So guys, we'll get started in just a minute. We got put up against complex total ankle and flat foot. So obviously, as moderator, I don't really rate very high apparently, but we'll get there. I will challenge the people in the complex total ankle course that this symposium will be much more pertinent to their take-home compensation than doing a complex total ankle revision will. But they'll figure that out the hard way, I would imagine. So let's get started. So welcome to Charlotte. I'm Bruce Cohen. I live here. And hopefully you guys will enjoy it here. We're not in Vancouver. I guess you figured that out. We're here in Charlotte. I had no part of that decision, well, maybe a little part of it. But hopefully you guys will enjoy it. So every year or every time we do a membership survey, probably the number one things on the survey, it's almost number one every single time of what people want to hear about is practice management. And so we're trying to be responsive both through our practice management committee as well as through stuff like this to really give people the opportunity to hear what's going on, because this is really important. And so obviously, as you'll hear, it's very important to me for many different ways. But we put together a really expert panel here to talk about all different facets of practice management and even dealing with people. And so we'll talk about that. So I want to give you a very depressing update on health care in the United States. And every day I waited to write this paper, health care got worse. So let's start with my disclosures. So I serve, as well as being a foot and ankle surgeon, I'm also CEO of a really large independent musculoskeletal practice. And this is almost every second of my life on top of my practice in dealing with what's going on in health care. I'm a board member of the OrthoForum, which is a large organization, a benchmarking organization of 100 of the largest independent orthopedic groups in the country. I'm also a former board member of a large hospital system, CIN and ACO. I'm also vice chairman of the Musculoskeletal Institute here in Charlotte with one of the largest non-for-profit hospital systems in the country that makes $600 million a year of profit, but they don't pay any taxes. That's a different story. And then I spend way too much worrying about the future of health care because we're in trouble, guys. So I have a whole team at OrthoCarolina that works with me on this. I have a chief quality officer and vice president of value-based care, as well as a close friend who RJ's worked with as well, Nate Kaufman, who if you ever get a chance to hear this guy speak, he's a consultant, he's awesome. And so I credit him on a lot of the skepticism and some of the doom and gloom you're going to hear. It's not all bad, but a lot of it is. So Houston, we have a problem. Health care costs are astronomically going to be untenable in the future. And if you look at spending of everything else, everything else is relatively flat and health care continues to go up. This doesn't even include this small thing called COVID that we just went through and apparently it isn't done. This can't go on forever. And so the projection is $5.7 trillion by 2026, which is just an unbelievable number. I run a large business that has 1,800 employees and a huge chunk of our revenue goes just to pay health care. And every year we try to save on health care and every year our costs go up. So this isn't about politics. And so there's not, as conservative Ken Ellington walks into the room, health care is not about politics and it's a problem for both sides, whether you're liberal or conservative. It's unsustainable and it cannot continue. And we can't go back. This isn't about, we're not going to talk about Medicare for all and things like that. It doesn't matter. It's an unsustainable system. So 17% of the gross domestic product in the United States is health care. It finally leveled out, but it's still $0.17 on every dollar in the United States is spent on health care. That is unbelievable. So the question is, how well do we do? Because we've got such an expensive health care system, but we have the life expectancy of Cuba, par with Cuba. And so unfortunately, our international friends and colleagues aren't here in the room because they couldn't get in the country. But their health care quality is better than ours, which is really embarrassing to say as much as we spend on it. And so if you look at where we are in that graph compared to France, Germany, Switzerland, and others, we should be embarrassed. But it's a problem. And so where's it rising? The administrative costs, the administrative burden on the insurance side is out of control. Big pharma, it's going up. Physician-related services, going up. Everybody's trying to cash out and monetize on it because it can't go up anymore. Hospitals, I mean, it's going up 5%. I'll get to COVID-related effects that we're feeling right now. Employment costs in the United States for health care are out the roof. For my organization, we have 100 open positions right now, and everybody wants a 20% increase. But I'm not going to get paid anymore. None of us are going to get paid anymore for what we do. So the cost of delivering that care just went up without an increase in reimbursement. So where does the money go? This is the shift that you see in the blue from the expensive inpatient setting to the more cost-effective outpatient setting. So we are positioned well in orthopedics because we can do so much outside of the expense of hospitals. Imaging. Imaging is in the crosshairs. Imaging and PT, don't kid yourself. We're making big checks on imaging and PT. Don't spend it all in one place because it's going to go down. And so the payers know it. The payers are going for those low-cost imaging centers. They're not allowing hospitals to charge two and three times what an outpatient imaging center does. Same thing with PT. If we look at surgery, surgery is the bright spot for us as foot and ankle docs, as orthopedists, we can control our destiny a bit here in ambulatory surgery centers and low-cost facilities outside of the expense of high-cost facilities. Now everybody's following us. They're following us with metrics they're creating that we have no input with. And so this is really dangerous here. And so as providers, you don't know, but you're being tiered based on your performance. Your performance has nothing to do with what we would consider in the total ankle room as great outcomes. It's about cost. They don't care about quality, it's about cost. We had a meeting with this company called Roadmap that Blue Cross Blue Shield of North Carolina hired to do this tiering. And they presented this in a room full of people in our CIN, and they singled out orthopedics and they said, these three doctors are the highest quality orthopedists. They're all three from my group. One was unfortunately had died, so he was low-cost. And the other two were non-operative. But it was garbage data. And that's the problem, is if the data's garbage and we don't have control over it, it's going to affect us. So we have to get involved. And this is kind of my passionate plea. I have a meeting coming up with the guy who runs healthcare for Walmart in a couple weeks. And he basically said, well, the data we have is the best out there. So if you can give us better data, we'll act on it. But right now, we're just acting on what we can get. And so if the data's garbage, they make decisions based on this. So what are the commercial payers using? I mean, do they care in hip and knee what a who's and who's score is? They don't even know what they are. They care about cost. They care about complications that cost money. They don't really care that much about getting people back to work. It's all about the dollar. So Warren Buffett, healthcare is the hungry tapeworm of corporate America. And it's out of control. But if you look at the companies, the companies care. So Marcus Osborne, he's the guy I'm going to meet with in a few weeks. And he spoke at the Ortho Forum meeting. He said, Walmart's not going to stand for this anymore. They created this center of excellence model, and they didn't do very well with that. Now they're creating Walmart healthcare. And they're going to have these hubs of healthcare so they can control it. Because look at the healthcare spent for Walmart, which is, you know, and we have a few people from Arkansas here who definitely know this, $4 billion in healthcare. But they think they can save, you know, $2, $3 billion. They went with the center of excellence approach, and what they deemed was about half the surgeries were inappropriate. Didn't even meet indications to be done. 90% of the spine surgeries were inappropriate. Now that's them, but some of us probably wouldn't disagree with that too much. Cancer diagnoses are incorrect apparently, but except I have the lowest producing spine center in the world, I think. So I think all of their spine surgeries are appropriate because they don't do very many of them, and I just can't figure it out. Fifty percent or more of the cancer diagnosis and plans, treatment plans, were revised once they went through a process. So the reality is that consumers are demanding the change. Standard fee-for-service is dying. So we are not going to get a contract that pays us more for fee-for-service for the rest of our lives. It's not going to happen. There's going to be other ways to capture that, and you've got to get involved. The payers will continue to decrease our professional fees. Our costs aren't going down, but our professional fees are going to. We need to be able to be incentivized, and we're going to have to take risks to do it. We're going to have to participate in programs to do it, and if we sit back and just try to live in these fee-for-service worlds, some geographic areas will adopt it quicker, sooner than others, but it's going to happen everywhere. Those who can own and manage the risk are the ones that are going to do well. Okay, so this is probably the guys in the total ankle room. I just want to be a doctor. I don't care about business. I don't want to get an MBA. I just don't care about it, but we're not going to be immune to it. Hospitals are going to struggle, so it's going to affect the people in hospital employment. We're going to have a debate on independent practice versus hospital employment. Nobody's immune to it. If hospitals make less money, trust me, what are they going to do? They're going to lower comp. Universities are going to struggle. They already are. Right now, the worst job in America is to be a hospital CFO. Your revenues are going down, increased competition, this thing called COVID, and the labor costs are skyrocketing. Scrub techs are getting $65 an hour as travelers and up to $100 an hour for a scrub tech. How are we going to do that? Hospitals are full, not so much because COVID, COVID is causing that. They're full because we don't have staff. People are leaving healthcare, nurses, medical assistants. They're leaving healthcare and they're going to work for Amazon and Target and Chick-fil-A because they can make more money and they can be treated better than they are in healthcare. I don't know if they're coming back. Where's the money going to come from? Is it going to come from hospital administrators? I purposely don't wear a tie for these meetings because my image of people who wear suits and ties are hospital administrators, so I try to prove that I'm a physician by not wearing a tie, but most of my panel has ties on. It's going to come from the employees and the providers. Business owner 101, pandemics suck. We've proven that. Decreased revenue, increased costs, uncertainty, running a business with a ton of employees and a lot of you guys are in independent practice, it was pretty uncertain last year. Last spring, were we going to get paid? I had one of my shareholders, who's an owner of the business, I had to remind her of that, ask if she could go on unemployment. I said, no, first of all, the payment's not going to really substitute for your monthly draw, but no, you actually own this business. You can't claim unemployment, but a lot of physicians just want to come to work and let somebody figure this out, but if you're in a practice, you're an owner. You own that business whether you want to or not. Maybe that'll change in the future, but I don't think this is going to get better for many years. The pandemic's not going away, the labor costs aren't going down, the reimbursement's not going up unless you start doing things like value-based care that we'll talk about in a second. We look at staffing crisis, the cost of goods, cost of everything's high. Benefits are more costly and the reimbursement's dropping, so we've got to do something different. The need for change has accelerated. It was coming anyways, but COVID accelerated it. It exposed gaps in our system. It proved that we will never be able to do a single-payer system. We're not set up for it, and we proved it. We can't do tests. This new plan that everybody's got to be vaccinated, and if not, you've got to be tested, so how in the world are we going to test 60 million people once a week? I can't even get a test if I want one for one person, 60 million people, or else