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Imagine this. You're at the Hyatt Regency Chicago

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surrounded by the top minds in the ambulatory

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surgery center industry.

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Welcome to the Becker's 30th annual meeting, the

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business and operations of ASCs from October 30th

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to November 2nd

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2024. Picture the excitement as you collect business

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cards from over a 1000 executive level attendees

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forging priceless connections.

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Feel the buzz of conversations

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as you participate in more than 60 sessions

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led by over

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225 elite ASC speakers.

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Envision yourself gaining actionable insights on topics like

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private equity strategies,

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ASC business growth, and innovations in spine, orthopedics,

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GI, ophthalmology, and cardiology.

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Now imagine yourself listening to inspiring keynotes from

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Hall of Fame boxing world champion, Lila Ali,

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and professional basketball player, Caitlin Clark. Their stories

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will motivate you to take your business to

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new heights. You'll leave with a wealth of

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knowledge and a network of connections to help

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lead your ASC into the next year. Don't

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miss out. Get registered today. Visit beckershospitalreviewdot

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com and click on the events page to

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find the conference website. That's the beckershospitalreview.com

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events page. See you in Chicago.

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This is Alan Connan back at the Becker's

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podcast. I'm delighted to have back on the

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podcast

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Tammy Smittle, who is the CEO

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of Stonegate Surgery Center and chief nursing officer

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of Northwest Hills Surgical Hospital, both of which

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are located in Austin, Texas.

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Tammy, delighted to have you back on the

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podcast with us today. Before we dive into

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some questions, I'd love to hand it over

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to you just to hear a little bit

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more about your background and your dual role

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as CEO and CNO of those two facilities.

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It's it's an interesting role.

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So I'm happy to be back, first off.

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So thank you guys for inviting me. I've

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been a nurse for 28 years. My entire

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career has been in the perioperative world, so

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surgery has been my life for the last

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28 years. And so if you put me

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on the floor somewhere, I probably wouldn't know

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how to behave. Do love myself the the

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anything in the surgery related. So currently,

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I'm CEO of a surgical of a surgery

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ambulatory surgery center in South Austin, and then

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I'm interim CEO and then chief nursing officer

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of a surgical hospital,

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in North Austin. Both are owned by SCA

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Health, so it makes it pretty easy. But

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I spend about half my

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time, I've I've moved throughout the day. So

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I'm half of the day at Sungate and

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half of the day at North West Hills.

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Like I said, I've been a nurse for

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28 years. I've this is not my first

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time of being CEO of a hospital. I've

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done that two other times in my career,

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and I've also ran surgery centers.

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I took up my first surgery center in,

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2008,

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So that's where it started.

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So I've got extensive history in this and

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and feel like I've kinda got a grasp

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on all the comings and goings in the

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ASC world and the surgical hospital world.

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Yeah. Absolutely.

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And, you know, such a unique position you're

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in as well wearing many different hats, I

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imagine, on any given day, especially in that

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dual CEO and CNO role of those two

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facilities.

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Mhmm. Tammy, I'd love to dive right in.

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I think,

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specifically, when you're thinking about the ASC

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sector today,

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can you give us a little bit of

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insight into what are 2 or 3 trends

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that you're paying really close attention to,

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and why?

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Okay. And it I don't know if it's

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much changed over the last year, but I'm

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happy to share.

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Obviously,

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I'm watching for increased case volume and complexity

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of cases within the ASC market. Obviously, starting

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January 1 this year, we're able to do

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total shoulder

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replacements and and total reverse shoulder arthroplasty. So

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that's been a big win for ASCs, and

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it's been a really big win for Stonegate

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Surgery Center. I picked up a bunch of

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surgeons actually that are performing these cases with

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us. So

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complexity of cases,

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is definitely the one thing that I'm watching.

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The second thing that is kind of I'm

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watching and interesting to me is kind of

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the expansion on the value based health care

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and kind of the incentives that insurance companies

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are creating for high quality cost effective care.

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And it's interesting because

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this is something I see in my dual

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role is, like, Medicare has the comprehensive joint

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replacement program within

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the hospitals and the surgical hospitals, and that's

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been in place

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for years. I I think it started maybe

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in 2010,

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but it still hasn't picked up in the

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ASC market, which it incentivizes

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the facility to keep costs cheap. And no

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one does that better than us in the

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ASC market. So it's really been surprising to

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me that that hasn't

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gone across to the ASC market yet, but

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I'm anxious to see where that goes. And

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then working with in with, employers directly to

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see,

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like,

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big systems in this town, like, with our

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HEB grocery stores. Can we work with them

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directly to take care of those patients and,

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you know, those that have that that pay

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for their work comp directly or their insurance

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directly, so the self funded care. So it's

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been interesting to to watch that and see

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how that's grown over the last year or

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2. And and the third thing, I don't

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completely think it's a positive thing, but I'm

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watching the consolidation and mergers amongst

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ASC markets and the hospital systems that see

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the need to own an ASCs.

