1 00:00:00,240 --> 00:00:02,980 Looking for a solution that helps alleviate administrative 2 00:00:03,199 --> 00:00:05,599 tasks for your staff and also helps your 3 00:00:05,599 --> 00:00:07,599 patients cover their out of pocket health care 4 00:00:07,599 --> 00:00:08,099 expenses? 5 00:00:08,480 --> 00:00:11,199 Find what you're looking for from CareCredit because 6 00:00:11,199 --> 00:00:13,919 CareCredit is a credit card and more. It's 7 00:00:13,919 --> 00:00:16,375 a helping hand for staff and a flexible 8 00:00:16,375 --> 00:00:19,434 payment solution for patients. For over thirty years, 9 00:00:19,574 --> 00:00:22,934 CareCredit, a Synchrony solution, has offered patients a 10 00:00:22,934 --> 00:00:25,894 credit card with promotional financing options to get 11 00:00:25,894 --> 00:00:27,894 the care they want while helping staff do 12 00:00:27,894 --> 00:00:30,649 what they do best, provide care. To learn 13 00:00:30,649 --> 00:00:32,929 more, visit carecredit.com 14 00:00:32,929 --> 00:00:34,789 forward slash beckerspodcast. 15 00:00:35,570 --> 00:00:37,489 This is Gracelyn Keller with the Becker's Healthcare 16 00:00:37,489 --> 00:00:39,250 Podcast, and we are recording live at the 17 00:00:39,250 --> 00:00:42,070 thirty first annual business and operations of ASCs. 18 00:00:42,445 --> 00:00:44,844 I'm currently joined by Patrick Garman, who is 19 00:00:44,844 --> 00:00:47,884 the executive administrator at Spartan Health Surgis Center. 20 00:00:47,884 --> 00:00:49,965 So, Patrick, thanks for being here. To kick 21 00:00:49,965 --> 00:00:51,325 us off, can you please share a little 22 00:00:51,325 --> 00:00:52,765 bit about yourself and your work in the 23 00:00:52,765 --> 00:00:55,265 ASC space? Surely. Thank you for the invite. 24 00:00:56,020 --> 00:00:58,420 Spartan Health Surgis Center is in its twentieth 25 00:00:58,420 --> 00:01:01,079 year. We celebrated our twentieth year last September. 26 00:01:01,460 --> 00:01:03,880 We're a joint venture with a hospital partner, 27 00:01:04,260 --> 00:01:05,079 multi specialty 28 00:01:05,380 --> 00:01:05,880 facility, 29 00:01:06,340 --> 00:01:09,564 15,000 square feet, three ORs, two procedure rooms. 30 00:01:09,564 --> 00:01:11,265 We do a lot of GI, ophthalmology, 31 00:01:11,644 --> 00:01:13,024 pain management, and orthopedics. 32 00:01:14,045 --> 00:01:17,265 We're located in the Pittsburgh, Pennsylvania market, Southwest 33 00:01:17,325 --> 00:01:17,825 Pennsylvania. 34 00:01:19,004 --> 00:01:21,084 Wonderful. Well, thank you for taking the time. 35 00:01:21,325 --> 00:01:23,664 And let's start our conversation with the ASC 36 00:01:23,724 --> 00:01:26,280 market. In The US, it's projected to reach 37 00:01:26,280 --> 00:01:27,959 $60,800,000,000 38 00:01:27,959 --> 00:01:30,760 by 2030 and continues to experience strong year 39 00:01:30,760 --> 00:01:33,239 over year growth. From your perspective, what are 40 00:01:33,239 --> 00:01:35,560 the most significant trends in market forces driving 41 00:01:35,560 --> 00:01:37,879 this expansion, and how should ASC leaders be 42 00:01:37,879 --> 00:01:38,780 preparing today? 43 00:01:39,400 --> 00:01:39,900 Well, 44 00:01:40,495 --> 00:01:43,534 I think a lot of what's gonna propel 45 00:01:43,534 --> 00:01:45,234 this movement is physician choice, 46 00:01:46,415 --> 00:01:47,795 a a transient 47 00:01:48,094 --> 00:01:51,295 physician population. As the older physicians retire, the 48 00:01:51,295 --> 00:01:53,295 new newer, younger doctors are coming out of 49 00:01:53,295 --> 00:01:54,754 their fellowships and their residencies. 50 00:01:55,519 --> 00:01:57,759 Some of them are very entrepreneurial in spirit, 51 00:01:57,759 --> 00:01:59,039 which is a very good thing for the 52 00:01:59,039 --> 00:02:00,180 surgery center market. 