they can't come back to work. We aren't set up in the United States to do it. We had to outsource it to Walgreens and CVS to deliver vaccines and to do tests because the government couldn't do it. They wanted the hospitals to do it, but the hospitals actually were taking care of sick people who were dying. It's really proven that our system is really broken and has no infrastructure to implement anything. The good news is musculoskeletal care is going to get better because of COVID. Some communities, the transition to the low-cost care and the ASCs and things like that was really good. My community, we have really large hospitals. If you go around, there's hospitals everywhere here, and they make tons of money. Up until COVID, patients say, do I really need to have that knee scope or my bunion in the surgery center? I want to go to the hospital. Hospitals are clean and good, and that's where good care and good anesthesia. Now they're like, do not bring me to the hospital. That's where people die. That's where it's a lot more expensive. I don't want to go there. It's never going back. This has turbocharged what was happening across the country. The projection, I know it doesn't mean much to us in this room, but it does to me running a large group. They're predicting by 2024, 80% of primary total joints will be done in an ASC. If you have an opportunity to own an ASC that they're doing joints in, buy in now because it's going to be really, really valuable. If you think about how much the hospitals are going to lose that, how much money will come back into the healthcare system, musculoskeletal practices are really, really going to have an opportunity to make all the negative things I said get better. We're positioned pretty nicely. It's not going to go back to where people would say, I'd like to pay three times more for my healthcare in a hospital next to a patient with COVID. They're not going to say that. I think we have a huge opportunity in orthopedics, but we need to change how we think about it. Even if you say, I don't want to know about this. I just want to work and take care of people. Somebody around you needs to care about this and do it. We are in a consumer business now. We need to embrace value-based care because that's the only way we're going to get more out of this system. Really won't go through the slide, but basically what it proved is alternative uses of healthcare, telehealth, all these other things are here to stay and we need to figure it out. Primary care has figured it out. Orthopedics, we're still saying, I've got to touch a patient. I really have to examine them. I think we need to figure out how to leverage technology because building bigger offices and we were going to build a brand new $50 million 10-story new headquarters for all our subspecialty centers. We put it on an indefinite hold because I don't want to spend that kind of money on offices because I don't know what the office of the future looks like. Are we going to be doing a lot of our follow-ups by telehealth? Are we going to be doing it out in the periphery and things like that? I think it's all going to change, but back to the original problem in healthcare, despite all the COVID-related changes, it's all about the money. It's a payer-run system. It's not a physician or provider-run system. The payers just care about the cost. They're going to track metrics. I already talked about it. They're going to use it as a gate to reduce costs. Traditionally, I'll go through how it was done, how it's being done now, and where it needs to go, but do they really care about quality? Their perspective was, initially, it was all about controlling utilization. Once they found that they were denying care, and people just weren't doing well, and there was pressure on fee-for-service, then, currently, everything's going to go down from a cost, at least in our space, because of this inpatient to outpatient conversion. The reality is, for us to be able to capitalize this in the future, we've got to get into risk, and we've got to go at risk. Our old system doesn't really make sense. No industry do you get paid extra for your complications. You do a really bad job, you get paid again, and oftentimes, you get paid more the second time. When the plumber comes to your house and they screw it up and the pipe and the connection falls apart and it floods your house. Do you pay them extra to come back and fix it? No. So it's not sustainable. And so utilization control didn't work. Cost control doesn't work because we can't, some of these things are out of our control, we can't control it. So cost actually goes up then. So now payers are rolling out these value-based programs. And so they kind of ignore us in foot and ankle. We're the bottom feeders. Nobody really cares about hand and foot. It's all about spine and hip and knee right now, but don't give up. We're gonna get involved. But shared savings, your group or your organization probably participates in some shared saving program. And that's just a retrospective look at how much you save, usually by either decreasing implant costs, excessive utilization. Most of the time, just taking a person from the hospital, what we call the HOPD, the Hospital Outpatient Department, to the ASC that hopefully you own part of, decreases cost. And you get a percentage of that. Now the problem is, it's a race to the bottom. Eventually, there's no more savings that you get credit for. So we don't really like those, but it's better than nothing. The prospective models are things like site of service enhancement. So with us, we're one of the larger payers, we get a 50% increase of our professional fee to take them to an ASC. To do an outpatient procedure in ASC, we get a 50% bump from the payer because they save three times the money from doing it in the hospital. A shoulder scope and a rotator cuff repair in a hospital is $90,000. In my surgery center, it's 3,500. So they can afford to pay us 50% more on our little, tiny professional fee because they just save 50, $60,000. So that stuff works. And then bundles, we'll talk about. Bundles are this step. The next step is even more complex. But bundles are this volume to value. Bundle payments, this is what everybody's talking about. And if we don't get involved in it as providers, it's gonna be done to us and we won't reap the benefits. So a bundle is a predetermined payment for a single episode of care. So let's say total ankle is the next one that we should really get into bundles. Not many people have, we're starting to, but it's something that we basically guarantee the cost. And so we get the payment from the insurance company for that total cost, and then we pay the anesthesiologist, we negotiate the implant rate, and you just have to avoid readmissions and expensive complications for, it's usually, some it's a day of surgery if it's an outpatient case. Sometimes it's 45 days risk coverage or up to 90 days. The reality is the complications are either gonna occur in the first week or two or after 90 days. So that's pretty much how it comes. And so it covers all that. And so you're going at risk. So you need to standardize care. You get patient navigators to follow these patients and they can do it virtually just to check on them and see how they're doing. And so you can do a bundle based on a procedure, based on a diagnosis, and you get a single payment up front. So what do you need to do? The providers have to be part of the process. You have to be willing to standardize. You gotta be willing to track and be accountable to your quality metrics that the group or whoever's running the bundle creates. You gotta have a care team. We have patient navigators who help with this. But part of this is assuming risk. So you can re-insure against that risk and that's a little more complicated than we don't need to go into. But if you lose money on that bundle, you gotta pay it. You usually have some stops, what we call stop loss where it only goes a certain amount. But then you have to analyze the data and you have to correct bad performers, potentially remove them from the program, or counsel them and help them get better. And you gotta know the true cost of things. Most of us have no clue what something costs. You book your patient for surgery and ask you how much it costs, what's your answer normally? I don't know. We'll get the business office to find out. I mean, it's kind of weird that we have no clue what things cost. How much does that plate cost? I really don't know. Now, at the surgery centers, we know it a little bit, but our professional fee, that's only a small part of the cost, but we really can't, we're telling these people they need something done and we're supposed to be incentivized, but we really, we don't know what it costs. It's even worse if you're in a hospital or a university, you really don't know what it costs and you probably don't, and you can say you don't care, but the patient cares. The patient cares if they gotta pay part of it. And so what's bundleable? I think that's not a word. Cardiac, cancer, musculoskeletal, so hip and knee, spine, but foot and ankle, think about our bigger procedures, total ankles. Primary total ankles definitely are bundleable. Fusions, outpatient cases, those would be day of surgery or just post the price. And there are a lot of, there's a few centers around the country, you go on their website and you say, I have an Achilles rupture, this is what it's gonna cost. 100%, this is what it's gonna cost. There's no negotiation, there's nothing. Same thing with a bunion, same thing with an ankle scope and a brostrum. And so if Kent wants to use 12 anchors in his brostrum, maybe somebody's gotta tell him we're losing money on his case. That was just hypothetical. Procedure-based bundles is what the government did and we won't go into that. It's BPCI and BPCI-Advanced. Obviously you can tell I'm passionate about this, we could talk about this a lot. But the reality is we've gotta think about the future here. The payers aren't, they'll give the risk to us if we take it. If not, they're gonna take it away from us. And so the next generation is what we call population health. That's where you go at risk for the entire spend, for the musculoskeletal spend. And that's the next generation to where you can really streamline care, coordinate care, and give better care. And if there's savings, you get to participate in it. And that's what we call bundles 2.0 and population health. And that's what we're looking at. Kevin Bozek at University of Texas in Austin is doing a lot of work on this disease-based population management to where basically the goal is we may operate less but end up doing better. It's getting rid of unindicated procedures, getting rid of things that can't be proven and justified with evidence-based medicine. And that's where you just manage the population. And if you manage it better and save money, you get a percentage of the savings. If not, you potentially go at risk and you have to pay back. And that will definitely correct behavior. But in summary, it sounded all negative, but there is some positive coming out of this for orthopedics. Some of the other fields, internal medicine's gonna struggle. But the payers largely have focused on utilization control and cost reduction. That's the past. Value-based payments are going to be here and are the best opportunity that we have. We need to figure it out. We're not high on the list with the payers. But once they get it set for hip and knee and spine, then they're gonna be looking for the extremities. So they'll probably get a shoulder next, but then ankle could be a good opportunity for us. Bunions and some of the forefoot stuff will probably be last. But we need to be willing to explore those things. And we gotta be willing to standardize our care a bit. We're gonna have to be able to justify it. But this is a good opportunity. Could be a great opportunity. But we've gotta be able to evolve. So I'll probably stop there with a good quote. And then let's kind of hit on kind of a potpourri of practice management. So next, Troy's gonna tell, Troy or Dwayne's gonna tell us how to get the most out of what we do. So coding, when I first got to my practice, Bob Anderson and Hodges Davis were there. It was a large group. And I came from another practice and we coded our own cases. And Bob and Hodges were like, why are you coding your cases? I'm like, so you don't care what is being billed? And guys like Troy Watson and myself were kind of beating the drum going, the only person who should care as much about how the coding's done and how it's done accurately is the guy who's actually gonna make the money off of it. And so you gotta be aware of the coding because it's probably where we leave the most on the table. And so I'll turn that over to Troy. Let me see if I can open this talk up. Good, okay, thanks, everybody. Thanks, Bruce. And look, we have plenty of time. We don't have case presentations at the end of this. We have plenty of time for questions. Maybe after every couple talks, we'll stop and see if we have discussions. All right, thanks, Bruce, for inviting me to talk about coding and exciting stuff. But it's something we all should know and try to do right to maximize our reimbursements. The old-fashioned way with direct payment from the