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So it's been interesting to watch

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independent centers

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learn that they it's hard to stay independent

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these days. You just have to

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partner up with a big hospital system for

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insurance contracts. And we did it at Stonegate,

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and it was a game changer.

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We partnered with Ascension Health. So it it

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was a game changer as far as our

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payer contracts go. So that's the third thing

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that I'm really trying to keep my eye

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on.

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Yeah. Yeah. Fascinating. I gotta get your perspective

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on bird's eye view there in terms of,

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like you said, the increased case volume, case

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complexity,

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specifically in relation to total shoulder and the

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ASCs,

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a little bit on body based care and

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and direct to employer models.

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And then I wanted to just follow-up on

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your your 3rd point there in terms of

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consolidation. It's, you know, something we've seen across

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the board, across the country,

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with hospitals, with health systems, with ASCs.

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Can you give us a little bit of

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insight into

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how how consolidation is affecting,

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competition in your market and kinda how you

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see that evolving over the coming years?

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So it's it's interesting.

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And I don't know

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I guess, obviously, with ASC,

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the majority of us, if not all of

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us, are physician owned. So the best thing

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everybody wants to make

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make more money for doing the same amount

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of work or you where you wanna smart

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work smarter and not harder. So, you know,

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if you have just straight up Medicare based,

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you know, contracts with insurance payers, you have

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to do

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one and a half times and twice amount

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of work in order to get the same

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reimbursement

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that I'm getting with some of my commercial

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contracts now partnering with the big system.

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And, obviously, you get more business in the

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door if you're doing distributions. Like, these doctors

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talk. So if we're doing distributions,

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then it's just much easier to get distributions

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out the door with good payer contracts. Obviously,

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that's a no brainer. So I I think

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that

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that that's the piece

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that you just kinda have to have these

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days. It's, I worked for an independent group

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before

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that we were negotiating our own contracts,

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and it's it's tough. It is a tough

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market. It's it's tough to even get a

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response to an email sometimes with some of

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the big commercial payers just because we're not

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high on their food chain. So,

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it's just a much easier to get their

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attention, and it it doesn't always work fast.

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And you guys, everyone that is in this

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business understands that the insurance

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it it works slow.

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Getting them built into the system gets is

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slow. But it's just hard to make make

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it work independently

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without having a big partner. I I'm not

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saying you can't do it. You can. This

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volume has to be higher.

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Mhmm. Yeah. Totally makes sense. And, Tammy, I

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wanted to follow-up with you. I know that

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one key area that a lot of ASC

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leaders are focusing on,

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focusing

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on, and I believe yourself as well in

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a recent, article with backers, is leadership training.

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When we think about the next the next

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generation of leaders coming through, can you give

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a little bit of insight into why you

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think that's

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so important and it's such a key investment

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area for for for many ASCs right now?

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Huge.

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So a couple of things. I feel like

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regardless of how

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great patient care you do, if you have

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that culture in your center, the doctors are

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not gonna be happy. And I'm from a

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strict belief that if the surgeons are happy

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and the staff is happy, and if staff

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is happy, patients are happy.

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So you just have to have a good

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culture. You have one bad and everyone has

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heard the one bad apple.

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It's so true in a small setting like

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an ambulatory surgery center. Then the cost. This

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is sheer cost of turnover, especially amongst leaders.

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It it's 1,000 and 1,000 of dollars per

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employee. So you put in you you put

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in the effort. A, it starts at the

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beginning. Right? Hiring the right people. You have

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to have someone who has the right fit

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with the right mentality for the culture.

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And I just it's I can't

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impress enough on how important culture is within

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these centers.

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So with SCA Health, they do a great

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job. They call it fleet a facility leader,

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onboarding. So it's,

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it's called Flow.

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They take this the new

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the new manager out of the center for

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a week. They they fly them to wherever

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is closest for SCA. For us, it's in

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Dallas, and they do nothing but 3 days

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of just drinking the Kool Aid. Right? Like,

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this is how SCA operates. This is why

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your voice is important. This is why you

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always get to have you know, you have

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a say in how this facility runs. So

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it's I think it's it's a it's cheaper

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for us to invest in our new leaders

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to teach them how to be a leader

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than to just keep hiring new leaders and

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the cost it is on onboarding them.

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It is it is crucial.

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And doctors hate change. They hate change. I

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I I have not met one surgeon that

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enjoys change. So if they have the same

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people that they can trust and they know

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they put their favorite scrub sack in the

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room every time, Or if they're having a

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bad day or we screwed up some, which

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happens. Like, they feel comfortable enough to call

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me or call the OR manager and be

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like, hey, bro. What were you thinking? So

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it's those relationships that if you have a

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new person in there, those doctors are gonna

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get up and move their cases somewhere else.

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Mhmm. Yeah. Yeah. It's such a big challenge

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across the health care spectrum. We're fascinated to

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kinda hear your perspective there, and I'm sure

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why many ASC leaders and listeners listen to

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this will also find that so so important,

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critical to the future as well.