53 00:02:01,280 --> 00:02:02,099 Every couple 54 00:02:02,479 --> 00:02:06,819 years, the, CMS Medicare model releases more procedures 55 00:02:07,515 --> 00:02:09,034 that can be done, allowed to be done 56 00:02:09,034 --> 00:02:11,354 in the outpatient setting that's providing some great 57 00:02:11,354 --> 00:02:12,814 opportunity for surgery centers. 58 00:02:13,194 --> 00:02:15,034 Twenty years ago, it was unheard of to 59 00:02:15,034 --> 00:02:17,194 be able to do orthopedic joints. Now my 60 00:02:17,194 --> 00:02:19,115 facility is doing them. A lot of facilities 61 00:02:19,115 --> 00:02:20,715 are being done. They're gonna be done safely 62 00:02:20,715 --> 00:02:23,520 and actually better. Now there's discussion about having 63 00:02:23,520 --> 00:02:25,840 cardiac procedures done in the surgery center setting, 64 00:02:25,840 --> 00:02:27,939 which is a phenomenal development and achievement. 65 00:02:28,400 --> 00:02:29,379 The cost savings, 66 00:02:30,080 --> 00:02:32,500 is very apparent. It's very transparent. 67 00:02:33,040 --> 00:02:35,694 Surgery centers have a role in saving the 68 00:02:35,694 --> 00:02:37,875 health care system billions of dollars a year. 69 00:02:38,335 --> 00:02:40,814 The efficiency model is pretty much was invented 70 00:02:40,814 --> 00:02:43,455 by surgery centers. If hospitals only would take 71 00:02:43,455 --> 00:02:45,534 the chance, the opportunity to look at how 72 00:02:45,534 --> 00:02:47,155 surgery centers run an efficient 73 00:02:47,455 --> 00:02:50,090 method, they would probably reduce their cost as 74 00:02:50,090 --> 00:02:50,590 well. 75 00:02:51,209 --> 00:02:51,709 So 76 00:02:52,330 --> 00:02:54,729 all surgery centers are for profit. Very, very 77 00:02:54,729 --> 00:02:56,650 few are not for profit. The majority of 78 00:02:56,650 --> 00:02:58,810 the acute care hospital settings in The United 79 00:02:58,810 --> 00:03:00,569 States are not for profit. So it's a 80 00:03:00,569 --> 00:03:01,469 totally different 81 00:03:01,849 --> 00:03:03,389 mind frame, a totally different 82 00:03:04,455 --> 00:03:05,354 established setup. 83 00:03:06,375 --> 00:03:06,875 Absolutely. 84 00:03:07,335 --> 00:03:09,895 And from AI and robotic surgeries to advanced 85 00:03:09,895 --> 00:03:10,955 DHR systems, 86 00:03:11,254 --> 00:03:13,495 technology remains both a make or break factor 87 00:03:13,495 --> 00:03:15,655 and a critical driver of ASC operations at 88 00:03:15,655 --> 00:03:17,800 scale. So how do you see deeper tech 89 00:03:17,800 --> 00:03:20,280 integration shaping the way ASCs deliver care and 90 00:03:20,280 --> 00:03:22,300 manage their business over the next few years? 91 00:03:23,319 --> 00:03:24,060 I think 92 00:03:24,439 --> 00:03:25,180 the technology 93 00:03:25,879 --> 00:03:27,879 that I've seen, for a long time, it 94 00:03:27,879 --> 00:03:30,439 was electronic medical records. Everyone's up to speed 95 00:03:30,840 --> 00:03:32,300 should be up to speed on that. 96 00:03:32,724 --> 00:03:35,764 Artificial intelligence. For the surgeon, it works one 97 00:03:35,764 --> 00:03:36,584 of two ways. 98 00:03:36,884 --> 00:03:37,705 It's an attractive 99 00:03:38,644 --> 00:03:39,625 marketing tool. 100 00:03:39,925 --> 00:03:42,164 It's it there's some glamour to it. It's 101 00:03:42,164 --> 00:03:43,064 terribly expensive. 