1 00:00:00,160 --> 00:00:02,720 Hi, everyone. This is Erica Spicer Mason with 2 00:00:02,720 --> 00:00:04,879 Becker's Healthcare. Thank you so much for tuning 3 00:00:04,879 --> 00:00:07,219 into the Becker's Healthcare podcast series. 4 00:00:07,759 --> 00:00:10,500 I'm looking forward to today's discussion about physicians 5 00:00:10,559 --> 00:00:12,019 and their employment decisions 6 00:00:12,400 --> 00:00:14,799 and the impact this has on financials, patient 7 00:00:14,799 --> 00:00:17,434 care, and more. And helping us navigate this 8 00:00:17,434 --> 00:00:20,635 topic today is Marty Nichols, cofounder and acting 9 00:00:20,635 --> 00:00:22,654 COO of Physicians First Bancorp. 10 00:00:23,355 --> 00:00:25,274 Marty, welcome to the podcast. Thank you so 11 00:00:25,274 --> 00:00:27,434 much for joining us. Well, thank you guys 12 00:00:27,434 --> 00:00:29,054 for having me. Becker's has been 13 00:00:29,390 --> 00:00:30,910 a big deal to my industry for a 14 00:00:30,910 --> 00:00:32,189 long time, so it's an honor to be 15 00:00:32,189 --> 00:00:32,689 here. 16 00:00:33,309 --> 00:00:35,469 We're thrilled to hear that, and we're equally 17 00:00:35,469 --> 00:00:37,329 honored to have you here with us, Marty. 18 00:00:37,629 --> 00:00:39,390 And before we get into the meat of 19 00:00:39,390 --> 00:00:41,469 our discussion today, would you mind sharing just 20 00:00:41,469 --> 00:00:43,409 maybe a little bit more about your professional 21 00:00:43,745 --> 00:00:45,365 background, your current role in organization, 22 00:00:45,825 --> 00:00:48,304 whatever feels top of mind for you? Yeah. 23 00:00:48,304 --> 00:00:50,325 Sure. I I I started in the orthopedic 24 00:00:50,465 --> 00:00:52,465 world and the MSK world in the mid 25 00:00:52,465 --> 00:00:53,445 to late eighties. 26 00:00:54,145 --> 00:00:55,585 I was fortunate to get on with a 27 00:00:55,585 --> 00:00:58,245 company called Depew Orthopedics. This was pre 28 00:00:58,979 --> 00:01:00,039 Johnson and Johnson. 29 00:01:00,420 --> 00:01:01,939 I started as a rep and worked my 30 00:01:01,939 --> 00:01:03,939 way up to a distributor with them and 31 00:01:03,939 --> 00:01:06,500 then started seeing some things change in the 32 00:01:06,500 --> 00:01:07,640 industry and especially, 33 00:01:08,099 --> 00:01:09,939 around the time of the Johnson and Johnson 34 00:01:09,939 --> 00:01:10,439 acquisition. 35 00:01:11,135 --> 00:01:12,114 There was a lot of consolidation 36 00:01:12,575 --> 00:01:13,795 going on in the device 37 00:01:14,094 --> 00:01:15,534 world at that time, and it's still going 38 00:01:15,534 --> 00:01:16,275 on today. 39 00:01:16,974 --> 00:01:19,295 I kinda realized and started looking at the 40 00:01:19,295 --> 00:01:21,855 industry was going to make devices a commodity, 41 00:01:21,855 --> 00:01:23,295 that a knee was going to become a 42 00:01:23,295 --> 00:01:24,814 knee, a hip was going to become a 43 00:01:24,814 --> 00:01:27,439 hip. And although I don't necessarily agree with 44 00:01:27,439 --> 00:01:30,000 that, I believe that there are differences in 45 00:01:30,000 --> 00:01:30,659 the devices. 46 00:01:31,119 --> 00:01:32,799 I think what the industry saw and knew 47 00:01:32,799 --> 00:01:34,799 was the real magic in the outcome was 48 00:01:34,799 --> 00:01:35,459 the physician. 49 00:01:35,840 --> 00:01:38,000 I've always believed, you know, that give me 50 00:01:38,000 --> 00:01:40,974 a a good physician and a mediocre implant, 51 00:01:41,355 --> 00:01:43,034 and I'll give you a better result than 52 00:01:43,034 --> 00:01:45,594 with a mediocre physician and a good implant. 53 00:01:45,594 --> 00:01:47,375 And I think that's true with the technologies, 54 00:01:48,234 --> 00:01:49,534 and stuff that we're introducing 55 00:01:50,234 --> 00:01:51,614 now today too. 56 00:01:52,230 --> 00:01:54,489 The physician is really what makes it work. 57 00:01:54,629 --> 00:01:56,549 And along with that consolidation in the big 58 00:01:56,549 --> 00:01:58,870 companies, we started to shift the focus away 59 00:01:58,870 --> 00:02:01,989 from the relationship between the with the device 60 00:02:01,989 --> 00:02:04,150 companies used to be the physician was their 61 00:02:04,150 --> 00:02:04,650 customer, 62 00:02:05,135 --> 00:02:07,855 and the hospital and insurance companies were entities 63 00:02:07,855 --> 00:02:09,294 that they had to deal with in order 64 00:02:09,294 --> 00:02:11,294 to do business with their customer, which was 65 00:02:11,294 --> 00:02:12,034 the doctor. 66 00:02:12,335 --> 00:02:14,735 The bigger companies started moving the the customer 67 00:02:14,735 --> 00:02:17,534 to be the hospitals. Contracts became more important 68 00:02:17,534 --> 00:02:18,995 than devices and sales, 69 00:02:19,300 --> 00:02:21,479 and the doctors started becoming the people, 70 00:02:21,860 --> 00:02:23,300 that you had to deal with in order 71 00:02:23,300 --> 00:02:24,759 to do business with your customer. 72 00:02:25,060 --> 00:02:26,659 So I was fortunate. I got an opportunity 73 00:02:26,659 --> 00:02:28,099 to jump on with a company called Pleus 74 00:02:28,099 --> 00:02:31,219 Orthopaedics out of Lucerne, Switzerland. We introduced a 75 00:02:31,219 --> 00:02:33,000 technology called Pi Galileo 76 00:02:33,504 --> 00:02:35,344 into the United States. We had a wonderful 77 00:02:35,344 --> 00:02:36,544 run with it. I got to work with 78 00:02:36,544 --> 00:02:38,544 some great physicians. We we did a lot 79 00:02:38,544 --> 00:02:39,844 of neat stuff with technology. 