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I wanted to

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get away from what we talked about, some

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of the challenges, some of the trends that

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you're focusing on at the moment.

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Wanted to flip the script a little bit

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in here about what what are you most

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excited about when you think about the future

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of health care?

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So I try there's some cool things. And

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and it also

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it also I I'm excited about neuromodulation within

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the orthopedic market, and let me explain why.

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I don't know if you've ever tried to

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recruit a surgeon, but it's not easy. It's

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it's a lot of work. It's a lot

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of work to get them in the door.

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So then it's I try to build the

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business of the the surgeons that are already

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in my in my door.

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So and it also creates stickiness, right, where

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they come to you for other things. So

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this is all just relationship enhancing.

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So

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one of my doctors and we were the

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1st surgery center in the state of Texas

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to do, peripheral nerve stems by an orthopedist,

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and an ASC was done at Stonegate.

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So,

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and now I have 5 orthopedic surgeons that

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are performing these cases, and it's for patients

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that have painful knees after total knees.

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It's 6 months post op total knees that

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are still having chronic pain or patients that

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BMI is too high or their a one

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c is too high in order to have

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a total joint replacement. This is stuff this

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is a procedure that can be done. It's

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a quick procedure that can be done and

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give pain relief so then patients can lose

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the weight or can get their, you know,

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their diabetes under control.

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So this has also created

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an outlet for my orthopedic surgeons that did

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not know what to do with their patients

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that continued to have. They have good movement.

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They have,

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they have good results from their chronic for

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their pay or for their total knee or

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their total shoulder,

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but they just still have pain. So this

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is an outlet for my orthopedic surgeons to

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to have another option for their for their

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patients. And this procedure has worked great.

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We've done a few cadaver labs, and I

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do it as much as I can to

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get my other orthopods in there. And anyone

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that's new starts with me, I tell them

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about this. It's a great procedure for the

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for the surgery center, and it's an excellent

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procedure for these patients. And it's creating pain

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free results.

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I also think that this could build the

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total joint replacement for the alternative knee. So

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if you're don't hurt after your first total

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knee, what's the likelihood of that patient coming

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back? If they're bone on bone on one

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knee, there's pretty high likelihood they're bone on

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bone on the other. So this has created

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some great options to keep patients in the

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yeah. Keep patients in the door, not have

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to refer them out, not ghosting them because

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they don't know what to do with them

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anymore.

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And then maybe even getting them back for

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the the other side for their total joint.

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Mhmm. Yeah. The neuromodulation

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in the orthopedic market, certainly an area of

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growth there. Earlier on in a conversation, you

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mentioned about recruiting some surgeons who are also

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performing outpatient total shoulder arthroplasty.

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Yeah. Can you give me a sense of

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when you're looking ahead, 12 to 24 months

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out, what are the other key areas of

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growth that you're focusing on?

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So I feel like you pick one thing

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and kinda do it better than anybody else.

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And I really believe that we do the

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orthopedic

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market in Austin better than anybody else, but

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it goes back to having great culture and

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a great team that hustles. And I mop

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floors and take out trash. Everyone mops floors

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and takes out trash there.

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So if you just put a hustle in

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there and you become partners with that physician,

387
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it's easy these guys talk,

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and it's easy to get the word out

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that your center is doing it better than

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anybody else. And as far as the growth

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has been, you know, volume brings volume. I

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I don't know if you I don't know

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what exactly what happens because you think some

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of these doctors don't wanna go where it's

395
00:14:17,779 --> 00:14:20,100
busy, but that's kind of the opposite. They

396
00:14:20,100 --> 00:14:21,779
wanna go where these other guys are going

397
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that because, you know, if these difficult guys

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come into Stonegate and they're having a great

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experience, then, man, my case, it'll be easy

400
00:14:29,034 --> 00:14:31,454
there. So it's it's

401
00:14:31,914 --> 00:14:34,554
word-of-mouth, and Austin is a competitive market. You

402
00:14:34,554 --> 00:14:35,615
have to work hard.

403
00:14:36,289 --> 00:14:38,049
I'm gonna say that the team at Stonegate

404
00:14:38,049 --> 00:14:40,209
works harder than anybody else in town as

405
00:14:40,209 --> 00:14:40,709
to

406
00:14:41,009 --> 00:14:43,509
making sure our surgeons are happy and and

407
00:14:43,889 --> 00:14:46,690
they're part of the team. Totally. Tammy, a

408
00:14:46,690 --> 00:14:49,009
pleasure having you back on the podcast again

409
00:14:49,009 --> 00:14:50,850
and hear about all the fantastic work you're

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00:14:50,850 --> 00:14:51,195
doing.

411
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Really, really enjoyed this conversation. Really can't wait

412
00:14:54,235 --> 00:14:55,754
to pick pick back up with you again

413
00:14:55,754 --> 00:14:58,075
next next year, hopefully. Thank you, Tammy. Yeah.

414
00:14:58,075 --> 00:14:59,375
Sounds great. Thank you.