building your volume. Employee benefits are similar to private practice groups. So you will have allocated CME funds, full health benefits, including life, health, disability insurance, and then retirement savings, which is the 401K, and then which may be unique to the employed model is the employer-matched deferred compensation plan, and that's where your employer will match a portion of your base salary as well as your bonus. And then you don't have to worry about medical malpractice. In terms of workload, this will be established at the time of contract negotiation, which will include clinical hours, call volume, but you can improve this with an adequate support staff. And what we talked about earlier is having a PA, which can see patients while you're out of town as well as do postoperative visits to improve your RV reimbursement, a scribe, which has been shown to improve efficiencies up to 33% to provide more face time for you and the patient, improve your patient satisfaction scores, medical assistant to help with clinical workflow, and then a surgery scheduler to authorize surgeries. And this can lead to an improved work-life balance. And as you become more productive, potentially having more vacation days available and then eventually dropping call when you get busy enough. Marketing is a big part of your growth strategy. You need to have a dedicated marketing team or personnel that will include social media, YouTube, and website presence. And make sure you have them help you with networking with local physical therapists as well as primary care physicians. And then get introduced to the hospital primary care physicians because those will be a big part of your internal referral sources through the hospital. I personally maintain a website, which helps with search engine optimization as well as controlling the website content that a patient will see when they look you up on the internet. Get involved in the hospital committee. So there's multiple positions in the hospital committee which you can be paid for, and this allows you to have a seat at the table when decisions are made in the hospital setting. Like we talked about with joint venture with hospitals also is ownership and ASCs. So this can be negotiated at the time of contract negotiation and then typically it's with a hospital healthcare system that has some sort of a surgery center ownership. And then look at ownership of ASCs as well and see if you can get involved with that. If you do any consulting outside of the consulting, make sure it's outside the hospital system so that this is excluded from the employer during contract negotiations and make sure to set up an LLC. And then I incorporate IMEs at the end of my clinic. And what's nice about this is I share about 5% of the profit and then it provides a seamless transition with my other patients. So take-home points, a large system employment can be very satisfying, lucrative, and successful if you have strong physician leadership interfacing with administration and adequate support staff, ability to separate outside activities from your employment contract, a high RV reimbursement, and then make sure when you negotiate your contracts that you have a contract lawyer, healthcare lawyer, look over your contract before signing. Thank you. Holy cow. So first, the day of our Lord, May 10th, 2025. Everybody was on time. Unbelievable. All right. How do you get the productivity to be this good? Okay. So here we go. We got 25 minutes for questions. Anybody have any questions? Here we go. All right. I'll call on you. You can walk up to the mic. You can go first, sir. Then you're next, Tim. These were our workers' comp companies, and the CEO broached the partners and said, hey, I have an idea. I think this... Because we were talking about direct to employer marketing, and in our hometown, there weren't a lot of opportunities. The one big company in Naples has partnered with a hospital. So my CEO said, let's approach workers' comp. And we had quite a few workers' comp companies that were working with us. Only I think it was three, only three bit. So we now only work with three workers' comp companies, but those three that work with us, it's very lucrative. And their companies are exceptionally happy. And I will tell you, our CEO holds us to that standard. If we don't get somebody in within 24 hours, we all get a personal phone call during clinic from our CEO, who's not very happy with us. So you do have to make an agreement. You're absolutely right, Sam. And you have to hold yourself to that agreement. But if you do it, it can be very lucrative. And actually, I don't mind seeing workers' comp now. So yeah. You got to be careful about work comp, though, because work comp isn't complicated. So the work comp, interestingly, what we don't know, and this is a full disclosure, I don't know, work comp underpayment collections company, because we were getting so screwed on work comp that we actually didn't know what to do with it. There's a company in between you and the work comp company, unless you do what Patrick says. It's called a repricer. So the insurance company pays the repricer a little bit of a discounted rate. So the repricer, that pays you crap. And if you don't realize that you've been paid not on your contract, they keep that money, which is sometimes, our group was underpaid one year, $650,000, and we don't do that much work comp. So be careful what you collect and what you think you should collect, and actually look at your contract and look at the EOB, because a lot of times, it's not nearly as lucrative as you think it is, unless you pay attention to it. That's a great point. How many people in this room talk to their, like Ian said, how many people in this room talk to their coders on a weekly or monthly basis, right? Everybody should be doing that. And when you do a worker's comp, like I'll email my worker's comp guy and be like, when did we get paid? Because they send me the contract, I get in an email and I'm like, how