80 00:02:40,384 --> 00:02:42,324 They got acquired by Smith and Nephew. 81 00:02:42,944 --> 00:02:44,305 I was then blessed, and I met the 82 00:02:44,305 --> 00:02:45,365 Siccardi family, 83 00:02:45,870 --> 00:02:47,810 and was able to get involved with Medacta, 84 00:02:47,870 --> 00:02:50,669 who looked at technology different than navigation and 85 00:02:50,669 --> 00:02:52,990 robotics and computers, but looked at technology as 86 00:02:52,990 --> 00:02:56,110 being a technique, surgical techniques or tables and 87 00:02:56,110 --> 00:02:57,884 things that we could change it, but really 88 00:02:57,884 --> 00:03:00,064 had a focus on the physician customer. 89 00:03:00,764 --> 00:03:02,044 So I was able to work with them 90 00:03:02,044 --> 00:03:03,664 as they brought the direct anterior 91 00:03:04,365 --> 00:03:06,604 approach in the United States and really focused 92 00:03:06,604 --> 00:03:07,344 on education 93 00:03:07,884 --> 00:03:10,145 and focused on, you know, physician driven 94 00:03:10,925 --> 00:03:11,425 products 95 00:03:12,330 --> 00:03:15,050 and services and and techniques. And then a 96 00:03:15,050 --> 00:03:16,830 very dear friend of mine and a mentor 97 00:03:16,889 --> 00:03:18,330 to me that taught me a lot about 98 00:03:18,330 --> 00:03:19,550 orthopedic, George Cipolltti, 99 00:03:20,250 --> 00:03:22,330 was at Omni at the time, and they 100 00:03:22,330 --> 00:03:24,730 were looking at a a technology acquisition out 101 00:03:24,730 --> 00:03:26,510 of Grenoble, France called Praxim. 102 00:03:26,974 --> 00:03:28,415 And he offered me the opportunity to come 103 00:03:28,415 --> 00:03:31,935 and integrate it into them. And we, developed 104 00:03:31,935 --> 00:03:33,155 what is now the Apollo, 105 00:03:33,694 --> 00:03:36,495 with Korn. Again, the company eventually gets acquired 106 00:03:36,495 --> 00:03:38,335 once the technology gets good enough, but we 107 00:03:38,335 --> 00:03:40,469 developed the the balancing and stuff. 108 00:03:40,949 --> 00:03:43,110 So now what I've done is shifted my 109 00:03:43,110 --> 00:03:45,189 gears, and I'm now working in and looking 110 00:03:45,189 --> 00:03:47,110 at the financial side of of health care 111 00:03:47,110 --> 00:03:48,710 and stuff and trying to give something back 112 00:03:48,710 --> 00:03:49,530 to the industry. 113 00:03:49,909 --> 00:03:51,830 And that is all of my career, we 114 00:03:51,830 --> 00:03:54,405 worked towards making physicians more efficient so that 115 00:03:54,405 --> 00:03:56,084 we can cut their pay every year, and 116 00:03:56,084 --> 00:03:58,104 they can still maintain a level of income. 117 00:03:58,405 --> 00:04:00,245 I'm now trying to work with physicians to 118 00:04:00,245 --> 00:04:02,405 find a way to increase the amount of 119 00:04:02,405 --> 00:04:04,564 money that they hold and hopefully allow them 120 00:04:04,564 --> 00:04:06,104 to start seeing less patients, 121 00:04:06,645 --> 00:04:07,319 and make 122 00:04:07,800 --> 00:04:09,560 the same money. Because I think we've kinda 123 00:04:09,560 --> 00:04:12,280 crossed a chasm where where efficiency is no 124 00:04:12,280 --> 00:04:14,379 longer a good thing in MSK. 125 00:04:16,199 --> 00:04:18,839 Marty, what a great intro. Really appreciate the 126 00:04:18,839 --> 00:04:21,875 background. And just based on your career path, 127 00:04:21,875 --> 00:04:23,795 it sounds like you have such a a 128 00:04:23,795 --> 00:04:26,214 unique perspective. You've got this medical 129 00:04:26,915 --> 00:04:29,074 device and kind of the business side that 130 00:04:29,074 --> 00:04:31,475 you've seen, but also it it sounds like 131 00:04:31,475 --> 00:04:32,535 you have a really 132 00:04:33,370 --> 00:04:35,389 strong working understanding of the clinical 133 00:04:35,850 --> 00:04:37,529 side and what physicians are facing on a 134 00:04:37,529 --> 00:04:39,689 daily basis as well. So I think it's 135 00:04:39,689 --> 00:04:42,029 great that you're here for for this conversation 136 00:04:42,169 --> 00:04:44,649 and especially to address this topic of kind 137 00:04:44,649 --> 00:04:46,889 of physician employment trends that we're seeing today, 138 00:04:46,889 --> 00:04:48,615 which to your point about how you noticed 139 00:04:48,615 --> 00:04:50,534 all of those changes in the medical device 140 00:04:50,534 --> 00:04:52,854 side, we're certainly seeing a lot of changes 141 00:04:52,854 --> 00:04:55,514 in in the ways that physicians are working. 142 00:04:56,214 --> 00:04:58,074 So to give you a a quick example 143 00:04:58,534 --> 00:05:00,134 example, and this is more so for our 144 00:05:00,134 --> 00:05:02,629 listeners, of course, We know that nearly 80% 145 00:05:02,770 --> 00:05:05,410 of physicians now work in an employed setting. 146 00:05:05,410 --> 00:05:07,730 So wondering if you can give our listeners 147 00:05:07,730 --> 00:05:09,990 a sense of the current landscape for independent 148 00:05:10,050 --> 00:05:12,449 physicians and the factors that have led so 149 00:05:12,449 --> 00:05:14,470 many to choose hospital employment. 150 00:05:15,415 --> 00:05:17,014 Yeah. No. This is a great question and 151 00:05:17,014 --> 00:05:18,375 something that we need to pay attention to. 152 00:05:18,375 --> 00:05:20,055 I think one of the challenges that we're 153 00:05:20,055 --> 00:05:22,535 seeing in America right now is we've become 154 00:05:22,535 --> 00:05:24,615 a country that's so divided that that that 155 00:05:24,615 --> 00:05:26,694 we tend to wanna think that there's only 156 00:05:26,694 --> 00:05:29,110 one solution. You know? Everybody should be a 157 00:05:29,110 --> 00:05:31,290 hospital employer. Everybody should 158 00:05:31,590 --> 00:05:33,750 be in private practice. And and that just 159 00:05:33,750 --> 00:05:35,910 couldn't be further, you know, from the truth. 