insurance company. So anyway, we're gonna talk about coding documentation a little bit more. So I really don't have anything disclosed in this talk other than the fact that I use codes to make money, just like all of you in this room. So maybe I do. So we're gonna discuss the new CMS rules for E&M management. We're gonna talk a little bit about optimizing documentation just generally. And we're gonna talk a little bit about coding for common foot and ankle procedures and just a few take-home tips. Try to be brief and to the point here. So basically, the new E&M rules came about this year in January. So hopefully you all know this and this is just gonna be a review. Because it started January 1st. Anyway, so what they changed were, the reason for the change is they wanted to put the patient first over paperwork, reduce time spent on documenting visits, and also document information pertinent to the patient case or patient care. Kind of cut out all the bullet points that we were trying to meet. And then create a resource-based reimbursement, less need for audits due to definitions and guidelines being extended. So timeline, in July 2019, Medicare proposed a new rule and then they implemented it in November of 2009. Sorry, they made it final in November 2019 and then they implemented it in January of this year during all our COVID stuff. So my group had, we talked about it last fall, I guess. Kind of getting prepared. And I'm sure most of your groups did the same thing. So one thing that came out about it, the 99201 E&M code was eliminated. Basically it has the same history and physical requirements and it's very overall straightforward for medical decision making, which is needed for the same, basically the same for 99202. So they also touched up on the new versus established patients. They revised some of the descriptions. Professional services added to distinguish that an E&M doesn't necessarily have to be previously reported to define established patient, which is kind of confusing. I don't really understand that one. But then also a new patient is one that hasn't been seen in the last three years by a physician or qualified health provider of the exact same specialty or sub-specialty in the same group practice. And obviously APNs and PAs are considered to be basically the same as you in your practice. So they kind of have to go by the same rules that we go by. They also eliminated the history and physical examination from the actual points. But obviously you're still required to document a pertinent history and physical exam. So just to compare from 2020 to 2021, they look, in 2020 we had to look at the history and the physical as well as the medical decision making. And then 2021, it's either time or medical decision making that count. So just to briefly look at time, basically it changed from typical to a minimum time. And the time includes face-to-face time, examination and or evaluation, counseling and education, non-face-to-face time, and also preparation to see the patient. So pre-prep time is counted if you're reviewing old records or other physician records, orders, documentation, interpretation of tests, and care coordination. So that all is included in time. So time's not used for emergency department services, mainly because ER docs and other physicians and or providers in the ER are seeing multiple patients at one time. So it's very hard to consider time. So, and also doesn't include counseling. Counseling and coordination of care is not required. And then obviously if you're doing shared or split visits with your nurse practitioner, you gotta add up the time together and only count it one time. Just a brief overview of time assignments. I know it's kind of boring, but it's just a chart that you can look at and what the time actually means. So restrictions in regards to time, you can't count time that the patient spends with your clinical staff, just you. And then individual encounters of physician qualified healthcare professionals reported on the same day. Nursery can't count that. And then obviously some of these rules may change with other payers. And this applies mainly to outpatient office visits. And then there are also some codes for prolonged service. If you need to add a little extra, you could look that up in the CPT book. So let's get to medical decision making in a new format. So basically they edited the elements for coding choice. They removed ambiguous elements. The guidelines for medical decision making interpreted further. They were reformatted. There are new definitions for data. Diagnostic tests are counted per test. And there's also some change to risk. Social determinants of health influencing diagnostic treatment and decision to hospitalize a patient added higher risk. So basically you can break down the medical decision making into three components. So you have your problems, or number and complexity of problems in one component. Amount and or complexity of data, one component. Then risk of complications and morbidity. And manage of the patient, another component. You're gonna use two of the three to come up with your level of care. I got some more charts further along here. So just a reminder that when you're performing and interpreting a test, such as like you order the x-ray, you can count that, but you can't count interpretation of that x-ray if you're gonna bill for it separately. So you can't count. So the patient comes to your office, you order the x-ray, and then you interpret it and bill for it yourself. That's not something you can count. And now if you look at a study from another physician and do an interpretation, you can count that, as long as you're not billing for it. So problems, basically you have new and established problems that affect medical decision making. Comorbidities and underlying diseases are considered in the medical decision making, but it doesn't necessarily increase or guarantee it's a higher level of care except for the fact that you may have more data to review. So that's how it affects it. And then the final diagnosis, if it's a very complex problem, doesn't necessarily increase the complexity or your ability to elevate your coding unless you meet all the data points. So here are the long list of problems that can be addressed. Obviously in orthopedics, a lot of our stuff is either simple, minor things or acute, uncomplicated or chronic illnesses that are exacerbated, such as bad arthritis. Of course, we also treat sick people as well. So we could run the whole gamut and probably reach all up to level five in some situations. So I know this is boring stuff, but data categories, basically category one, you review prior external notes from each unique source. You review the result from each unique test or you order a test. So those are all points you can get from category one. Category two, assessment requiring an independent historian or interpretation of independent tests with some communication or discussing. And then category three, discussing management of test interpretation with, say, another physician that you've consulted or something. Anyway, so risk, looking at risk. Risk can be changed by different things now. I mean, they consider moderate. Things you look at are social determinants of health, economic stability of the patient, neighborhood or physical environment, education, food, community, social context, healthcare system, all these things go into play. And you kind of have to make your own determination of this risk. And then high risk may be someone that you decide to hospitalize. So here's a chart that I got from a AMA CPT article. And it basically breaks down each level that you can build. Obviously, level one is no longer existing. And then level two, whether new or established, basically you have to look at the base of two of the three elements. So you have to look at your complexity of the problem addressed versus the data versus the complications. You only really need to look at two. If you reach, you look at two. If you can reach it, then you can build for that level three visit if you get to it. So it's somewhat self-explanatory. This is something you might want to make a copy of, put it next to your work computer so you can go back to your stuff and review it and get it done. So level four, obviously it has to be a more complex problem. And you can see the list here, you know, acute complicated injuries such as like a bad ankle fracture dislocation. And then the patient comes in, you know, from the ER after being reduced. And you're going to sign them up for surgery. You're reviewing the ER documents, documentation from the physician. That's one data point. You're trying to reach any combination from the following. So and then you're trying to get to three to potentially get to this four. So you review the results of a test. So you got an x-ray in the ER showing the fracture, review that, might have a CT scan for some other sort of injury, review that. And then you may order another follow-up x-ray to make sure the fracture is still in the same position. So you count that. So boom, you reach that. And then you decide that he's going to have to have surgery, which has some significant risk. So you can most likely reach a level four in certain instances. So basically just follow the points and get the right diagnosis. And obviously, level five, things that change in level five, obviously it's a higher complexity of a problem. And it's a little bit more extensive data points that you have to reach. You have to get at least two out of the three categories, which can be a little tough to get to. And obviously, a higher risk of morbidity and mortality with the associated treatment. So I just made a small case example. This is a 21-year-old female college basketball player who you've seen in the past, operated on, did a Brostrom-Gould procedure a year ago. Patient back to play in college basketball, rolled the ankle. She seems to be getting better. She saw the team physician who ordered x-rays and an MRI and decided to send her back to you to clear her to go back to playing. So you see the patient. You review his notes. You review the MRI, which was pretty much normal for what she would have. And she's obviously getting better. So just to review the points, it's an established patient, acute, uncomplicated injury. You review the notes, MRI, and then talk to the trainer and tell them that she can go back to play and just rehab it whenever she wants to. So it's about a level three. So pretty simple. I think it's important to summarize and go over the data when you're making that or doing the coding. So we're going to move on to a little bit about optimizing documentation here. This is a little bit redundant, just thinking back. So in the clinic, what are you going to do? You're going to summarize your visit, look at your medical decision-making points, and maybe refer back to your chart if you're having any trouble doing it. And then go ahead and remember your modifiers if you're doing anything that needs to be modified and get it done. So E&M modifiers can be used for clinic visits, E&M codes. And it identifies that the office visit is separately billable to other procedures or services. So modifier 24 is basically a modifier used for someone that's in a 90-day global period that you see with a new problem. So your bunion patient comes in with plantar heel pain or an infected toenail from the other side, a new problem, modifier 24 so you can get paid for the E&M visit. And remember that your nurse practitioner or PA are basically an extension of you, so they have to also do the same modifiers in clinic. Modifier 57, which is a decision for surgery. Hopefully everybody knows about this. Basically, you see the patient the day before and you decide to operate that same day or the next day. You need a modifier E&M visit with a modifier 57 if it has a 90-day global. Modifier 25, it's something for a 10-day global period, not used that much in the office. But just one example is say you see a patient that has some complex lacerations to the head and you happen to fix that, but you're also treating for a concussion and it's a truly separate treatment and it's indicated that you would modify that visit with a modifier 25 so you can get paid for the E&M as well as the procedure. Just a brief discussion about incident to billing. It is essentially related to the office billing and the physician has to come up with the plan and then the non-physician provider can follow up that treatment plan and bill basically the same as the physician would for further follow-up care. Obviously, non-physician providers can't bill incident to if it's a new problem or a new patient. The physician has to come up with that. Shared or split visits, just a review. It's basically performed in a hospital setting. If you do that with your nurse practitioner or PA, obviously you have to see the patient face-to-face and evaluate them and then document your involvement in the case and legibly sign the record and you can't just say senior degree in order to get paid if you want to stay out of trouble. Operative reports. In my practice, what I like to do obviously dictate in a timely fashion, but I try to make it easy for our coders and the insurance companies to really understand what I'm saying by listing diagnoses and then