much did we get on that contract? And normally, it's pretty good now because of it. But he's right. You need to follow up on this stuff, because if something is not right, you need to address your leadership and you need to find out what's going on. So we should be more proactive in that. EOB. EOB. Explanation of Benefits. Look at your Explanation of Benefits, and you don't have to look at every one, but start taking a look at a couple of months. You'll be surprised how different they are from what you think you got paid. All right, Tim, you're next. Go ahead. Well, all right. So I have a question along that. But there's two sides to worker's comp. My practice takes exclusively medical legal. And we do about 70% worker's comp and PI. But all of our clients are the attorneys. The patients are the patients. The clients are the attorneys. We get paid. We don't like to negotiate with the worker's comp company. They kind of hate us. But the attorneys are responsible for getting our bills paid. And so we get paid on the settlements. And that's a little bit of a different thing. So I have a question along that. But there's two sides to worker's comp. My practice takes exclusively medical legal. And we do about 70% worker's comp and PI. But all of our clients are the attorneys. The patients are the patients. The clients are the attorneys. We get paid. We don't like to negotiate with the worker's comp company. They kind of hate us. But the attorneys are responsible for getting our bills paid. And so we get paid on the settlements. And that's a little bit, you know, larger pay. But what I wanted to understand was, you know, what's the difference between a worker's comp and a patient's comp? And what's the difference between a worker's comp Yeah. Yeah, so it's their commercial general health population. So what they would do is market to their employees and say, hey, if you have a knee issue, osteoarthritis, go see these physicians first. We have a direct agreement with them. So you're able to get around all of the insurance company deals and they'll say we'll actually offer you $2,500 if you go here. They look at their rates in their markets to say, hey, look at it's, let's just say $30,000 or $25,000. We'll give somebody $2,500 to go here all day. And that's really what they're trying to do is these employers are getting smarter with their claims data to say how much are we paying? They're looking at their EOB similar. How much are we paying per patient? And so it's really how do you formulate a arrangement with these employers? Your CEO, like you said, you can push them to say, hey, how many can we get more of these relationships? But it's going around a lot of those traditional insurance contracts. So that's... Back corner. Yes, sir. You mean I like at a hospital I'll let everybody answer that I'll go first. I think the hospitals know how much money they make off us They know we're getting pennies on the dollar for what they make what you just showed was it six times and that's one example So if you can fill two rooms, the hospital would be a fool not to let you have two rooms The only time they're not gonna let you have two rooms is if you can't fill it I'll let I'll let we'll start at dr. Beach and we'll work our way back to you. And what do you think sir? Turnover time is in excess of like 45 minutes Then you have the two rooms make sense if you're doing scopes and stuff Having said that if you're slow, that's not profitable for them So it really becomes how fast you are versus the turnover time So if you're in an ASC where you're pretty quick and the turnover times quick It's probably a moneymaker But we got guys in our group who are slow and it doesn't really make sense for them to get to The turnover time is 12 minutes Or you send them to the hospital We used to have a guy that it would take literally two hours to tie his shoes and so in the ASC we pretty much have to ban him because he would take two hours to do a simple minisectomy and When you start to a cost analysis, it's just awful A bunion just can't take four hours So I think I think efficiency matters I think subspecialty and it reproducing the same steps over and over matters There's some ASCs and I'm in rural Georgia But there's some ASCs in my market that are my friends practice in that are doing 18 joints a day and that's because a lot of the closures are being done by Subspecialty physician extenders all the way from the capsule They're you know, 30 minute implant in time and go to the next room So we're gonna see a continuation of kind of manufacturing principles applied to medicine we're gonna have to be more efficient and you want to be ahead of the efficiency curve because costs are going to continue to go down so to be competitive and Continue to generate the income that that we have we're gonna have to do more So Yeah, this was a pearl from from my senior mentor for literally a hundred years ago He would go in the OR and just say I do it the same way every time and he had ten steps to do a total joint and he had ten steps to do a rotator cuff and Pretty soon if you get a team That's so used to doing that to your point. It increases the efficiency Just like a manufacturing plant would be if you guys just all use that principle and try to do it the same way every time Your efficiency will increase 25 30 percent because the our staff knows exactly what the next step is I do it the same way every time except when I do it different All right, good Robbie, yeah on that on that note, you know in the in the state that I did we It when we started we were initially going to try to sort of parse out like if you have two rooms versus one room and Then you know how much sort of downtime you have, you know with turnover time and whatnot It was just a little bit hard to do based on the logistics of it But that's definitely something that that I think is really important to look at is to see Really how much and and I think what that what that study really speaks to is how much how