160 00:05:35,910 --> 00:05:37,670 The reality of it is is you need 161 00:05:37,670 --> 00:05:41,110 competition. You need multiple different venues or or 162 00:05:41,110 --> 00:05:42,870 places for this to go, and that's what 163 00:05:42,870 --> 00:05:45,805 drives, you know, better care. The most concerning 164 00:05:45,805 --> 00:05:47,964 thing to me about the trend towards the 165 00:05:47,964 --> 00:05:49,824 physician employment of hospitals 166 00:05:50,365 --> 00:05:51,824 is the reason why 167 00:05:52,125 --> 00:05:54,604 the physicians are going there. If you look 168 00:05:54,604 --> 00:05:55,504 at it traditionally, 169 00:05:56,204 --> 00:05:56,784 a physician 170 00:05:57,084 --> 00:05:59,724 health care shouldn't be about profit. Health care 171 00:05:59,724 --> 00:06:02,100 was never about driving profitability and things. It 172 00:06:02,100 --> 00:06:04,500 was about treating an ailment, making a a 173 00:06:04,500 --> 00:06:06,040 vulnerable patient better. 174 00:06:06,419 --> 00:06:08,419 When a when a physician in a private 175 00:06:08,419 --> 00:06:09,560 practice negotiates 176 00:06:10,180 --> 00:06:12,039 terms or or treats a patient, 177 00:06:12,579 --> 00:06:13,319 the profitability 178 00:06:13,779 --> 00:06:16,180 is basically the salary, the money that they 179 00:06:16,180 --> 00:06:17,084 get paid. 180 00:06:17,544 --> 00:06:20,104 When you introduce 3rd parties into this, things 181 00:06:20,104 --> 00:06:21,004 like a hospital, 182 00:06:21,305 --> 00:06:22,904 now you not only have to pay that 183 00:06:22,904 --> 00:06:23,404 physician. 184 00:06:23,865 --> 00:06:26,504 You also then have to make shareholders happy. 185 00:06:26,504 --> 00:06:28,044 You have to support other 186 00:06:28,600 --> 00:06:31,019 areas within the hospital and make that work. 187 00:06:31,240 --> 00:06:33,080 So my biggest trend is and I'm not 188 00:06:33,080 --> 00:06:35,000 one of these people that says that hospital 189 00:06:35,000 --> 00:06:37,879 employment is bad. It's not bad. There'll always 190 00:06:37,879 --> 00:06:39,660 be a role in a place for physicians, 191 00:06:40,360 --> 00:06:41,980 hospitals to employ physicians. 192 00:06:42,514 --> 00:06:44,595 What's bad is if a physician feels that 193 00:06:44,595 --> 00:06:46,615 they didn't have any other choice. 194 00:06:47,154 --> 00:06:48,694 And that's what we see right now 195 00:06:49,394 --> 00:06:51,794 with our financial institution or with the holding 196 00:06:51,794 --> 00:06:54,035 company as we're interviewing and talking to these 197 00:06:54,035 --> 00:06:54,535 doctors. 198 00:06:55,475 --> 00:06:55,975 About 199 00:06:56,729 --> 00:06:57,229 20% 200 00:06:57,529 --> 00:06:59,769 to 30% of the physicians that we talk 201 00:06:59,769 --> 00:07:01,370 to that are within the first five years 202 00:07:01,370 --> 00:07:03,129 of their practice after getting out of a 203 00:07:03,129 --> 00:07:05,789 residency or fellowship that are hospital employed. 204 00:07:06,250 --> 00:07:07,529 As we talk to them, they'll tell us 205 00:07:07,689 --> 00:07:09,264 they say, look. When I got out of 206 00:07:09,264 --> 00:07:10,704 medical school or I got out of my 207 00:07:10,704 --> 00:07:12,785 fellowship, I just really wanted to take care 208 00:07:12,785 --> 00:07:14,464 of patients. I just I was trained to 209 00:07:14,464 --> 00:07:16,144 do surgery. I was trained to see patients. 210 00:07:16,144 --> 00:07:17,584 I was trained to treat them. I didn't 211 00:07:17,584 --> 00:07:19,264 wanna have to run a business. I didn't 212 00:07:19,264 --> 00:07:21,425 wanna have to hire and fire people. I 213 00:07:21,425 --> 00:07:23,490 didn't wanna do all that other stuff. So 214 00:07:23,490 --> 00:07:25,329 they, in essence, hit the easy button. They 215 00:07:25,329 --> 00:07:27,430 went to work, you know, for the hospital, 216 00:07:27,490 --> 00:07:29,250 and that's good. If that's what they wanted 217 00:07:29,250 --> 00:07:31,170 to do and that's what their passion is, 218 00:07:31,170 --> 00:07:33,250 that's a good thing. I think later on, 219 00:07:33,250 --> 00:07:34,930 they start to realize that some of their 220 00:07:34,930 --> 00:07:36,470 autonomy gets taken away, 221 00:07:37,410 --> 00:07:38,790 so it can be challenging. 222 00:07:39,314 --> 00:07:41,475 The other 70% that we talked to, this 223 00:07:41,475 --> 00:07:43,074 was the scary bunch. These were the people 224 00:07:43,074 --> 00:07:44,754 that you talked to that said, look. I 225 00:07:44,754 --> 00:07:46,995 would have really liked to or preferred to 226 00:07:46,995 --> 00:07:48,834 go into private practice when I got out 227 00:07:48,834 --> 00:07:49,974 of my training residency. 