follow that up with a list of the procedures using CPT terminologies where possible, at least all the time, most of the time. And then also follow up in the body of the operative report in a paragraph form with each separate procedure dictated in a separate paragraph so they can easily see what I'm talking about. And also, don't forget about the modifiers. All right. Just to review, the National Correct Coding Initiative which was implemented in 1996 was basically developed to promote national correct coding methodologies and control improper coding leading to inappropriate reimbursement. And they based this all on CPT, specialty society standard medical practices and current coding practices. And what they, you know, what they come up with is this medically unlikely units which you could look up online to see which procedures may be more likely to be bundled in and it'll kick it out. It doesn't mean you can't appeal or appropriately modify it to get things paid for, but it's just something that you need to know about, at least your coding department should know about. Moving on to surgical modifiers, modifier 51 is a modifier used for multiple procedures. Modifier 59 is basically two separate distinct procedures that you might do. Modifier 50 is for bilateral, same procedure done at the same time. Modifier 22 is basically a modifier you can use to try to get reimbursed for increased work, although I found that using that requires, you know, submission of the operative report as well as a letter to get it, to get paid a little bit more. So I rarely ever do it. I may have done it once or twice in 11 years. And then when procedures are performed in a global period, there are some modifiers you need to know. Obviously the one that's staged or planned, take for instance, you do an open pilon fracture, reduce it, debride it, and X-fix it. And you dictate and know that you're going to come back in a few weeks to do a formal open reduction and remove the X-fix. Obviously that modifier goes on to the next procedure, but you need to implicate that in the prior operative report if possible. And then obviously modifier 78 is someone going back to the operating room in the global period for a complication. And obviously don't forget about the toe modifiers, the T's, T1 through 8 and TA, just a reminder. And then, you know, a few things, just general coding, bunion codes, two, three, maybe four years ago, some of these bunion codes were deleted, like 28290, your simple or silver bunionectomy code, which was something I used a lot whenever I was doing Halix and PFusions and a patient had any kind of Halix valgus, just try to get a little extra reimbursement. That's been deleted, so you can't really use that anymore. And I have had some success using 28292 with that, although that code in the description says you have to take away some of the proximal phalanx bone, which you could easily say that in your dictation, and I have been able to get paid for some of that with modifier 51. And just looking at the bunion codes, one of the more common ones I do is obviously the 28299, the double osteotomy, some sort of metatarsal osteotomy with an aching, it's probably one of the higher reimbursed codes, but obviously they're all there and readily used. Lesser toe deformities, just a quick review, the most common one I use is for hammer toe would be a 28285 code, remember your T modifiers for the toe. Another thing you need to know, the girdle stone flexure to extensor transfer code that I use is a 28285 as well, because there's really no code in the CPT book for tendon transfers in the toe. And just further on to review, metatarsal osteotomy code is 28308, make sure you diagnose and give some sort of diagnosis for that code, so you do a wild osteotomy for a patient with angular deformity, you may give them the diagnosis code metatarsitis, sometimes that may get kicked out if you don't give a diagnosis code for that problem. And there's a few other codes for simple bunionette excision, bunionette correction, metatarsal osteotomies. Moving on to what Bruce alluded to, total ankle orthoplasty, just to look at what you get reimbursed for total ankles, they take a good amount of time, 27702, currently get reimbursed about 900 bucks from Medicare, which is not that great. Somebody want to go next door and just tell them that? And a revision is, you know, $100 more, so not that great, but it's very complicated sometimes. So I do a lot of total ankles, and over the years, I find that at least recently in the last few years, pre-certification has become a little more of an issue, I've been getting some denials, and most of the time it's for my lack of documentation of these things, like assistive devices, bracing, BMI, so if you have a patient with BMI 30, 35, you must document weight loss discussion. If you have a patient with BMI 35 to 40, you must document a plan and then follow up, and if they're really big, you probably shouldn't do it. And then obviously document adjacent joint arthritis, nostril trial, physical therapy. Put in the note when you send it in for the pre-cert, you're more likely to get it pre-certed. Just a few changes recently, the arthroscopy for form or loose body code, 29894 or 29904, and it's pertaining to arthroscopy codes in the shoulder and the knee as well, other joints. But the form body needs to be the size of the cannula that you're using or bigger, or that you need it, and you need a document that you enlarge the incision to get the loose body out. Anyway, just something to think of. Ankle ligament procedures, modified brostrum includes ATFL and CFL when you use the 27698 code, repair of secondary disrupted collateral ligaments. And then of note, perineal tendon repair is not bundled with a brostrum, but obviously you code it with a 51 modifier and that'll help you get paid for that. Just a few things about insertional Haglund's, insertional Achilles and Haglund's surgery. I usually use 27654, which is secondary repair of the Achilles tendon. And then I also use 28120 more often than 28118. And I don't really have any problems getting paid for that with a 51 modifier. And then when I code FHL transfer to the calcaneus, I use this code in combination with it, 27691 with a 51 modifier. I don't really say I'm tying it into the tendon, I'm moving it into the heel. And then obviously if you do a gastroc recession with the appropriate diagnosis through a separate incision, code for that as well. So what I'm saying is, code for everything you can and get reimbursed while you can. Ankle arthrodesis, getting kind of pinched for time, I'm going to move on, but obviously you can see all of the codes, there are a lot of them. And then just a few take home tips, medical decision making matters. I think self-coding really makes a difference. You know what you did, you know how you document, so you really should submit your own codes at least to your billing department so they can look at your reports, make sure you're right and submit it on. And then obviously if you think you're correct, appeal it and don't be denied. Look at your explanation of benefits and go from there. Anyway, thank you. Have a fun time in Charlotte. Thanks, Bruce. Thanks, Troy. Thank you. Anybody have a quick question for Troy? Come to the microphone, please. One of the things I struggle with a little bit is ankle arthroscopy in the setting of other procedures. Can you guys tell me what your experience has been? You know, we get MRIs before we do brosterems or they've already been done. And we do MRIs before we do perineal tendon repairs. And we may or may not see anything in the joint. Some people would still advocate doing ankle arthroscopy in some of those instances. And if you do that, do you have trouble getting paid? So most of us in Charlotte will do an ankle arthroscopy at the time of a lateral ligament reconstruction. I think with diagnosis of synovitis and things like that, we have not had a problem getting those documented. We do get them pre-authorized at the beginning. I think it's important to pre-auth as many procedures as you can because trying to get things approved retrospectively are very difficult. David. Two quick questions. One just on the arthroscopy. I was wondering if you guys have much experience with doing arthroscopies in conjunction with ankle fractures and are you having any difficulty getting paid for that and what you do for pre-certification? The second question is totally unrelated to that. But Troy, when you have, like I get a fair number of patients sent in from other parts of Indiana and they've had two and three surgeries. So we actually put them in the category of a complicated case. And then I have my assistants who's an athletic trainer go through piles of charts, read over that and make a summary for me that I can look at the scans and look at their summary. Is my assistant's time reading through that chart something they should document? And is that considered part of the evaluation time? So the answer to that is time can be you and your team but it's only up to 20% of the total time I believe in the new medical decision making. Can be in the outside documentation review or interpretation portion. They capped it at 20% of the total time. So they should at least, if we have somebody who can document, they looked at it. She can put it on the ready. I spent 15 minutes, 20 minutes, 30 minutes doing that. On the arthroscopic, you're billing for time. You're billing with the use of time for this, right? Or you're still using your medical decision. Yeah, for that one, you'd have to be documenting the time in your note that X amount of time was spent in face-to-face as well as reviewing the patient. Then you can count it. But I think it only counts up to 20% of the total time documented. How about ankle fracture scope-wise? I don't routinely do it. I don't routinely do it either. I've done it in the past. I haven't had any feedback saying I'm not getting paid for it though. And I can't say I routinely pre-cert that either because fractures usually show up if we do it the next day or something. With the athletes that you operate on, it's probably fairly frequent that you're doing that. I just don't know if we're getting reimbursed. Yeah. Ben. I had a quick question about your Haglunds. I've been doing the 28120, but I've been then doing Tinalysis of the Achilles tendon, but you're doing a secondary reconstruction code? Yes. Is that what you're doing? And that's what we do as well. That's what I do. I've always done that. Yeah, we've always done that. We use the 28118 instead of the 28120. I think there's one RVU difference or so, and they're both partial excision of bone calcaneus. It's weird that there's two codes. We switched. See, I'm on RVUs, the RVUs for 120 is higher than 118, so I do the 118 if I just do a Haglunds and don't do anything to the Achilles, do a 120 if I do like a speed bridge, take the whole thing down. So how are you saying it to get the secondary reconstruction, because I mean, I like to breathe the Achilles. Well, you're detaching it, you're partially detaching the Achilles then reattaching it, which is a secondary reconstruction. Thank you. Yeah, that's what I do. That's exactly what I say. I must have learned from you, Bruce. Yeah, so I'll just echo that. The 28120, if you have an assistant, blows it up. So a couple comments and not really a question. I love to hear Bruce's thoughts on these, my thoughts on kind of global health care. So you said that it's about the payer, and that's true, right? We learned when we were kids or when you're an adult and you follow the money, and I think that's what health care is. It's the only industry that I'm aware of that has smoke and mirror reimbursement. So if you go to Del Frisco's, the stake is $50. You know it's $50. You pay $50. But in health care, to your point, no one knows anything about any price, the patient, the consumer, and then the provider, the doctor. And so patients ask all the time how much it costs, and I don't know because there's 10 different insurance companies and 1,000 different plans. And so that smoke and mirrors, I think, is used to their advantage. And as a capitalist, as you pointed out when I came in, I'm all about the stock market. And, you know, and I love a company that makes money, and that's their job. Blue Cross, Adenai, if you looked at their stock value during COVID, they all doubled. United, Cigna, right? And I want my stock portfolio to double. I do. I definitely, you know, Apple, Tesla, whatever. But there is a conflict of interest in some regards that these companies are out to make money, and they do it by providing a service to their customer. And the only way they save money is to increase premiums and decrease distribution and reimbursement to the provider, us. And that creates a conflict. And although I'm a capitalist and I say that proudly, and I don't think the government should control health care, but I think there is some solution at some point. And the last thing I was going to say is that, you know, population health, you mentioned this. My view on that is that population health de-risks the insurance company clouded to improve health care, right? And so, again, they want to increase, they want to improve their bottom line. And they say that just like when we're on these