much downtime you have? Because in the clinic, you know, you're using patients back-to-back There's like almost no downtime. Whereas in the OR, you know, you're waiting for room turnover, you know, maybe you know something goes slower you're delayed from anesthesia, whatever it is and that and that's really where it sort of brings in the Inefficiency and why you spend you know more time in surgery and then you know more controlled time in the clinic. I Think what Robbie study showed is, you know used to be even when I was in training 12 years ago or 13 years ago Now it was hey you had clinic to fill your ORs That was why we did clinic and that's why you know, no surgeons like clinic We like to be in the OR but what you're seeing now is Clinic is your productivity moneymaker and I I tracked my dad. I recommend anybody should do that I'm extremely anal retina. If I I like my spreadsheets I love Excel and I've looked at my numbers over the last eight years and I only operate on 6% of my patients So 94% of my patients are not getting surgery and I know when we come to these conferences We measure ourselves by first thing we say to each other's how many surgeries you doing this year? How many surgeries you do when in reality maybe we're looking at the long wrong percentage of patients those 94% of non-operative patients can be exceptionally productive and I think The Medicare and the reimbursements were starting to show that's what we're gonna have to start focusing on and Robbie study showed that Had we not been screwed by Medicare and the private insurers So what happens is they updated the office visits, right? I showed you an extra RV you after for a level for New patient or established patient visited from the old rules to the new rules, right? You're so what did how did Medicare screw us? They didn't update the post-operative global package visits Right, so for every global package We have like three or four visits and some over two which is wrong some of our threes case a four Okay, those are still the old values We should be so irritated and we should be we just got totally screwed by Medicare and the private Insurers because they essentially devalue all of the visits in the global period by about three RV you Okay, so you're being underpaid for your surgery and the global package now by three RV use so You got so the way that works is that? Those post-operative visits the average post-operative visits go into the original surveyed value for the total RV you amount so They didn't change the value of the global visits that were included in rotator cuff repair They didn't they didn't update all of the surgical codes with updated E&M and that number that he said that one RV you That's like I think for a level three. It's like a 35 or 40 percent increase in total RV use So the numbers are tiny But percentage wise it was a big shift of the pie of the Medicare Part B pie to the E&M service space It's crazy It's also relative because this is in the face of you know The fourth consecutive year of two to three percent decreases in the Medicare conversion Reimbursement which is not all insurance, but it certainly sets the standard for negotiating with the with the private sector Tens and hundreds of thousands of 65 year old three-year-old Beneficiaries on the list so it has to go down. There is absolutely no way you can't get it unless Congress goes and saves it bill You don't come on that sir Yeah, do you want to explain that to the group Well, I know I we did Minnesota was the First day to do capitated care and I still have Receipt I keep in my desk drawer from 1987 where I was paid $250 for a total hip Because the GP's wasted all the capitated money 85% went to the GP's And there was 15% left for the specialist I want to ask one question for the employed docs. How many of you are happy with your salary? Can I see a show of hands? One guy two guys two guys. Well, yeah, you've got the PSA Degradation But back to the before we leave the capitated plan capitated plan everybody know what the capitated plan You get paid. So let's say there's 10,000 people in that organization. They may say you what? Two bucks a buck for the work be care three. So So it's a change in your mindset Instead of being an orthopedic surgeon who thinks yeah, I can fix that. It's like oh no free surgeon You know, I avoid fixing that because I don't make any more money if I fix it than if I don't fix it As a matter of fact, they're gonna look at me in a different way if I fix it Denying delay. So let me go ahead. I'm gonna well, I just want to make a comment The reason I asked the question is collect your EOBs that was mentioned before so I used to tell my patients To bring in your explanation of benefits, especially if you're employed doc, you want to renegotiate your contract So many of the times when I've been representing a group and sitting across from administrator They say we're gonna follow the MGM a which is absolute bullshit, by the way Because they want to put you at the 50% mark, right? So that my comment always was okay So my guys are really the best of the worst. Are they the worst of the best, right? So you should be in that 70th 80th 90th percentile so that you can get above that 455 550 Becker's pay range. So the way you if you keep your EOBs They can't lie to you. They can't tell you what we're only being paid this much so I had a group do that and they suddenly pulled out all these EOBs and they just Totally disputed everything the administrator said and we're able to lay it out So that's how they negotiate at higher salaries your patients will be happy to give you their EOBs to see what? Actually was reimbursed and so don't forget that it's a great negotiating principle Go ahead, sir So this is something I started I started about three years ago just What we started is we started a wellness program and Basically, and I've got health care attorneys. It's all legal. It's all above board. I started a wellness program with my wife And basically what I do is