102 00:03:44,245 --> 00:03:44,985 It is 103 00:03:46,669 --> 00:03:49,150 prohibitive and that it slows the the surgeon 104 00:03:49,150 --> 00:03:51,250 down. So if the surgeon values 105 00:03:52,030 --> 00:03:54,189 his or her time and they're efficient and 106 00:03:54,189 --> 00:03:55,729 they're they have great outcomes 107 00:03:56,349 --> 00:03:58,689 and they move with precision and speed, 108 00:03:59,205 --> 00:04:02,324 adding artificial intelligence or AI at that cost 109 00:04:02,324 --> 00:04:04,564 is actually gonna slow them down. That's a 110 00:04:04,564 --> 00:04:05,844 fact. Some of the, 111 00:04:06,405 --> 00:04:09,125 hospital settings or the large surgery centers that 112 00:04:09,125 --> 00:04:09,625 include 113 00:04:09,925 --> 00:04:12,025 AI, robotics, things like that, 114 00:04:12,789 --> 00:04:14,409 especially robotics and orthopedics. 115 00:04:14,870 --> 00:04:16,949 They're doing it because nobody else is doing 116 00:04:16,949 --> 00:04:18,949 it, and they're doing it because it's an 117 00:04:18,949 --> 00:04:19,449 attractive 118 00:04:20,149 --> 00:04:23,050 there's some traction. Some patients are saying, hey. 119 00:04:23,269 --> 00:04:25,509 I like this concept. I heard it's state 120 00:04:25,509 --> 00:04:26,870 of the art. It's a thing of the 121 00:04:26,870 --> 00:04:27,370 future. 122 00:04:27,724 --> 00:04:29,264 I'm gonna go to a doctor that 123 00:04:29,564 --> 00:04:31,024 engages with that technology. 124 00:04:31,485 --> 00:04:33,004 There's so there's the place for it right 125 00:04:33,004 --> 00:04:33,504 there. 126 00:04:33,805 --> 00:04:35,644 The flip side of that is it's time 127 00:04:35,644 --> 00:04:36,144 consuming. 128 00:04:37,004 --> 00:04:38,464 It slows the doctor down. 129 00:04:38,925 --> 00:04:40,144 It's not cost effective. 130 00:04:40,789 --> 00:04:42,389 So it's a it's kind of a happy 131 00:04:42,389 --> 00:04:45,029 medium. The rest of the technology coming across 132 00:04:45,029 --> 00:04:46,329 the table is gonna be 133 00:04:46,789 --> 00:04:48,410 from GI, from ophthalmology, 134 00:04:49,029 --> 00:04:49,529 gynecology, 135 00:04:50,470 --> 00:04:53,849 the whole spectrum. There's always advancements in medicine. 136 00:04:54,149 --> 00:04:56,569 There's always advances in pain relief. 137 00:04:57,084 --> 00:04:57,584 Orthopedics, 138 00:04:58,444 --> 00:05:00,845 especially, when you're having your shoulder, knee, or 139 00:05:00,845 --> 00:05:01,665 hip replaced, 140 00:05:02,044 --> 00:05:03,564 the patient is in a great deal of 141 00:05:03,564 --> 00:05:04,064 pain. 142 00:05:04,524 --> 00:05:08,044 That medication, that interventional pain relief is very 143 00:05:08,044 --> 00:05:08,544 critical. 144 00:05:09,165 --> 00:05:11,324 It's a difference between a successful outcome and 145 00:05:11,324 --> 00:05:13,110 a painful one. So So those are the 146 00:05:13,110 --> 00:05:15,110 kind of technology improvements that we need to 147 00:05:15,110 --> 00:05:16,330 watch, we need to enhance. 148 00:05:16,790 --> 00:05:18,790 And quite honestly, we'll let we'll let the 149 00:05:18,790 --> 00:05:20,629 vendors compete with one another who comes out 150 00:05:20,629 --> 00:05:22,629 with the best products. It's an exciting place 151 00:05:22,629 --> 00:05:25,209 for us to be at right now because 152 00:05:25,270 --> 00:05:26,089 all of the 153 00:05:27,064 --> 00:05:28,904 all all of the vendors, all of the 154 00:05:28,904 --> 00:05:30,985 the labs, all of the companies are all 155 00:05:30,985 --> 00:05:33,384 striving to be as good as they possibly 156 00:05:33,384 --> 00:05:36,425 can. They're always out offering the newest, latest 157 00:05:36,425 --> 00:05:36,925 platform, 158 00:05:38,105 --> 00:05:40,540 to trial. And, it's all it is, it 159 00:05:40,540 --> 00:05:42,699 just benefits us in the industry just to 160 00:05:42,699 --> 00:05:44,779 watch this technology unfold. It was on it 161 00:05:44,779 --> 00:05:46,540 wouldn't didn't happen forty years ago. It didn't 162 00:05:46,540 --> 00:05:48,220 happen twenty years ago. So every two to 163 00:05:48,220 --> 00:05:49,899 three years, it continues to happen. It's very 164 00:05:49,899 --> 00:05:51,740 exciting to see, and it helps our patients 165 00:05:51,740 --> 00:05:52,240 out. 166 00:05:52,764 --> 00:05:54,764 Some. And kind of a follow-up to that, 167 00:05:54,764 --> 00:05:56,305 I'd love to dig in a little deeper. 