hospital committees, right? We want to provide better care. They just want to make more money, which is fine. But in this industry, it's a complicated moving target. And you, the CEO of our group, biggest in the world, in control of massive health care dollars, I'd love to hear some insight. The problem is nobody knows the answer. And so, you know, a single-payer system we know is not going to work, especially if it's administered by the government. Look how we've handled a global pandemic from a health care standpoint. And so, you're right, the payers made the largest profits in the history of their companies last year. How was that? Because they got paid extra to take care of the pandemic, and health care spend went down. But at our group, our premiums for next year are going up 5%, even though it was the lowest spend year they've ever had. And so, that's where the problem lies is, you know, UnitedHealthcare made, I think, $600 billion last year. And we didn't. And the 11 million unemployed didn't. So, it's a problem. Great. You get to ask a question, then you get to come up here and give your talk. Yeah, okay. I could wax poetically about single-payer health care system, but I'll say that. Yes. My question for you, Bruce, is as we go to value-based care, and we're watching that very carefully in Columbus, is I'm interested in the biometric profiling of patients and how far we can go there. So, taking Apple Watch data, or Zimmer Biomet just released the persona knee that's got canary tracking in it. So, it'll talk about range of motion, number of steps. Have you had those conversations with payers yet about biometric data? How responsive to that are they? And does anybody believe that data is accurate enough to make decisions? So, we've had those conversations. We're actually having those conversations with Google right now. And Google and Apple are all over this. And so, the payers don't understand it yet. You know, everybody's about, you know, whether it's virtual care, whether it's patient optimization, whether it's virtual visits afterwards, virtual PT, all these things, but nobody's there yet. That's why some of these programs, whether it's a value-based program, whether it's a bundle program, where we have the incentive to do it as the providers, is probably the best way to initiate it. So, I don't think the payers are going to do it off the top. You know, they're doing it with wellness programs and things like that, but they're not doing it for disease-based management yet. But I think it's going to get there. Well, great. Okay, so let's keep moving. So, we're going to flip this one a little bit. And so, Greg Burlett now gets to go from asking a question to giving the talk on how to work with industry. And so, I would remind everybody, tomorrow the meeting is in the Crown Ballroom, which is on the other side of the convention center. The exhibit hall is directly below us. Remember to visit the exhibit hall starting today at 4 o'clock and then tomorrow, because they help support this meeting. But Greg's going to tell us how to actually work with industry. All right. So, I think you could appreciate that this talk could be political hot potato. With that in mind, I'm really trying to give it a perspective from me. Okay? So, I'm not advocating. I'll talk about my journey, what I've learned, and then we can kind of take the questions from there. So, I said working together with industry for a better tomorrow. So, I do believe that we can be complementary. These are my disclosures. And this slide is the one that made me the most nervous of them all, because I'm going to show you a slide in a moment that shows that most disclosures done at meetings are not accurate. So, many faces of industry is you can participate as a key opinion leader, a KOL, as a design consultant, as a royalty-bearing design consultant, as a med-ed consultant, a medical officer, clinical or scientific advisory board member, or an investor. And I've participated on all levels. The Open Payment Database came out in 2010. This is the same thing as the Physician Payment Sunshine Act. And it's a national disclosure program designed to promote transparent and accountable health care systems. So, a pretty lofty goal. It's publicly accessible. You can type in a name, find out how much the reporting entities reported that person received last year to people like us, physicians. So, what's the orthopedic foot and ankle industry look like? Well, here's a paper by PathEc in 2021 looking at payment data from 2014 to 2017. They said that in the ortho foot space is in those three years the number of physicians reported on the Sunshine Act went from 490 to 556. Ninety-one percent of the total foot and ankle payment went to the top five percent. And the median payment for this group increased from 107, this is the top five percent I'm now referring to. The median payment for that top five percent increased from $177,000 in 2014 to $192,000 in 2017. So, meaningful numbers. How about sports guys? Well, much bigger industry than ours. The median total industry payment to surgeons was $460. Remember, that includes dinner, they bought you a glass of wine. Ten percent received 95 percent of the payments. Five percent received none. But it's highly skewed data. There's one surgeon, which many of us could guess who it was, received $19.5 million. And he made up approximately a third of the total combined payments of all surgeons. Good year, huh? So, but it's only good as the data. Here's where I say, can you believe it or not? It's 35 percent rate of inconsistencies when disclosures from presenters at the 2014 AAOS annual meeting were compared with the open payments database. Kind of cool study. What was paid to them and what did they disclose? And 35 percent were off. Eighty-three percent of AGSM authors had discrepancies between disclosures they self-reported to the journal and the industry-reported disclosures found in the open payment database. So, not super awesome. So, Camp et al. said, all right, well, what do patients think of this? This was a post-surgery arthroplasty survey. And they asked them, what do you think about the idea of your surgeon being compensated to review medical implants or to be involved in their development? Only six percent said they were worried about their surgeon's possible financial benefit. And 69 percent believed it was appropriate for surgeons to receive royalties for inventions as long as the devices benefited patients. So, the lesson is, transparency with full commitment to patient care and altruism correlates with a positive public opinion. So, I call this my story. Really, it's our story. So, OFA opened in 1999. We opened up as a foot and ankle focused practice. We were the first orthofocused foot practice in Ohio. And our draw area immediately became Ohio and all the adjacent states. We evolved our practice into a multidisciplinary foot team on purpose. So, we evolved MD, DO, DPM. And we established research as a founding principle. We've had a research coordinator from day one. And we support two of them now. It allowed us to look at the industry in a way that a lot of other practices won't. We had a large focused volume. And one of our first things was an MTP fusion, lock plates for MTP fusion. We identified very early on that MTP fusion was too unpredictable with cross crews to be scaled for greater use. So, we got involved in industry. This was our first major involvement. It was with Darko. Darko was a lock plate system, the first lock plate designed for MTP fusion, developed with Darko, which is a U.S. company, marketed in Europe, primarily Germany, eventually brought to the U.S. and introduced to this market, Wright Medical purchased Darko plating system in 2007. Well, Wright Medical, around the same time, developed a strategic interest in foot and ankle. They were selling hips and knees. And they said, you know what? The future, we think, is in foot and ankle. And they had partnered with the Miller Orthopedic Surgeons. Bruce to my right, Bob Anderson, Hodges Davis. They were growing rapidly, and they had a very heavy demand on these guys' time while they were in practice. So, three of our surgeons, myself, Tom Lee, and Chris Heyer, joined the development team to expand the capacity, the viewpoint, and the scope. And for the first time, this included the podiatric perspective from Chris Heyer. Really key idea. You need to remember, in foot and ankle industry, 70% of all implants are sold into the podiatric space. You cannot design an orthopedic-only implant and win in the market. It just won't work. So, the key attributes of a development team is you have to have voice. That can be with publication. It can be from the podium. It can be with fellowships. Or it could be with social media. You have to have volume. You've got to be able to use to be relevant. You have to be able to use the product. You have to be accessible. You will miss work for this job. Design development meetings are not done on Saturdays and Sundays. They're done in the week when the engineers are working, and you'll miss your regular job. You have to be creative, but you don't have to be an engineer. There's lots of smart engineers around who will tease it out of you, but you do have to be creative. You have to be a team player. Egos stay at the door. The more you're open to a broad perspective on our foot and ankle industry, the more attractive you're going to be as a team member. And then one is going to sound like two, but it's a little different. You've got to be able to use the products that you use and influence your local implant advisory committee. In other words, you have to be able to develop expertise with your own implant. If you're designing for a company, but your hospital has a GPO and you can't use it, you're not useful to that team. You've got to be able to use your own product. So the anatomy of a product. It all starts with a market need, and that's what we're really good at. We sit in this meeting. We go, hey, I just watched so-and-so present on this, and I got a great idea. Good. Pitch the idea and then see how big of a market it really is. Then we move on to the con step, and we start playing this out about what the IP portfolio might look like. How busy is it? Is there space in there for something new? Then take it to market viability. We're going to do a project budget requirements and financing. When that's all done, then, who's ever going to lead this from a financing point of view? We'll go thumbs up, thumbs down. Thumbs up means project activation. We're going to go and we're going to put resources. Number six, I'm going to break out on my next slide, but here we get into design meetings, prototypes, validation, ultimately launch. We do a regulatory submission and approval, support with research and podium, and then if it's that good, usually you can pull through line extensions. You're going to see in a following slide this easily can take six years. This is what a typical product development plan looks like, and the bar width represents the relative time and money required. The first one planning, then input, development is a big one, and you'll see the yellow boxes underneath. That's hazard analysis. There's times that you'll go all the way through. You'll go to the end of development, and all of a sudden the project gets deep-sixed. It's costing too much money to make. It's not going to make sense. No matter how much the market needs it, it's got to make business sense. So here's an example. So this is with Stryker, not with Wright Medical. So Stryker had developed a licensed know-how on a pin that would melt at a predictable location under ultrasound energy. They called it the sonic pin. Its indication at that point was in bunion, and it was being used in Europe, not in the United States. We were invited to review the technology and provide feedback. So they engaged me as a consulting physician on a fee-for-service basis. So our feedback was there was some promise with how it's valgus, kind of cool idea, you can fix a bunion without seeing any metal hardware, and we thought it warranted a clinical study. We brought in our research team, and we collaborated with Stryker Clinical Research. So now I'm acting as a fee-for-service research consultant. But we thought the likely better indication was for soft tissue anchoring to bone, not the way they had originally envisioned it. So we started playing with the concept. Where's the optimal melt point for the anchor? How will this anchor device hold a suture? What size of hole do we need to drill? Because remember, ultrasound energy goes through the anchor, has a little bit of resistance, and that resistance will set the melt point. How does the ultrasound affect the suture? What size of suture do we need? What type of needle size? So now we're going to flip it again, remember? I started as fee-for-service consultant. Then I was a research consultant. Now we have taken existing technology, and we've said new indication. So now we're going into royalty-bearing design consultant negotiations. These rates can be all over the map. I've seen as low as 0.1%, as high as 6%. 