228 00:07:50,354 --> 00:07:51,794 But with the amount of debt that I 229 00:07:51,794 --> 00:07:53,334 had from my student loans 230 00:07:54,139 --> 00:07:55,439 and no work history, 231 00:07:56,060 --> 00:07:58,240 I couldn't afford to buy into the ambulatory 232 00:07:58,379 --> 00:08:00,699 surgery center and the private practice. I couldn't 233 00:08:00,699 --> 00:08:02,699 afford to buy into the PT and the 234 00:08:02,699 --> 00:08:03,439 other ancillaries, 235 00:08:04,060 --> 00:08:05,740 so I didn't feel I had any other 236 00:08:05,740 --> 00:08:08,240 choice. The deal that the hospital offered me, 237 00:08:08,345 --> 00:08:10,264 you know, was a better deal. And this 238 00:08:10,264 --> 00:08:12,185 is why we have so many doctors reaching 239 00:08:12,185 --> 00:08:12,685 burnout, 240 00:08:13,785 --> 00:08:16,025 and an unhappy point in their care of 241 00:08:16,025 --> 00:08:18,025 their patients and stuff is they took a 242 00:08:18,025 --> 00:08:20,345 position not because that was what their passion 243 00:08:20,345 --> 00:08:22,449 was and what was driving them. They took 244 00:08:22,449 --> 00:08:24,629 a position because they didn't feel they had 245 00:08:24,769 --> 00:08:26,529 any other choice, and and that's what I 246 00:08:26,529 --> 00:08:28,470 think we need to address in health care. 247 00:08:29,649 --> 00:08:31,970 Yeah. Marty, you're you're touching on something that 248 00:08:31,970 --> 00:08:33,809 we know just from our readers and what 249 00:08:33,809 --> 00:08:36,184 we hear at our our conferences and events 250 00:08:36,184 --> 00:08:38,584 is that physician autonomy is so crucial, not 251 00:08:38,584 --> 00:08:40,745 just to the physician's own happiness, but the 252 00:08:40,745 --> 00:08:43,964 way that they deliver care and their experiences 253 00:08:44,024 --> 00:08:45,245 with patients. So, 254 00:08:46,184 --> 00:08:48,184 yeah, I really appreciate you kind of painting 255 00:08:48,184 --> 00:08:50,639 that that landscape for our listeners. I think 256 00:08:50,639 --> 00:08:51,539 that's really helpful. 257 00:08:52,000 --> 00:08:54,240 And I wanna dig into just a few 258 00:08:54,240 --> 00:08:56,159 other business trends that I think would be 259 00:08:56,159 --> 00:08:58,019 great to get your perspective on. 260 00:08:58,399 --> 00:09:00,639 So we know that within about the last 261 00:09:00,639 --> 00:09:03,295 decade, the number of physician practices that are 262 00:09:03,295 --> 00:09:06,014 owned by private equity groups has jumped more 263 00:09:06,014 --> 00:09:06,754 than 600%, 264 00:09:07,535 --> 00:09:08,274 which is 265 00:09:08,975 --> 00:09:11,134 a jarring statistic. We do know there has 266 00:09:11,134 --> 00:09:12,894 been a bit of a slowdown in the 267 00:09:12,894 --> 00:09:16,100 last year, of private equity activity, but in 268 00:09:16,100 --> 00:09:18,820 any case, huge jump. And so we'd like 269 00:09:18,820 --> 00:09:20,120 to know based on your experience, 270 00:09:20,500 --> 00:09:23,240 how has private equity affected private practices? 271 00:09:23,699 --> 00:09:26,820 And what challenges or even opportunities do you 272 00:09:26,820 --> 00:09:27,480 see here? 273 00:09:28,074 --> 00:09:30,394 Yeah. And, again, I I don't think it's 274 00:09:30,394 --> 00:09:32,554 good to label something good or bad. I 275 00:09:32,554 --> 00:09:34,315 think you have to look at why. You 276 00:09:34,315 --> 00:09:37,214 know, ask why why what's driving that 600%, 277 00:09:37,995 --> 00:09:39,855 you know, drive and everything else? 278 00:09:40,789 --> 00:09:41,690 Private equity, 279 00:09:42,230 --> 00:09:43,909 there could be a role in a lot 280 00:09:43,909 --> 00:09:45,830 of different companies or a lot of different 281 00:09:45,830 --> 00:09:48,089 industries and stuff. I'm just not sure 282 00:09:48,470 --> 00:09:52,250 that private equity is right for MSK delivery 283 00:09:52,389 --> 00:09:53,804 with where we're at today. 284 00:09:54,205 --> 00:09:55,325 And and and I'll talk about that a 285 00:09:55,325 --> 00:09:58,125 little bit deeper in the reality that what 286 00:09:58,125 --> 00:09:59,825 private equity really does 287 00:10:00,284 --> 00:10:04,284 is they make money through efficiencies, through driving 288 00:10:04,284 --> 00:10:04,784 efficiencies. 289 00:10:05,485 --> 00:10:07,085 And I think one of the really big 290 00:10:07,085 --> 00:10:09,570 challenges that we're seeing and why you're seeing 291 00:10:09,570 --> 00:10:10,850 the drop off and I think the drop 292 00:10:10,850 --> 00:10:12,230 off's even gonna be higher, 293 00:10:12,690 --> 00:10:15,090 and accelerate almost as fast as it ramped 294 00:10:15,090 --> 00:10:17,250 up. I think it's gonna start to deteriorate 295 00:10:17,250 --> 00:10:18,930 and go out the other way. This is 296 00:10:18,930 --> 00:10:21,590 an industry that was already so efficient 297 00:10:22,194 --> 00:10:24,274 that it was almost frightening. When when I 298 00:10:24,274 --> 00:10:25,414 got into this industry, 299 00:10:25,875 --> 00:10:27,714 the giants, as they talk about at the 300 00:10:27,714 --> 00:10:29,554 meetings that we stand on the shoulders of, 301 00:10:29,554 --> 00:10:31,735 the John Insoles, the Engs, the Westmorelands, 302 00:10:32,194 --> 00:10:32,855 the Hungerfords, 303 00:10:33,954 --> 00:10:34,615 the Harris', 304 00:10:35,519 --> 00:10:39,279 These doctors did 80 to a 110 total 305 00:10:39,279 --> 00:10:40,420 joints a year, 306 00:10:41,120 --> 00:10:42,720 and they were able to make the money 307 00:10:42,720 --> 00:10:44,639 that they needed to make and practice medicine 308 00:10:44,639 --> 00:10:46,420 the way they wanted to practice it. 309 00:10:46,879 --> 00:10:49,120 Today, we have a gentleman out there that's 310 00:10:49,120 --> 00:10:52,254 talking about 12 by 12, doing 12 total 311 00:10:52,254 --> 00:10:53,715 joints by 12 o'clock, 312 00:10:54,335 --> 00:10:55,475 in the in the afternoon. 