168 00:05:56,444 --> 00:05:59,324 Can you identify one specific technology or innovation 169 00:05:59,324 --> 00:06:01,504 that stands out to you as especially transformative? 170 00:06:02,285 --> 00:06:03,664 Well, to go from paper 171 00:06:04,800 --> 00:06:05,540 to electronics 172 00:06:06,160 --> 00:06:08,160 is very, very important. There was a lot 173 00:06:08,160 --> 00:06:10,160 of fight, a a lot of pushback from 174 00:06:10,160 --> 00:06:12,160 the doctors. They didn't wanna have to slow 175 00:06:12,160 --> 00:06:13,919 down. They didn't they'd rather whip the page 176 00:06:13,919 --> 00:06:15,519 and sign something, and they don't have to 177 00:06:15,519 --> 00:06:17,040 type up this laptop and do all this 178 00:06:17,040 --> 00:06:20,235 stuff. But physician offices led the way. Almost 179 00:06:20,235 --> 00:06:21,995 every physician office I know of, there's a 180 00:06:21,995 --> 00:06:24,074 laptop in the doctor's office, whether it's a 181 00:06:24,074 --> 00:06:25,375 pediatrician, a GP, 182 00:06:25,915 --> 00:06:27,615 orthopedic, neurology, whoever. 183 00:06:27,915 --> 00:06:28,415 That's 184 00:06:29,194 --> 00:06:31,675 way it's happening. The the the hospitals all 185 00:06:31,675 --> 00:06:34,975 have sophisticated electronical mac matter of hours now. 186 00:06:35,115 --> 00:06:38,259 So the paper chart to paper chart format 187 00:06:38,259 --> 00:06:40,020 is really a thing of the past. As 188 00:06:40,020 --> 00:06:41,939 far as other technology go, getting back to 189 00:06:41,939 --> 00:06:43,560 artificial intelligence and robotics, 190 00:06:44,020 --> 00:06:44,840 that's still 191 00:06:45,300 --> 00:06:48,100 finding its way. Because of its cost, because 192 00:06:48,100 --> 00:06:50,694 of its expense, it's finding its way. Not 193 00:06:50,694 --> 00:06:53,415 everyone's embraced it. Others have. So it's kinda 194 00:06:53,415 --> 00:06:54,154 fifty fifty. 195 00:06:54,615 --> 00:06:55,115 Absolutely. 196 00:06:55,895 --> 00:06:57,915 And with 60% of health systems, 197 00:06:58,935 --> 00:07:01,895 considering ASC joint ventures, and many ASCs are 198 00:07:01,895 --> 00:07:04,375 already partnering with systems in their communities, what 199 00:07:04,375 --> 00:07:06,759 opportunities do you see for collaboration, whether with 200 00:07:06,759 --> 00:07:09,160 providers or vendors, to strengthen patient care and 201 00:07:09,160 --> 00:07:10,139 operational efficiency? 202 00:07:11,400 --> 00:07:14,680 Forming a joint venture with either a hospital 203 00:07:14,680 --> 00:07:15,180 system 204 00:07:16,280 --> 00:07:17,740 or a management company 205 00:07:18,439 --> 00:07:20,139 has to fit the needs of the doctors. 206 00:07:20,794 --> 00:07:22,794 The doctors, the surgeons are the single most 207 00:07:22,794 --> 00:07:23,694 important component. 208 00:07:24,235 --> 00:07:25,294 Without the doctors 209 00:07:26,314 --> 00:07:27,294 writing the prescription 210 00:07:28,475 --> 00:07:31,134 or the order to have the surgery performed, 211 00:07:31,274 --> 00:07:33,194 whether it's an admission at the hospital or 212 00:07:33,194 --> 00:07:35,129 a procedure in a surgery center, That's where 213 00:07:35,129 --> 00:07:37,669 it starts. It's all centered around the doctor. 