I offer my patients three tiers They can pay twenty five hundred dollars for six months thirty five hundred dollars for a year or even five thousand dollars for a year With that five thousand dollar plan they get two free PRPs and they get my personal cell phone the other plans We have an app they communicate through you can do it any way you want You offer three plans because typically they choose the middle one The twenty five hundred dollar six month plan is for all my big surgeries my rotator cuff my total joints I offer them all six months. I have three PA So I say hey look if you want to see me you want to reach out to me anytime you want It's six months. It's a big surgery. This will give you unlimited access to me. You can call my therapist I pay my therapist a little bit. You can call my therapist whenever you want. My wife's a nutritionist You can also get nutrition with my wife But if you don't and you have to be very careful here I say if you don't that's okay We're gonna take good care of you. You'll follow up with my PA's You'll see me in three months and but I review all your charts, right? so over the course of three years, I now have about 105 people in the program my Revenue last year was 300. It's an 80% margin so you can do the math And what's shocking as I offer a prorated refund? I tell everyone I'll give you your money I'll give you your money back. If you're not getting your service. I've yet to have anyone ask for a refund and I have a 50% renewal rate. I Started off this year already with 150 K in the bank so It is a patient's what's going on as I saw. This is what's changed in the reimbursements doctors are seeing Doctors offices or cattle clinics, right? How many doctors you know my clinic and make my PA sit down examine? No notes are allowed to be taken with people night But not a lot of not a lot of doctors do that They just look at an MRI and walk out of the room So patients don't want that anymore patients will pay for care and everybody thinks it's because I'm in Naples, Florida I will tell you right now over 50% of my patients are middle-income on a fixed income Oh 50% of my patients are on a fixed income They want that care, right? They want to be able to get in whenever they want which I will honor that because they're paying for a wellness program I build their insurance and it's legal so they come in they can see me every week I build their insurance every single time I come in usually a level four believe it or not if I can get it and They still pay me an annual fee. So because they want to get in they want access They want care and all I'm doing is answering text. I'm gonna ask me how much I do I said even in the worst case scenario if someone gives me an annual fee of $3,500 if I answer What 100 text a year that's $35 to text I mean if you guys don't want to get paid $35 a text that's on you But I mean we're what we're doing is we're finally getting paid for our value and patients recognize our value more than we recognize our value so Concierge medicine is the future. You can do a hybrid clinic like I do and I think it's it can be done with specialists. It's just our models different. We're not looking for renewals We're looking to get it routinely like every six months every year because a lot of my patients leave that's what we need But this is another ancillary we can use right? You don't have to make seven figures a year on your concierge But if you're making 150 200 that's arguably your best ancillary you're gonna have and it's actually really good health care Because they're gonna call you the moment they have something go wrong and you're gonna be on top of it right away So just another alternative it's coming around the corner You better look out for it because there's more and more concierge going on and patients are more and more aware of it than they've ever been You can see my PA That's right But no and you can you can do whatever you want that's the beauty of it, right like I all my It's my my program is called ortho Well, all of them get 30% off on biologics So some of them like they come in every every three months for a PRP whether they need it or not I'm like, well look you can save yourself this much money. You might as well join the program and they're like, yeah All right, I'll join the program. And so it's It's another way to provide better care and to generate some ancillary revenue And that's what we're talking about, right? Because if the insurance companies aren't going to give us our value your patients will So just another thing to think about but real quick I want to talk real quick to Tim because we have a lot of employee Physicians in here. So Tim and Aaron just left unfortunate because I wanted to ask Aaron Aaron was a chair of the Mayo Clinic orthopedic department and our newest board member, but As an employee physician, it has to be intimidating to confront administration So what are your tips to the employed physicians in here? Because what you brought up are very salient points Hey, go to your administration show him the proof. But what dr. Burt said show him these EOBs I'm not getting my value. But how do you talk to them? Because it's going to be a compromise So you're not going to get everything you asked for So give some tips and pearls here on how to address the administration and to get what you need Yeah, I mean, I think a big part of it is leverage so when you know, I've been employed for 13 years now in the hospital system and I did change over after four years to new hospital system So the biggest I think the biggest thing is going to the negotiation table is to have leverage So if you come from a previous practice Yeah, show them your numbers. I think the biggest thing is if you're productive You know show them that you are productive and show your percentile You know, they should they'll do MGM a like my dad talked about and I think if you have a high You know high high volume practice that you're leaving and coming into a new practice That's probably