6% is probably the absolute max, and you have to come with solid patent filings that you own to get 6%. The question would be, are these royalties being paid in just the U.S., or are they being paid worldwide? And what's the term length? The first deals I negotiated way back were 10 years. Today, it's more likely you'll negotiate, at best, a seven-year deal. So the value proposition of Sonic was it's a disruptive technology. No other anchor could claim the same level of compatibility with cancellous bone. The polymer interdigitates into the bony surface, so you don't have to have a cortex. And it was the superior solution for small bones with no sacrifice in pull-out strength. Our project deliverables when this was done was an ultrasound handpiece, instrument a handpiece tip, a tip tool to put on that handpiece tip, a drill, which was single-use, and then an operative technique guide. So that was an example of how we go through it. When we did, they looked at this entirely different from me. Now, striker hat on, they're going, how does this thing play out? So if you're starting, you first have to look at the timeline, the development, and how much capital are they going to have to apply to it. Or if you're a startup, you're going to have to raise to get this project done. When you make the implants, you've got to make them cheap. You need margins 70% or higher on these implants. So you don't make a screw for $200 and sell it for $250. You make a screw for $20, and you sell it for $250. You need gross margins that are high. This one was kind of expensive because we've got an ultrasound generator, and we've got to get that generator to the facility. You have to think about what you're asking sales price, and then your big key accounts, like OrthoCarolina, where they go, yeah, I'm not paying that. And so it would be discounted off the average sales price. Remember, your royalty is paid on net, and consulting income paid to develop the implant is clawed back. That means that you're being paid while you're developing, and the reason you're being paid is to offset your lost productivity in the office. So I'm going to pay you such and such per hour, assuming that that's how much you were making had you stayed home in your office. So it's not net positive when you're developing. It's just an offset. The consulting in this product, this one, there was no net royalties until Q3 of 2018. There are no royalties paid on implants used at the institution or institution where the royalty-bearing surgery performs. So if I'm at a hospital, and the number one producer in the country is at that hospital, I'm getting no royalties. It's not me, but it's that institution. And there is regular and transparent reporting, and we always have a right to audit. You can always go back to Stryker and say, I need to see your books on sales and on what the average sales price is and make sure they're being fair in their reporting. So here's what the Sonic Anchor timeline looked like. Our initial discussions were May 2012. It was activated in November. We went to design lock in September of 2013. We did product launch in 2015. Then they started clawing back all the money they paid me to offset my time out of the office. And that was net positive Q3 2018. Six years later, I'm net positive on a project that is taking dozens of meetings, multiple design labs, and a big-time commitment to the vision. So you can see the picture I'm painting here. This is not a get-rich-quick scheme. This is a long-run idea. So when you're doing development, what's the bad part? Well, we already work hard. Nobody has ever accused an orthopedic surgery practice as being an easy way to get through life. We already work hard and this is extra. Maybe with a few exclamation points. Your family has to be supportive. You will miss soccer games. You will miss parties. You will miss that. I was often introduced at parties as the guy that they didn't believe existed because I just wasn't around in my core development years. I wasn't around as much as maybe I could have been. You can't do development in a bubble. Remember, voice, volume, accessibility, creativity, team player, and ability to use. Some companies will set the expectation of broad support. Hey, we're having you develop this device for us. We expect you to use across our entire platform. Illegal, flat, wrong, say no. I don't believe in that at all. You're committing to that project for that thing. Now, a lot of times they'll provide the support in your office, not your office, in your OR and they will be the ones that are around anyways because you're working with them closely. It would make sense that you might use them a lot, but don't be strong armed into that. It's not true. You get paid as a 1099. That's an independent contractor. The reason that's relevant is there are no taxes withdrawn. You have to kind of watch this and you have to put money aside for next year's tax payments. There are non-competition covenants. If you design an MTP plate, you'll be non-competed out of designing another MTP plate until you're off royalty, which can be 7 or 10 years. Some companies are easier to work with than others. Reporting takes time and diligence. You have to kind of get into that part of reporting expenses and tracking. You have to make a real conscious effort to look at assignment of intellectual property. Who owns your IP? If you're at a university, it might not be you. Your contract will probably call out IP and you just need to know it. Now, you can negotiate that. I know many people that are in academic institutions who've carved out their IP or maybe give them a small cut. Then lastly, remember conflict of interest at your academic institutions. Maybe they have an awesome contract with a GPO and they're using one company that happens to compete with the company you're designing for. Just keep it in mind. The good, and this is really good. Engineers are some of the smartest people I interact with and they become really, really good friends. They know an entirely different thing than we know and it's super cool to hang out with them. You can have an enduring impact on a much broader scale than you could achieve individually. In our practices, we will reach thousands of people. With this, you can reach tens of thousands of people. It is mailbox money once it arrives. They work efforts long ago and all of a sudden now you're getting some royalties. You'll need to support your programs, sometimes in great locations. You get to participate in a different side of our industry and you develop strong lifetime friendships. I think this makes me a better surgeon. It's fun. It's intellectually stimulating. It forces me to be creative and I'm in a lab a lot, a lot, a lot, a lot and that has me doing that surgery that much more than I'm doing in the OR. So I'm super proud of our accomplishments. When we started with Wright, they were small. Wright just sold to Stryker for $4.5 billion. These listed below, they all came off of our original team. Treece Medical, Artalon, Medline, Crossroads, Paragon 28, all led by Wright Medical guys when we started that journey and there's many others more. So it can be fun and we've made a big impact. Is it ethical? You've got to answer that for yourself. My answer is yes. I am transparent and honest to my patients about why I do development and how this is beneficial to their care. I try and lead with integrity with you guys, with accurate updates in my conflict of interest. I do it at least twice a year, maybe three times a year and I think it makes you a better clinician, therefore a better person serving your patients. If you have an idea, write it down in a format that's comprehensive. Keep an inventor's notebook that includes signature, dates, chronology. The details you want to include, who's the inventor, what was their specific contribution to the invention, who else participated and what was their contribution. You need a descriptive title of the invention, a detailed description. Has this been previously disclosed? If so, what was the date? Any models and drawings you have are helpful. What you don't want to do. Don't disclose in a public format like a society meeting. Don't publish a paper that includes your novel idea. Don't broadly share in a format that would qualify as public knowledge and don't undervalue your knowledge, experience and creativity. We have insights that the industry doesn't have. They can't do it without us. So those who would say that this is wrong, don't understand, particularly in orthopedics, is we cannot evolve our discipline without this collaboration. It is necessary. Thank you. Thanks, Greg. That was great. We are running a little bit behind, but what I will say on this topic and due to some work with the society, yesterday at our board meeting we did approve our new conflict of interest policy that will be distributed eventually once we set up our new conflict of interest committee for folks serving in leadership positions for the society. I think this is really important. Greg's presentation was awesome, but obviously we as a society want to make sure that our leaders, our committee chairs have disclosure and active management of their conflicts. That's really important. Some folks in this room worked really hard on this. The next is going to be fun. We're going to catch up. It's going to be a debate, point counterpoint, of types of practice, employed versus independent. RJ Sullivan and John Campbell are going to debate this. I think RJ is going first? Okay. They may make personal attacks on each other, but they're friends. They may not appear to be friends for the next 15, 20 minutes, but we'll see. Thanks. When I first was asked by Bruce to do this, I was like, debate? There's really no debate. I'll prove that in a minute. These are my disclosures. My other disclosure is that I stole all of John Campbell's slides. This actually really existed. That's John and I during fellowship. For us, even though I don't believe in hospital employment, we have an excellent co-management agreement with our hospital and our hospital system. I think that's critical for our success. Everything is not always as it appears. You actually don't know what you don't know. As Bruce talked before, transparency from institutions is historically poor. If you don't have the information, then you're making poor decisions. Why private practice? Well, that's where the money is. This is actually the inside of our new hospital. Those that don't learn from history are destined to repeat it. You can just look at what happened to the employed primary practices of the 90s and see where that went. Another statesman said, private practice physicians are the driving force that's increasing employed physicians' income. I think that's true. There's advantages and disadvantages for being a hospital employee. Really, as a private practitioner, there's really only advantages. Some of the advantages are you can do whatever you want as practice management. You have autonomy. You have a significantly higher income. You have access to all kinds of ancillary revenue. We'll go through that in a minute. You can own your own real estate. Bruce and I were talking about that earlier. You can form co-management agreements with hospitals and they'll build you a hospital. There's significant tax benefits. If your boss says you only get four, five, six, seven weeks of vacation, well, if you're a private practice, you just do whatever you want. I don't really care what other doctors think and I don't care what other doctors want. I care what orthopedic surgeons want to do. For me, it's a great powder day. There's different types of private practice. There's solo practice, small orthopedic-only group, large orthopedic-only group, multi-specialty group. Actually, I didn't even think of Greg's option of multi-specialty foot and ankle group. Recently, there's been a big push for umbrella partnerships. As far as total compensation, well, where do we actually make money? We make money in the office, seeing patients, getting x-rays, doing ultrasound, DME, injectables. We make money doing surgery, both inpatient and outpatient. We make money on administration. If we're on a committee for a hospital, we're getting paid an hourly rate. We make a lot of money on ASCs because we own them. We partner with some of them as well with our co-management agreement. We own real estate. We get paid for call. We get paid for trauma call. We get paid for spine call. We get paid for hand call. We renegotiate that every year. We own a number of physical therapy places. We were talking about that earlier. That might be a money loser at some point, but it still does well. We own pharmacies, especially for workers' comp patients. We own and run several orthopedic urgent cares. There's profit and gain sharing, and obviously, there's a few but not many physicians-owned hospitals. As far as foot and ankle-specific compensation, you must look at everything involved with your practice. Just add it up. Figure out what you do. I did. For the 25th percentile for a foot and ankle surgeon overall, you're bringing in over $4 million a year. This was a couple of years ago when I did another talk at the same meeting. That's all-in including ancillary. That's what you do for the hospital. That's what you do for your surgery center. It's what you do for your physical therapy. It's what you do for your MRI, your CAT scan. That's all-in what you generate just by existing at a relatively low level