313 00:10:55,934 --> 00:10:58,014 And as with anything in business, there's a 314 00:10:58,014 --> 00:11:00,274 curve even with the technology and the efficiency 315 00:11:00,415 --> 00:11:03,054 curve. There is no doubt in my career, 316 00:11:03,054 --> 00:11:05,820 I was I've seen a transition from there 317 00:11:05,820 --> 00:11:08,139 was a point where the more that the 318 00:11:08,139 --> 00:11:10,540 physicians did of this procedure, the better the 319 00:11:10,540 --> 00:11:12,460 outcome and the better procedure came and the 320 00:11:12,460 --> 00:11:13,279 more efficient, 321 00:11:13,740 --> 00:11:16,139 things got. But with all things like that, 322 00:11:16,139 --> 00:11:17,980 there's also a point in that curve and 323 00:11:17,980 --> 00:11:19,120 a point in that time 324 00:11:19,485 --> 00:11:21,884 where efficiency can now start to bring. And 325 00:11:21,884 --> 00:11:24,284 when you start moving these surgeons from from 326 00:11:24,284 --> 00:11:26,764 a 110 joints a year to the middle 327 00:11:26,764 --> 00:11:29,105 of the road, surgeons now are doing 400 328 00:11:29,644 --> 00:11:30,464 to 650 329 00:11:30,845 --> 00:11:31,745 of these surgeons 330 00:11:32,129 --> 00:11:34,450 surgeries in a year, what happens is there's 331 00:11:34,450 --> 00:11:36,370 a point where something starts to break and 332 00:11:36,370 --> 00:11:39,190 you no longer gain benefits from that efficiency. 333 00:11:39,730 --> 00:11:41,570 Something breaks down on the other side of 334 00:11:41,570 --> 00:11:43,330 it, whether it's the quality of the outcome 335 00:11:43,330 --> 00:11:45,090 because you're doing too many of the same 336 00:11:45,090 --> 00:11:45,590 procedure 337 00:11:45,985 --> 00:11:47,985 or you start to lose the efficiencies of 338 00:11:47,985 --> 00:11:48,644 the cost. 339 00:11:49,105 --> 00:11:50,725 And I think if you look at why 340 00:11:50,945 --> 00:11:53,745 PE got into health care, PE got into 341 00:11:53,745 --> 00:11:55,825 health care because they saw an opportunity for 342 00:11:55,825 --> 00:11:56,325 profits. 343 00:11:56,785 --> 00:11:59,024 And as I said before, health care shouldn't 344 00:11:59,024 --> 00:12:00,004 be about profitability. 345 00:12:00,570 --> 00:12:02,410 Health care should be take be about taking 346 00:12:02,410 --> 00:12:04,649 care of a patient, you know, that that 347 00:12:04,649 --> 00:12:06,910 needs help and needs that assistance. 348 00:12:07,290 --> 00:12:10,090 So what's one of the challenges that PE 349 00:12:10,090 --> 00:12:12,170 is going to see is the fact that 350 00:12:12,170 --> 00:12:14,024 we've peaked that deal or they're trying to 351 00:12:14,024 --> 00:12:15,164 come into an industry 352 00:12:15,544 --> 00:12:16,605 that's so efficient 353 00:12:17,225 --> 00:12:19,865 in in the delivery of the actual product, 354 00:12:19,865 --> 00:12:22,284 the surgery to the patients, that the efficiencies 355 00:12:22,504 --> 00:12:25,225 have to come from taking away, taking away 356 00:12:25,225 --> 00:12:27,990 services, taking away, you know, staff on the 357 00:12:27,990 --> 00:12:29,990 inside, taking away something else. And one of 358 00:12:29,990 --> 00:12:31,669 the biggest things that are taken away that 359 00:12:31,669 --> 00:12:33,990 scares me the most, they're taking away the 360 00:12:33,990 --> 00:12:35,049 patient physician, 361 00:12:36,149 --> 00:12:39,429 relationship. We now hear the term provider used 362 00:12:39,429 --> 00:12:41,565 an awful lot, and there's actually people that 363 00:12:41,565 --> 00:12:43,904 would like provider and physician to be interchanged. 364 00:12:44,365 --> 00:12:46,445 And that's a really dangerous bad place. There's 365 00:12:46,445 --> 00:12:48,845 a reason the physician's a physician. There's a 366 00:12:48,845 --> 00:12:50,284 reason they go to the school that they 367 00:12:50,284 --> 00:12:52,125 go through, and they carry the licensure that 368 00:12:52,125 --> 00:12:54,600 they do. That's not to diminish what providers 369 00:12:54,600 --> 00:12:56,299 provide. Providers, PAs 370 00:12:57,240 --> 00:12:59,559 and nurses and scrub techs all provide a 371 00:12:59,559 --> 00:13:02,059 critical role. They're trying to make it homogeneous 372 00:13:02,200 --> 00:13:04,539 that they're all the same. They're just not. 373 00:13:04,600 --> 00:13:06,215 And within my career, one of the things 374 00:13:06,215 --> 00:13:07,254 that I saw and one of the things 375 00:13:07,254 --> 00:13:09,335 that this efficiency in the PE has really 376 00:13:09,335 --> 00:13:11,575 taken away from it is is that they 377 00:13:11,575 --> 00:13:13,975 now want a provider to preop the patient 378 00:13:13,975 --> 00:13:16,535 because the the doctor's making them money, making 379 00:13:16,535 --> 00:13:19,720 a hospital money and making PE money when 380 00:13:19,720 --> 00:13:21,799 they're putting a knife to skin. So they 381 00:13:21,799 --> 00:13:23,960 want the provider to see the patient and 382 00:13:23,960 --> 00:13:25,799 work them up before the surgery. They want 383 00:13:25,799 --> 00:13:28,360 the provider to see them post op after 384 00:13:28,360 --> 00:13:30,679 the surgery. And that's a really dangerous thing 385 00:13:30,679 --> 00:13:31,179 because 386 00:13:31,559 --> 00:13:33,000 a lot of these cases that I saw 387 00:13:33,000 --> 00:13:34,555 early on with these doctors, there was times 388 00:13:34,555 --> 00:13:36,254 that we would walk out of the OR, 389 00:13:36,315 --> 00:13:38,235 and we'd shake our head. Things didn't go 390 00:13:38,235 --> 00:13:39,675 as well as we wanted them to. It 391 00:13:39,675 --> 00:13:41,035 was a struggle. You know, it was a 392 00:13:41,035 --> 00:13:42,715 fight. And they'd go, oh my gosh. I 393 00:13:42,715 --> 