214 00:07:38,209 --> 00:07:39,889 My opinion, I've been in the field thirty 215 00:07:39,889 --> 00:07:41,509 five years, the doctors rule. 216 00:07:41,889 --> 00:07:42,870 So that's why 217 00:07:43,569 --> 00:07:45,430 hospital groups try to employ them. 218 00:07:46,050 --> 00:07:48,529 That's why surgery centers are were invented as 219 00:07:48,529 --> 00:07:50,310 a as an extension of physician, 220 00:07:50,904 --> 00:07:53,644 you know, practice and and, entrepreneurial 221 00:07:54,504 --> 00:07:55,404 spirit. So 222 00:07:56,425 --> 00:07:57,865 leave it up to the doctors. If the 223 00:07:57,865 --> 00:07:58,365 doctors 224 00:07:58,665 --> 00:07:59,485 want a collaboration, 225 00:08:00,024 --> 00:08:01,785 if they think it makes sense to partner 226 00:08:01,785 --> 00:08:05,000 with a management company to get enhanced insurance 227 00:08:05,060 --> 00:08:08,180 contracts or cost savings on purchasing supplies, things 228 00:08:08,180 --> 00:08:11,139 like that, a bigger, larger network, if it 229 00:08:11,139 --> 00:08:13,220 makes sense to partner with a local hospital 230 00:08:13,220 --> 00:08:15,699 because the hospital would would, you know, find 231 00:08:15,699 --> 00:08:17,779 a creative way to get them privileges and 232 00:08:17,779 --> 00:08:20,214 have them earn a stipend for doing inpatient 233 00:08:20,214 --> 00:08:22,134 care at the same hospital. There's all that 234 00:08:22,134 --> 00:08:23,735 stuff will play out, but it has to 235 00:08:23,735 --> 00:08:25,514 be focused to start on the doctor, 236 00:08:25,894 --> 00:08:28,055 whether it's a group of physicians, all aligned, 237 00:08:28,055 --> 00:08:29,595 or just an individual surgeon. 238 00:08:30,470 --> 00:08:32,070 And is there anything we didn't touch on 239 00:08:32,070 --> 00:08:33,750 or any final thoughts you'd like to share 240 00:08:33,750 --> 00:08:35,210 as we wrap up this conversation? 241 00:08:35,830 --> 00:08:36,330 Yes. 242 00:08:36,710 --> 00:08:38,009 It's a painful one. 243 00:08:38,549 --> 00:08:39,049 Anesthesia 244 00:08:40,870 --> 00:08:42,250 is becoming an unsustainable 245 00:08:42,950 --> 00:08:43,450 expense. 246 00:08:44,070 --> 00:08:44,570 Okay? 247 00:08:45,205 --> 00:08:47,365 Five, six years ago, pre COVID, it was 248 00:08:47,365 --> 00:08:49,044 not an issue that we really, really had 249 00:08:49,044 --> 00:08:50,745 to concern ourselves with. 250 00:08:51,205 --> 00:08:53,865 But, as in most professions, you have 251 00:08:54,325 --> 00:08:56,424 one segment of the population retire 252 00:08:56,804 --> 00:09:00,269 either replaced properly with enough volume or not. 253 00:09:00,590 --> 00:09:03,230 And so the cost of anesthesia continues to 254 00:09:03,230 --> 00:09:07,149 rise. That's also offset with declining reimbursements for 255 00:09:07,149 --> 00:09:07,649 anesthesia. 256 00:09:08,029 --> 00:09:09,009 For too long, 257 00:09:09,470 --> 00:09:09,970 anesthesiology 258 00:09:10,429 --> 00:09:12,190 as a profession was caught up in this 259 00:09:12,190 --> 00:09:14,290 battle between the physician, anesthesiologist, 260 00:09:14,670 --> 00:09:15,649 and the CRNA, 261 00:09:16,195 --> 00:09:20,615 sir certified registered nurse anesthetist. Okay? Both qualified 262 00:09:20,674 --> 00:09:23,794 in individuals. The majority of the procedures performed 263 00:09:23,794 --> 00:09:25,894 in the surgery center are performed by CRNAs, 264 00:09:26,674 --> 00:09:28,534 but they spent so much time feuding 265 00:09:29,049 --> 00:09:30,730 from state to state and around the country. 266 00:09:30,730 --> 00:09:32,009 They took their eye off the ball. They 267 00:09:32,009 --> 00:09:33,790 did not pay attention to their own reimbursement. 