your biggest point of leverage in order to get a higher reimbursement and then Like he said earlier is you'll be I think showing what kind of compensation that you you're potentially could You could get and the type of reimbursement that you're you're getting through the EOB. So what's been your success as an employed physician? getting Being allowed to get some revenue off your ancillaries surgery center, etc. Much like the private docs do yeah So we're talking about building a clinic right now And then there's some discussion about Pete's sharing revenue and PTA both MRI I currently have ownership in one surgery center, but we do have the potential have ownership in two surgery centers The company I work for is tenant and so they have USPI And so with USPI they do allow us to have ownership in a surgery center that is managed by USPI So that is one benefit. I don't know if I mean there's obviously a lot of They'll be just throwing up over there. I don't know if there's yeah, obviously that's not gonna be the situation for everybody But if you do have a parent company that has a surgery center ownership I think they they will they should allow you to have some ownership in that which which makes a big difference for your passive income Poll for everybody There is and this is in the physician employed side of things There's a rural hospital about two hours away from me that is offering a annual cost of living increase of 3% To their contracts and certainly underserved and and they've had an exodus of orthopedics one guy got sick Is anybody hearing that is anybody talking about that and their contracts so that they're I mean, it's it's pretty sweet Opportunity, but I think they're 76. I know RV units a 3% annual cost of living increased three-year contract term I I Don't know the designation potentially, but I mean, it's a nice town It's 25,000 probably people in the city about an hour north of Tallahassee It is that but the concept of a cost of living increase in a contract That sounds more reasonable Out there next time The other comment I'll make it what Tim said about the LLC I was talking to one employee physician before I came in here and at her hospital. She's not allowed to have an LLC I got my military man right here when I was in the Navy I've you're not allowed to be a consultant, right? You know that so I started an LLC and I put only my wife on it and I made all the companies pay my LLC So I was a consultant through the Navy. So when my CEO would confirm me he'd be like Jordan are you getting paid? I'm like, no, I'm not getting paid My wife's LLC is getting paid, but I'm not getting paid. And so I think there are ways to work around things You know And I think Tim's pointed even as an employed physician get an LLC and then you can make some investments in concierge Even as an employed physician you can do things and have it paid through your LLC So you can have opportunities outside the hospital as long as your hospital will allow you to do that Has to do what your wife your parents Agree get a health care attorney. That's what I did for my concierge program said make sure everything was above board That's how my practice. Let me do it So you have to get a health care policy attorney and just just make sure when you guys are negotiate contracts You get rid of all that language. It says you can't do IMEs Let's say you one of you guys discover something that becomes a multi-million dollar royalty from a company there's a lot of contracts that says that the Ownership of that royalty is by the system that you're employed by which is just ludicrous to me But a lot of contracts I've seen say that which is sad Yep, exactly. Yeah anything else one more final question right here Oh So that's something I'm exploring I've talked to some docs up here I do think again, we're talking alternative revenue streams here, right? And like I said change is an opportunity not a curse And so I think look at your private look at your plastic surgeons. Look at your Dermatologist right? They all have their own spas and their practice. We have PT Why can't we have recovery just so y'all know real quick have done the data on here recovery centers It's a nine trillion dollar a year market nine trillion, right and it's owned by chiropractors and business people Why can't orthopedic surgeons get into this space? Why can't medical providers get in this space and actually make it legitimate other things? We're doing my practice owns an urgent care. We're about to open a second urgent care. It's extremely productive That's how a lot of us have gotten off call a lot of our Fractures a lot of our ACLs or ankle sprains are coming through our urgent care and then come into us So these are other alternative revenue streams, right? Good, sir So we don't label it an urgent care if you put an urgent care, there's a lot of laws It's called a fast care and it's a fast care. It's a walk-in clinic. We build like everything else Well, we had a separate standalone Building and it's serving like an orthopedic urgent care We've just marketed it that way and so like a high school as a coaches even the ERs are sending people there now because they don't want to deal with some of these fractures and They're just coming in through our fast care coming right to our clinic We have a non-op sports medicine physician there But we also have PAs and a lot of us if someone calls your clinic sometimes and you can't get a man We just send them right there. So that is a wonderful Ancillary that a lot of practices are doing That is that is that can generate a lot of revenue and downstream revenue for the group I Bill are y'all doing anything like that urgent cares Eric So, this is great, I appreciate everybody coming this is a wonderful ACL, thank you everybody

orthopedic specialists

alternative revenue streams

healthcare landscape

coding practices

E&M values

clinic visits

ancillary services

in-office MRIs

physical therapy

physician extenders

direct contracting

concierge model