00:13:44,555 hope that this goes well. And, man, I 394 00:13:44,555 --> 00:13:46,394 hope we didn't do any damage. I hope 395 00:13:46,394 --> 00:13:47,915 that this doesn't end up a revision. I 396 00:13:47,915 --> 00:13:49,935 mean, their passion in them, they really hurt. 397 00:13:50,289 --> 00:13:51,970 And it was that patient that 2 weeks 398 00:13:51,970 --> 00:13:53,490 later or a month later, they saw in 399 00:13:53,490 --> 00:13:55,410 their clinic, and it was that patient that 400 00:13:55,410 --> 00:13:57,490 hugged them and cried and said, you know, 401 00:13:57,490 --> 00:13:59,330 doctor, you gave me back my life. You 402 00:13:59,330 --> 00:13:59,830 know? 403 00:14:00,210 --> 00:14:01,809 I'm so happy. And the and the doctor 404 00:14:01,809 --> 00:14:03,169 was sitting there shaking their head going, oh 405 00:14:03,169 --> 00:14:05,250 my gosh. You know? If she's happy or 406 00:14:05,250 --> 00:14:07,195 he's happy, you know, what what are my 407 00:14:07,195 --> 00:14:09,215 other patients doing? We're taking that 408 00:14:09,835 --> 00:14:11,455 aspect of passion and 409 00:14:12,075 --> 00:14:13,455 and and and that part of the care 410 00:14:13,514 --> 00:14:15,215 away by just having these doctors 411 00:14:15,754 --> 00:14:18,394 operate every single day. I think the other 412 00:14:18,394 --> 00:14:20,315 challenge that PE is facing and the problem 413 00:14:20,315 --> 00:14:20,815 is 414 00:14:21,379 --> 00:14:23,220 our medical system is broke that if I, 415 00:14:23,220 --> 00:14:24,039 as an entrepreneur, 416 00:14:24,500 --> 00:14:27,059 build a company and I grow it from 417 00:14:27,059 --> 00:14:28,919 nothing to 10,000,000 or $20,000,000 418 00:14:30,019 --> 00:14:31,860 one of the bigger companies is gonna look 419 00:14:31,860 --> 00:14:33,875 at it because I've made an impact. And 420 00:14:33,875 --> 00:14:34,526 at the end of my career, I can 421 00:14:34,526 --> 00:14:35,523 sell my business. And if I'm doing 10,000,000 422 00:14:35,523 --> 00:14:38,115 in sales or 10,000,000 in in gross profits, 423 00:14:38,115 --> 00:14:39,794 I can sell that for 3x to 10x 424 00:14:39,794 --> 00:14:42,195 to one of these other companies, and that's 425 00:14:42,195 --> 00:14:43,654 part of my exit strategy. 426 00:14:47,240 --> 00:14:49,399 We have this terrible misnomer in the United 427 00:14:49,399 --> 00:14:51,559 States that physicians are rich because how much 428 00:14:51,559 --> 00:14:54,200 they're paid, and yet they're cut every single 429 00:14:54,200 --> 00:14:56,139 year. We've cut the physician's reimbursement, 430 00:14:56,600 --> 00:14:58,759 but the cost of health care is going 431 00:14:58,759 --> 00:15:01,404 up. Physicians make the money they make because 432 00:15:01,404 --> 00:15:03,644 of how hard they work, not how hard 433 00:15:03,644 --> 00:15:05,725 they pay. And then the second thing that 434 00:15:05,725 --> 00:15:07,004 hits them is they get to the end 435 00:15:07,004 --> 00:15:09,504 of their career, and there's no exit strategy. 436 00:15:09,565 --> 00:15:11,585 The day they can't see patients anymore, 437 00:15:11,889 --> 00:15:14,129 they can't make money, and nobody's gonna buy 438 00:15:14,129 --> 00:15:16,049 their practice from them because they're saying, look. 439 00:15:16,049 --> 00:15:18,610 This guy can't operate forever. They're gonna have 440 00:15:18,610 --> 00:15:20,529 to to drop out. I'll just pick up 441 00:15:20,529 --> 00:15:22,769 their patients when it comes out the other 442 00:15:22,769 --> 00:15:23,669 side. So 443 00:15:24,184 --> 00:15:26,664 PE tends to focus on those physicians that 444 00:15:26,664 --> 00:15:28,345 are late in their career that see a 445 00:15:28,345 --> 00:15:30,584 nice piece of money, a a means with 446 00:15:30,584 --> 00:15:32,345 which to sell out their practice and move 447 00:15:32,345 --> 00:15:33,245 into retirement. 448 00:15:33,705 --> 00:15:34,904 But for the people that are on the 449 00:15:34,904 --> 00:15:36,929 other end of the curve, PE may not 450 00:15:36,929 --> 00:15:39,009 provide the same value and the same solution. 451 00:15:39,009 --> 00:15:40,929 And I think alignment is a real challenge 452 00:15:40,929 --> 00:15:43,029 within our our industry and 453 00:15:43,409 --> 00:15:44,549 and and and physician satisfaction. 454 00:15:45,409 --> 00:15:48,230 So I don't know that PE is necessarily 455 00:15:48,370 --> 00:15:50,174 bad. I'm not gonna say PE is bad. 456 00:15:50,334 --> 00:15:52,575 I don't think PE is the solution for 457 00:15:52,575 --> 00:15:55,214 where this industry is at in its, in 458 00:15:55,214 --> 00:15:56,834 its maturity and its curve. 459 00:15:58,815 --> 00:16:01,375 I really appreciate the perspectives here, Marty. I 460 00:16:01,375 --> 00:16:03,480 feel like we almost need a multi part 461 00:16:03,480 --> 00:16:05,480 podcast episode to get into so many of 462 00:16:05,480 --> 00:16:07,240 those points that you addressed. I would love 463 00:16:07,240 --> 00:16:09,100 to come back. I agree. 