268 00:09:34,090 --> 00:09:36,750 So the anesthesia reimbursement continues to plummet 269 00:09:37,129 --> 00:09:39,290 while hospitals get increases every year, and the 270 00:09:39,290 --> 00:09:40,809 surgery center gets a little bit of a 271 00:09:40,809 --> 00:09:42,330 bump. Some of the doctors get a bump, 272 00:09:42,330 --> 00:09:44,269 some of them don't in the right direction. 273 00:09:44,735 --> 00:09:47,934 Anesthesia reimbursement continues to plummet. So now in 274 00:09:47,934 --> 00:09:50,495 order to sustain their costs and the expense 275 00:09:50,495 --> 00:09:51,154 of providing, 276 00:09:51,774 --> 00:09:53,855 you know, the necessary anesthesia so we could 277 00:09:53,855 --> 00:09:56,654 do surgery, we have to sustain that with 278 00:09:56,654 --> 00:09:57,235 a stipend, 279 00:09:57,710 --> 00:09:59,809 and sometimes it gets uncontrollable. 280 00:10:00,350 --> 00:10:02,750 That's a major issue. I've heard about it 281 00:10:02,750 --> 00:10:05,149 all day today from a variety of different 282 00:10:05,149 --> 00:10:08,210 settings. I don't remember discussing it this seriously 283 00:10:08,269 --> 00:10:09,870 before, and this I've been this is my 284 00:10:09,870 --> 00:10:12,110 twelfth straight year coming in June and October. 285 00:10:12,110 --> 00:10:14,565 I've never seen it reach a point where 286 00:10:14,565 --> 00:10:15,784 it's it's unsustainable 287 00:10:16,164 --> 00:10:16,664 concern. 288 00:10:17,205 --> 00:10:17,945 That's one. 289 00:10:18,804 --> 00:10:21,225 The paper payer reimbursement issues, 290 00:10:22,245 --> 00:10:24,965 yeah, everybody has revenue cycle challenges. We have 291 00:10:24,965 --> 00:10:26,485 to make sure that we're getting paid for 292 00:10:26,485 --> 00:10:28,970 what we do because whoever we buy supplies 293 00:10:28,970 --> 00:10:31,210 from sends us an invoice, and we're gonna 294 00:10:31,290 --> 00:10:32,970 they're gonna get paid regardless of what we 295 00:10:32,970 --> 00:10:35,129 get paid. That's an ongoing challenge for us. 296 00:10:35,129 --> 00:10:36,570 We have to make sure that we're doing 297 00:10:36,570 --> 00:10:37,710 a diligent job. 298 00:10:38,330 --> 00:10:39,690 And then it just like I said, leave 299 00:10:39,690 --> 00:10:41,290 it up to the doctors to figure out 300 00:10:41,290 --> 00:10:41,790 exactly 301 00:10:42,365 --> 00:10:43,884 how kinda what kind of a model they 302 00:10:43,884 --> 00:10:45,504 want. If they wanna be a solo, 303 00:10:45,804 --> 00:10:47,024 no partners necessary, 304 00:10:48,444 --> 00:10:51,004 employ good people, form their own governing board, 305 00:10:51,004 --> 00:10:53,024 that's fine. If they want a joint venture 306 00:10:53,084 --> 00:10:55,004 with a management company, of which there are 307 00:10:55,004 --> 00:10:57,480 several good prominent large ones around the country 308 00:10:57,559 --> 00:11:00,139 or a local regional hospital, that's fine too. 309 00:11:00,440 --> 00:11:00,940 So 310 00:11:01,320 --> 00:11:04,440 that determination will be made once, the people 311 00:11:04,440 --> 00:11:05,740 that are the true stakeholders, 312 00:11:06,360 --> 00:11:07,639 sit down at the table and figure out 313 00:11:07,639 --> 00:11:09,320 how they're gonna do with how they're gonna 314 00:11:09,320 --> 00:11:10,059 go forward. 315 00:11:10,795 --> 00:11:12,634 Absolutely. Well, Patrick, thank you so much for 316 00:11:12,634 --> 00:11:14,394 sharing these thoughts and insights today on the 317 00:11:14,394 --> 00:11:16,475 podcast. And joining me, again, we are recording 318 00:11:16,475 --> 00:11:18,394 live at the thirty first annual business and 319 00:11:18,394 --> 00:11:19,695 operations of ASCs. 320 00:11:20,154 --> 00:11:21,934 Thank thank you for having me.