of productivity. If you're bringing in $4 million, how much of that do you actually deserve? I say a lot. Employed physicians talk about incentive-based productivity, and they get bonus based on incentives. I don't really care about that because if I work more or I work smarter or both, I get paid more. As far as retirement plans, this is actually stolen from John, too. Ours are very similar. The big difference is that in my profit-sharing plan, I'm the employer, so I pay myself. The hospital doesn't contribute to that. We take advantage of our HSA plans and use our HSA plans as investments for the future. As far as ancillary income, this is getting bigger and bigger for us. There's people in our group that are making more than 50 percent of their income just on ancillary revenue. Ancillary income for us is based on surgery center, physical therapy, MRI. We don't own a CAT scan because that's a certificate of need, and we can't get one for Connecticut. We own a number of pharmacies. We have a big durable medical equipment business, including a brace shop. We own and run two urgent cares. Many people in our group do consulting, and obviously Greg knows a lot about that. You can make a fair amount of money doing that. Specialty hospitals, the hospital system that we're with built us one, so we get paid by them. We get paid for the administration. We get paid for call. We get paid for professional and personal service agreements, and we have individual service line agreement dollars that come our way. We just renegotiated a research stipend as well. As far as autonomy, when I was employed, this is what I dealt with pretty much every Friday as Michael can attest to. Got some sound? Well, this is just, say it, say it, say it. That was my chairman and me arguing pretty much every Friday morning. Then I quit because I figured I couldn't do any worse. Unfortunately, this is what it became, and this is the end of the same movie when he's saying that I don't have to take shit from no one. Actually, I beeped out at the expletive, but sorry about that. Apologize. Sorry, my bad. Clinical practice, again, this is really actually stolen from John. Practice location, OR block time, ASC access, and staffing. You can say what you want about being a hospital-based physician, but what would happen if you owned every aspect of that or co-managed some of these aspects or maybe did both? What do you get if you're in clinical practice and you own your own practice? If you're hospital-based, maybe they get you a standing CT or an ultrasound, but for us, we just build a surgery center or a new office building, and we own everything about it, and we run the entire thing. Everything is actually negotiable, including specialty hospital, and we proved that, actually, three of my partners, two former, wrote a nice article on AOSNOW last year specifically on our co-management agreement. Quality-driven care, everybody's going to have to think about this, but the thing you really have to think about is what Greg was saying, who owns the data? Because whoever owns the data has the power. Academic pursuits, well, there's different kinds of academic pursuits. You really can do anything you want. In private practice, you can take the time you want to do whatever floats your boat. As far as leadership, I mean, we've got plenty of people in our group that do lots of different things for leadership. We're solely private practice, and we're intimately involved at every level. This is stolen from John, but he's talking about job security. I don't really care. I do care about cybersecurity, and unfortunately, income security has been a problem because of COVID. COVID's been actually a big game-changer for us. What it did for us as a group is it decreased our per-partner income by 11 to 24 percent for the fiscal year 2020 compared to 2019. Obviously, quarter two was our biggest hit. For quarter three and quarter four, actually, of 2020, we were 133 percent above 2019 numbers. Partners, we did pay our associates, but our partners did not get a paycheck from February through July. Some private practice groups didn't survive because of this. What did employed physicians do? Some friends of mine left employed physician models because it wasn't going well, and it got worsened by the pandemic. Other people were doing nasal swabs. We were helping out in a different way, trying to keep our practice alive. The shameless plug here is I'm doing a COVID talk on Friday from 2 to 4. Actually, not all those two hours, but part of those two hours, so please come. Hospital revenue, well, really, I mean, hospital revenue increased during the pandemic. It actually increased. Bruce was talking about non-for-profits. That's a joke. Non-for-profit made $600 million. The reason they can call themselves non-for-profit is because they hide their money, and then they don't get taxed on it. I would say that hospitals are the enemy, especially of private practice physicians. The real enemy, though, is insurance companies, because the insurance companies should be embarrassed by what they did and how much money they made, not only during COVID, but the CEO from two years ago before he retired to probably buy a few mansions and a few yachts made $500 million in one year. There's an orthopedic surgeon who made $19 million in revenue doing actual work, and the CEO makes $500 million of a healthcare insurance company. He should be embarrassed. In summary, the grass is not always greener, but you never know until you make a move. For us, really, co-management has been a key, especially during our last year and a half with COVID. For us, it always begins and ends with our group. We're an orthopedic association of Hartford. This actually doesn't say anything, again, but it's, if you don't know, not now you know. Thank you. Good news is it sounds like we're going to make up some time. I think we saw most of John's slides. Great job, RJ. We'll keep moving. After John goes, we still have two more talks, but this is very entertaining, so we'll keep going. I want to thank Bruce for inviting John Campbell from Baltimore. I want to thank Bruce for inviting me to be the sacrificial lamb. These are my disclosures. Most of them are academic or related to the society. I do have stock ownership in a search center, so keep that in mind. As you saw from RJ's slide, we've been doing this to each other for 30 years, back to when both of us and Meyerson had hair. We're very dear friends and we come at things from a little different perspective, so I think that's refreshing. And I'm going to change the rules of the game, if you'll humor me. I'm going to try to reject this false dichotomy that you have to be one or the other. They're not all good or all bad. They both have pros and cons, just like every surgical procedure we do, every new invention we come up with, there's pluses and minuses. I think all of us are sophisticated enough to recognize that. So first of all, why are we talking about employed surgeons, employed physicians? Because that's where increasing number of jobs are. We're in this brave new world. RJ says we're doomed to repeat the past from Edmund Burke, one of my favorite philosophers. But there's also that other advertising campaign years ago, it's like, this is not your father's Oldsmobile. We're not going back to 1960 where everybody's in private practice and we all take off Thursdays and Fridays and play golf and we make a bazillion dollars. You've heard very elegantly from Bruce, revenues are going down, down, down, down, down. Your income is going to keep going down no matter what position you're in. So I don't think we're going backwards in time. So how do we optimize going forward? Here's some benchmark data from AMA. You're all aware that in the United States now more physicians are employed than in private practice across all disciplines. And there's some interesting demographic trends which I found, you know, higher percentage of younger physicians are employed and a higher percentage of female physicians are employed rather than private practice. I just don't know if those are going to reverse and go back in the other direction. You know, is it suddenly going to flip where the blue is bigger than the red? I don't know. But certainly the last slide showed that trend is down in terms of that percentage. So I'm sorry the sound is not working, but I'm going to quote one of my favorite American philosophers, Vince Lombardi, who said, what the hell is going on out there? And there's a lot of different factors involved. So we'll move on. So conventional wisdom, you know, what are the advantages of being an employed physician? You know, you have other people helping you or, you know, covering you for practice management. You may not have to be as involved in that in terms of personnel and IT and benefits and so on. Another big plus for a lot of us is you have a steady salary, you know, with your contract. And it may free you up to concentrate on patient care or skiing or research or innovation or whatever you want to do in addition to taking care of your patients. You know, what are the downsides or disadvantages? And I think Dr. Jays alluded to some of them, you know, lower income, you know, you may not have the same access to ancillary revenue. We'll talk a little more about possible loss of autonomy. So you know, pluses and minuses, as we said. I think this is my basic theme. You got to figure out what you want, what are you interested in, what makes you happy, what makes you, you know, thrive in your professional life, and, you know, kind of come to finding that in your work environment. You know, here's some data looking at employed physicians and what are they most like about being employed, not in private practice. And it's, as you'd expect, you know, pretty steady guaranteed income, not having to deal with a lot of the business of running their practice, which if you're not into that, you know, RJ's a great businessman, a great innovator, you know, Steve Neufeld's a great entrepreneur. They love that. They get into that. That's not my thing. So I'm fine not being as involved with that. I'm kind of referring to people employed by hospitals or like health or health network, either local or regional or like some of the health corporations. We're not really focusing on sort of those special employed people like military or VA or health service or RJ's junior partners who are not yet partners in his group and they're employed by him. They probably have the worst situation of all. Compensation. You know, I found Bruce's talk very interesting because in preparing this, I really struggled to find good, reliable data, not garbage data. And it is tough. Okay. Like, what do we all make? You know, there's no like central repository to get good numbers on this. So first, if we start out with ortho in general, you know, one survey on Medscape said there was about 500,000, 511 is mean compensation. Another one was Merritt Hawkins survey was 533. The trends I could find this year are relatively flat. There hasn't been a big increase and that may be related to COVID as we'll talk about. This was a survey from American Alliance of Orthopedic Executives. I would assume those are people working in private groups and practices, but this shows you where foot and ankle works in the ortho universe. We're on the lower end of the scale. I think the only one lower is peds and they're not even on this. So take that, take that with a grain of salt. Here's some data that was somewhat reliable. It's from MGMA. It was their 2020 report. So it reflects 2019 data before this came along. And interestingly, this is broken down into percentiles, a 25th percentile. Red is mean and green is 75th percentile. And you can see, you know, increasing clinical compensation. The thing that I found really interesting with these numbers, which again, there is probably sampling bias. This is not going to reflect the entire, you know, foot and ankle universe, but it was pretty much the opposite of what I expected, which is the higher you got on the scale, there was less differential between employed and private practice. The lower on the scale, there was a bigger difference. I would have thought it would have been the reverse, maybe, you know, with my friend, Dr. Rockefeller over there, but you know, it just surprised me. So those percentages were not as big. R.J. pooh-poohed the idea of productivity or incentive bonus, because that's what his whole practice is. But for those of us who are salaried, this can be a pretty big chunk of money on top of what your base salary is. And I don't think, you know, when I was in academics 20 years ago, this was barely on their radar. And now I think you'd be challenged to find employed physicians who don't get some degree of productivity or incentive bonus. And there's different models of how to do it, you know, revenue only or RVUs or a combination or hybrid, which is what we have. But, you know, this can make up a chunk of your compensation. Also, you know, you're eligible for retirement plans for tax-deferred investments, and some of which can be contributed by the employer. So technically, that should go on as a line item of part of your employment, so your compensation. So you know, that number can go up to in the high 70s. Here's probably the biggest