464 00:16:10,039 --> 00:16:11,879 Yeah. But just wanna say I I really 465 00:16:11,879 --> 00:16:14,279 appreciate kind of this reframe on efficiency that 466 00:16:14,279 --> 00:16:16,600 you're bringing up here. I think in almost 467 00:16:16,600 --> 00:16:19,235 every podcast episode or or virtual panel that 468 00:16:19,235 --> 00:16:21,794 I've moderated lately, efficiency is coming up as, 469 00:16:21,794 --> 00:16:23,975 you know, a key topic area, something that 470 00:16:24,115 --> 00:16:26,035 hospitals and health systems really need right now 471 00:16:26,035 --> 00:16:28,535 to work with slimmer staffs, you know, 472 00:16:29,075 --> 00:16:30,914 respond to an increase in demand for care. 473 00:16:30,914 --> 00:16:33,069 But but it's interesting to consider, you know, 474 00:16:33,069 --> 00:16:35,230 when efficiency is pushed to a certain point 475 00:16:35,230 --> 00:16:37,250 on that curve like you like you mentioned, 476 00:16:38,029 --> 00:16:39,870 what's at stake and what has to be 477 00:16:39,870 --> 00:16:40,850 sacrificed. So, 478 00:16:41,470 --> 00:16:43,470 so, Marty, you know, considering all of the 479 00:16:43,470 --> 00:16:46,804 trends that that we've discussed, whether it's physician 480 00:16:47,105 --> 00:16:47,605 employment 481 00:16:48,225 --> 00:16:50,304 and where we're at with that, the status 482 00:16:50,304 --> 00:16:52,324 of PE investment in health care, 483 00:16:52,865 --> 00:16:55,424 what advice or best practices or even next 484 00:16:55,424 --> 00:16:58,225 steps would you recommend to ASCs and physician 485 00:16:58,225 --> 00:17:01,360 owners to really support and sustain their private 486 00:17:01,360 --> 00:17:01,860 practices? 487 00:17:03,120 --> 00:17:05,140 Yeah. So first of all, 488 00:17:05,599 --> 00:17:07,759 ASC owners and managers, the people that do 489 00:17:07,759 --> 00:17:08,660 that, you know, 490 00:17:09,119 --> 00:17:11,679 make sure that the physician and pay physician 491 00:17:11,679 --> 00:17:13,404 patient relationship is the focus, not profitability. If 492 00:17:13,404 --> 00:17:15,460 you if you do the right thing in 493 00:17:15,460 --> 00:17:16,620 health care, about taking care of the patients 494 00:17:16,620 --> 00:17:18,144 and stuff, money should take care of itself. 495 00:17:18,144 --> 00:17:19,825 If you if you start to focus too 496 00:17:19,825 --> 00:17:21,825 much on the money, you know, we give 497 00:17:21,825 --> 00:17:23,505 up what the real prayer the real principle 498 00:17:23,505 --> 00:17:25,525 of all this is, which is health care. 499 00:17:28,339 --> 00:17:30,580 For the physicians and stuff coming up today, 500 00:17:30,580 --> 00:17:32,099 you know, I I don't think you get 501 00:17:32,099 --> 00:17:33,240 caught up in the argument, 502 00:17:33,619 --> 00:17:35,960 you know, or the concern, you know, hospital 503 00:17:36,019 --> 00:17:37,240 employment versus, 504 00:17:38,099 --> 00:17:40,599 private practice, which is better, which is worse. 505 00:17:40,820 --> 00:17:42,974 It's a it's a personal answer to you. 506 00:17:43,454 --> 00:17:44,974 The thing that I found and learned with 507 00:17:44,974 --> 00:17:48,095 physicians is that it most physicians, it truly 508 00:17:48,095 --> 00:17:50,174 is a calling. It it's the passion that 509 00:17:50,174 --> 00:17:52,494 they have to provide, you know, care to 510 00:17:52,494 --> 00:17:53,154 the patients. 511 00:17:53,535 --> 00:17:55,294 So I think that the two things you 512 00:17:55,294 --> 00:17:57,315 have to do is follow your passion 513 00:17:57,750 --> 00:17:59,210 and then look for the culture 514 00:17:59,509 --> 00:18:00,730 that allows you 515 00:18:01,269 --> 00:18:03,750 to to follow your passion. If if hospital 516 00:18:03,750 --> 00:18:04,250 employment 517 00:18:04,950 --> 00:18:07,589 truly allows you to do what you believe 518 00:18:07,589 --> 00:18:09,589 is in the best interest of of your 519 00:18:09,589 --> 00:18:11,269 training and stuff and and and care of 520 00:18:11,269 --> 00:18:13,369 the patient, then find the hospital 521 00:18:13,694 --> 00:18:15,375 that has, you know, is going to give 522 00:18:15,375 --> 00:18:17,615 you at least the autonomy of the implants 523 00:18:17,615 --> 00:18:19,694 and stuff that they contract with or ones 524 00:18:19,694 --> 00:18:21,534 that you're comfortable with you use, that the 525 00:18:21,534 --> 00:18:23,694 staff that they provide you, that you have 526 00:18:23,694 --> 00:18:25,534 some touch point and stuff in their own. 527 00:18:25,534 --> 00:18:27,294 When we talk autonomy, it's such a big 528 00:18:27,294 --> 00:18:30,299 word. It's not just patient physician relationship. It's, 529 00:18:30,299 --> 00:18:32,220 you know, might doing a procedure with a 530 00:18:32,220 --> 00:18:34,220 with a nurse that was in a heart 531 00:18:34,220 --> 00:18:36,380 room an hour ago, and so I'm having 532 00:18:36,380 --> 00:18:38,539 to train the nurse or the scrub tech 533 00:18:38,539 --> 00:18:40,140 at the same time I'm trying to do, 534 00:18:40,140 --> 00:18:41,200 you know, my case. 535 00:18:42,005 --> 00:18:44,005 So if you're gonna go into the employment 536 00:18:44,005 --> 00:18:45,924 world, you know, follow your passion in that 537 00:18:45,924 --> 00:18:47,924 employment world and then look for those sorts 538 00:18:47,924 --> 00:18:49,945 of things. Make sure that they allow you, 539 00:18:50,085 --> 00:18:52,164 you know, the the autonomy of of treating 540 00:18:52,164 --> 00:18:54,505 the patient in the best manner with which, 541 00:18:54,565 --> 00:18:56,424 you know, you can treat that patient. 542 00:18:56,730 --> 00:18:58,410 And I think the same thing with with 543 00:18:58,410 --> 00:19:00,569 private practice. If you believe that private practice 544 00:19:00,569 --> 00:19:02,589 can take you, there's a lot of organizations, 545 00:19:03,609 --> 00:19:04,509 like myself, 546 00:19:04,890 --> 00:19:06,349 what we're doing here at PFBI 547 00:19:06,809 --> 00:19:09,369 and others. There are some really neat groups. 548 00:19:09,369 --> 00:19:12,255 For years, we've talked about how physicians traditionally 549 00:19:12,315 --> 00:19:14,634 aren't good business people, and I think that 550 00:19:14,634 --> 00:19:17,375 that's just wrong. Physicians weren't focused on business. 551 00:19:17,434 --> 00:19:19,994 They're they can be good business people if 552 00:19:19,994 --> 00:19:21,755 you want them to. And if you look 553 00:19:21,755 --> 00:19:23,910 around again, if you're gonna go into into 554 00:19:24,150 --> 00:19:24,970 private practice, 555 00:19:25,349 --> 00:19:26,869 make sure you find that culture. And there's 556 00:19:26,869 --> 00:19:28,789 some really strong I mean, we're seeing groups 557 00:19:28,789 --> 00:19:31,289 like Emerge Ortho and and and OrthoVirginia 558 00:19:31,750 --> 00:19:34,090 and CAO out of DC and OrthoIndy 559 00:19:34,630 --> 00:19:35,369 and OrthoCinci, 560 00:19:35,830 --> 00:19:38,549 DMOS. I mean, as these physicians are coming 561 00:19:38,549 --> 00:19:40,744 in groups, are coming together in their in 562 00:19:40,744 --> 00:19:43,464 their consolidation and what makes their consolidation difference 563 00:19:43,464 --> 00:19:46,664 is they're consolidating not to make more money. 564 00:19:46,664 --> 00:19:47,484 They're consolidating 565 00:19:47,785 --> 00:19:49,724 to stay in private practice. 566 00:19:50,105 --> 00:19:52,744 While PE and hospitals want doctors to make 567 00:19:52,744 --> 00:19:54,924 more money by seeing more patients, 568 00:19:55,559 --> 00:19:57,720 The value on private practice is if you 569 00:19:57,720 --> 00:19:59,079 get in with the right ones, you should 570 00:19:59,079 --> 00:20:00,599 be able to see the right amount of 571 00:20:00,599 --> 00:20:03,159 patients to provide the care that you want. 572 00:20:03,159 --> 00:20:05,179 And there's organizations now like PELTO, 573 00:20:05,799 --> 00:20:06,539 and Hopco, 574 00:20:07,159 --> 00:20:09,179 a lot of people that are focusing on, 575 00:20:09,355 --> 00:20:11,755 know, keeping physicians independent if that's what you 576 00:20:11,755 --> 00:20:12,255 want. 577 00:20:12,634 --> 00:20:13,994 And and I think that that's where we 578 00:20:13,994 --> 00:20:15,115 need to go. And I think that's the 579 00:20:15,115 --> 00:20:17,274 most important message to to health care right 580 00:20:17,274 --> 00:20:19,774 now. Competition is good. There shouldn't be one 581 00:20:19,914 --> 00:20:20,414 solution, 582 00:20:21,274 --> 00:20:23,434 for physicians to come out and treat patients, 583 00:20:23,434 --> 00:20:25,569 but there should only be one focus, and 584 00:20:25,569 --> 00:20:27,410 that focus should be the health care or 585 00:20:27,410 --> 00:20:28,630 the health of that patient. 586 00:20:29,410 --> 00:20:32,450 Mhmm. So well said, Marty, and really important 587 00:20:32,450 --> 00:20:35,329 considerations for our listeners about following their passions 588 00:20:35,329 --> 00:20:36,470 and looking for culture, 589 00:20:36,769 --> 00:20:38,565 workplace culture that can enable it. 590 00:20:39,204 --> 00:20:41,764 Again, really appreciate the time and and your 591 00:20:41,764 --> 00:20:44,565 insights today. Before we close our discussion, is 592 00:20:44,565 --> 00:20:46,565 there anything that you'd like to share with 593 00:20:46,565 --> 00:20:48,585 our listeners? Any final thoughts here? 594 00:20:49,044 --> 00:20:51,204 No. Just thanks to Becker's and and and 595 00:20:51,204 --> 00:20:53,019 and, you know, and all these doctors and 596 00:20:53,559 --> 00:20:54,059 stuff, 597 00:20:54,359 --> 00:20:55,373 get involved. You know, part of the problem, 598 00:20:55,373 --> 00:20:55,972 I think, that that that we've gotten the 599 00:20:55,972 --> 00:20:56,006 industry to where it is is because a 600 00:20:56,006 --> 00:20:56,039 lot of physicians, a lot of people in 601 00:20:56,039 --> 00:20:57,879 this industry just kept their head down and 602 00:20:57,879 --> 00:21:00,039 thought, you know, as long as I just 603 00:21:00,039 --> 00:21:02,220 work hard, as long as I do this, 604 00:21:04,894 --> 00:21:07,054 everything else will take care of itself. If 605 00:21:07,054 --> 00:21:08,654 you want a better environment to work in, 606 00:21:08,654 --> 00:21:10,174 better outcome and stuff for your patients, you 607 00:21:10,174 --> 00:21:12,095 know, get involved. In in in the Becker's 608 00:21:12,095 --> 00:21:14,434 meetings, there's a lot of really good meetings 609 00:21:15,054 --> 00:21:16,654 out there and stuff, but but you have 610 00:21:16,654 --> 00:21:18,014 to be involved. You can't sit on the 611 00:21:18,014 --> 00:21:19,634 sidelines and hope somebody else 612 00:21:20,269 --> 00:21:22,429 make sure life and your work environment a 613 00:21:22,429 --> 00:21:24,190 better place to work. You know? So 614 00:21:26,029 --> 00:21:28,589 Oh, Marty, thank you again. I've truly enjoyed 615 00:21:28,589 --> 00:21:30,990 talking to you today. Thanks again for making 616 00:21:30,990 --> 00:21:33,309 time for our podcast. I will see everybody 617 00:21:33,309 --> 00:21:34,049 in Chicago 618 00:21:34,525 --> 00:21:36,384 in the new at the next ASC meeting. 619 00:21:36,845 --> 00:21:39,184 Can't wait to see you there. And Alright. 620 00:21:39,964 --> 00:21:42,545 We'd also like to thank Physicians First Bancorp 621 00:21:42,605 --> 00:21:44,785 as well for sponsoring today's episode. 622 00:21:45,167 --> 00:21:47,087 So listeners, you can tune into more of 623 00:21:47,087 --> 00:21:50,367 our podcasts by visiting Becker's podcast page at 624 00:21:50,367 --> 00:21:50,867 beckershospitalreview.com.