drawback, which is ancillary income. Yes, private practice groups have this, which a lot of us don't. Whether it's imaging modalities or owning a physical therapy group or pharmacy or, you know, ASCs and DME. You know, one caveat is, like, our hospital is a great partner, and we co-own an ASC with them, a physician corporation. So that's available. Another caveat, I'm in a state where, like, you can't do MRI. And as Bruce said, those may get increasingly restricted. So you may start seeing more of these dropping off the list for the private practices. So where that goes, who knows. Autonomy is another big issue. And you know, RJ, I think, believes that I go to work with my partners who most of you know, and we're like those guys in the old Gladiator movies, like, you know, rowing in the bottom of the slave ship. You know, it may be our particular situation, but we have an incredibly cohesive and cooperative, you know, relationship with our hospital. They would not think of expanding our group or bringing on other personnel or, you know, making changes to our clinical practice with us being at the table. We're heavily involved in that. I think some of that is, you know, not to get squishy, but if we're not happy, we're not as productive. And also, there's the potential for turbulence and turnover. And then somebody leaves, and then they have to go out and find somebody else, just like any other, you know, industry or corporation. You want to keep your personnel stable so there's no, you know, turbulence and more cost potentially. So we have a good amount of involvement with that. As a counterpoint to RJ, you know, private practice, yes, you have autonomy. I think it depends on size. And I do think having friends who are in this role, you know, a lot of times the younger surgeons in the group, if their practice, if they've now, you know, graduated to be partners, still kind of feel like they're doing a lot of the work and the senior guys are cashing out. And it can kind of make this sort of top-heavy relationship, so you have to be careful with that. Does RJ's newest junior partner really have the same autonomy as him? I would doubt that. Clinical practice, more in terms of your day-to-day, you know, we have a great setup where we practice OR, ASC access, our staffing model. You know, we have all the latest, greatest technology in our office, hospital-provided. So my bottom line in terms of the money is, you know, is everything negotiable? You may be able to come up with creative ways to augment a baseline salary or bonus program with stipends for teaching or academics or administrative committee work, like RJ said, or, you know, even things like licensure fees and, you know, board exam fees, et cetera. So, you know, when you go into that, talk about it and see what else you can extract. Bruce and RJ commented on quality-driven care, and I completely agree this is going to be crucial moving forward. I don't look at this so much as a dichotomy between private practice and employed. I kind of look at it based on size. The larger entities, whether it's a hospital or a large employer or a large group, like the two of them have, probably have much more robust, you know, EMR programs, IT programs, outcomes, like Judy's interest, and, you know, quality programs. You probably have better systems in place the bigger your entity is. Smaller private groups probably have a harder time managing that, and so it's not so much a matter of do you own your data as can you actually act on it, evaluate it, and then make changes based on that, and a small private group may have that challenge, whereas a bigger hospital or bigger corporate group may be able to do better with that. So I don't think that's necessarily a disadvantage for us. And Pursuit, same thing. We're both involved in academics and teaching, which I really enjoy. We can do research. We can, you know, people can be involved in industrial collaboration and things that Greg alluded to, so that's no drawback. Same with leadership, and as RJ said, all of my partners are involved with AOFAS, with the academy. We're involved with our state, you know, medical or ortho society, even hospital administration. I'm involved a little bit with that, with some of the committees, and, you know, that's open to you as well. So if you enjoy that, carve that out. Do it. Security, this is probably the final big topic for me. You know, this is a biggie, and, you know, having some stability with your defined contract and protected income can be very, very valuable and, you know, reassuring. Maybe a larger entity can better buffer turbulence. If you're in a group of 100 surgeons, you may have an easier time than if you're in a group of five, you know? And I don't really need to remind you, the perfect case study of all this is last year, and as both of them mentioned, you know, practices in hospitals saw some declines in revenue. We probably all experienced to some degree at least slowdown or even outright cancellations of surgeries, and, you know, some data says salaried physicians were protected a little bit better. Jim Ficke had a nice study from hospital data from Maryland, and of all the different services ortho got hit the worst in terms of decreases in elective inpatient surgeries. You know, a lot of our stuff's outpatient, but the joint guys got penalized bad, and it took longer to recover. Found an interesting thing in Medscape, 12% of orthosurgeons think their income is not going to return to pre-COVID. It's kind of scary. So I guess I would combine my thoughts on this with Bruce, you know, what's our next big crisis, you know, or inflection point? We don't know. How many in 2019 could possibly have predicted what was going to happen in 2020? Are we going to have more shutdowns? Are we going to 2.0, or is it going to be regulatory, or is it going to be insurance, as Bruce said? You know, could it be fiscal, you know, entitlements are going to head off the cliff? What happens then? So, you know, having some fiscal financial stability as an employed physician was good. You'll be happy to know that during those three months when RJ was not being paid, I was getting full salary, and I was sending him stipends so he could keep buying his Bordeaux and stay happy. So it all worked out good for the two of us. All I want to tell you is I think this slide probably matters more than anything else I've said, which is who's happier, employed or self-employed, and they're basically identical. I think the key is finding out what you want to do, what makes you happy, what kind of practice you want to be in, and then go for that, and, you know, it could be one or the other. I thought this was a cool quote. There's no standard for what private practice, academics, or hospital-employed positions look like. So I would close and say, don't be like RJ. Think for yourself. Find what makes you happy and be like me. And the final thing is intangibles, and as he said about his partners, I have the best partners in the entire universe, and that, to me, is worth a huge amount of money every day to be able to work with these guys. So I thank them for all they do for me. Awesome. So I have a deal for you guys. So we still have two more talks left. You can tell how passionate everybody is. Welcome reception starts at 4 o'clock. If you stay in the room for these two talks, I'll buy you a beer downstairs in the exhibit hall. Obviously, you can tell why people want us to talk about practice management, because everybody's interested in it. So let me call James Toussaint up here from Gainesville, Florida. I've got to get his talk up first. Let's see. I think this may be it. That may be it. OK. And so I'll get James to talk, and then Casey Humbert's going to close us out with talking about conflict and disruption, which is perfect before you get your free beer from me. All right, Bruce. So I don't want to look like a hospital administrator, so I'll loosen up my tie. Right? You're private equity, so you're somewhere in between. Somewhere in between. OK. So I'll keep the tie on, but I'll loosen it up. All right. So I know we're running close on time, so I've got about three minutes. So I'll go as quickly as I can. So as it relates to this presentation, I have no disclosures. We're going to talk about schedule optimization, physician extender optimization, billing, and ASC optimization. So scheduling first. So as you can imagine, a smooth schedule is critical for a healthy practice, both for yourself, your employees, and for your patients. So it's obvious that if your clinic isn't going well, you'll find yourself waiting around for the next patient, your staff is going to miss their lunch break, they won't get home on time, and your normally happy patients will start to complain. So that's when things start to get a little heated in your clinic. So an optimal clinic schedule will optimize both the surgeon's preferences and the patient's satisfaction. And obviously, you can't just lower the number of patients you see per day, because then it'll lead to bankruptcy, especially with our increasing overhead and decreasing payment per RVU. So you have to find your break-even point to cover your expenses. On average, how many patients do you need to see in your clinic to cover the expenses and keep your volume running? Determine how much time is needed for different types of patient visits. What time increments do you need to see your patients for? Is it 15 minutes per or is it 10 minutes per? You have to look at different scheduling designs, which we're going to look at in a minute. And then don't forget to run your proposed clinic schedule by your assistant, because obviously, or maybe it's not so obvious, but you'll find out that they know a lot more about how the clinic runs than you do necessarily. So sample clinic options, so you'll have options to double book, which will minimize downtime but can irritate on-time patients who must wait around for you to finish the first one. Modified wave scheduling, and that's where the patient appointments overlap, so that way if one is late or you're done early, then there'll be another patient waiting. You can have the ability to group certain patients that are similar in diagnosis or treatment. So for example, if you're going to be doing multiple injections or multiple, you know, two-week post-op visits, you can set them up in a row. Staggered starts, that's similar to the modified wave, but basically, you're going to minimize the lost efficiency from late patients or no-shows. And then group meetings, group meetings tend to be a little bit more conducive to, let's say, somebody like an arthroplasty surgeon who sees multiple total hips, multiple total knees at the same time. They can just group them together, and they can do the patient education, talk about the preoperative, postoperative things all at the same time. So that's probably not as meaningful for a foot and ankle surgeon, but there's some utility there. So this is an example of something that I would use in my clinic. This is a wave schedule. So the first few will be, you know, follow-up MRIs, maybe some post-ops, and while I'm seeing them pretty quickly, you know, I don't have to wait for them to go in and out of the X-ray room. I will have a, let's say, patient C right there, which might be a straightforward ankle fracture. So they'll be getting their X-rays while I'm seeing the first few patients, and then when I'm done with that, then they'll be ready to go. That's just an example. So despite everything that you've done, there are still going to be some roadblocks. You know, there'll be patients that don't show up, there'll be late arrivals, some bottlenecks like X-rays backed up, you know, people who are walking in, people who have unanticipated problems or maybe you just don't have the capacity. So the schedule example that I showed you here is something that allows the combination of double booking and maybe a wave so that way you can keep accommodating these types of unexpected patient problems. What I found is that if I maximize RVUs rather than volume, that helps. You know, I'll make sure that the new patient slots are protected, and I learned that during fellowship that you don't let your assistant book a post-op in a new patient slot because the post-ops aren't necessarily going to be paying you anything because they're still in the global period. I certainly hired an extender. I hired an extender relatively early in my practice because I realized that if I treat them right and if I train them right, that they are essentially an extension of me and I can be in two places at the same time. The other thing that you can do is you can create a triage list for your scheduler, right? So if a patient comes in that's been referred from a key provider in a neighborhood or a new patient or somebody who has a fracture, you don't want them waiting around until the next clinic visit open slot. You want to let your triage person or your scheduler know that you want to see them as a priority. And if you have any trouble with something like this, there are also third-party companies that can help you optimize both your clinic and surgical schedule. So that was the clinic piece. So physician extenders. What you'll find is a physician expender will pay for his or herself. They are certainly a profit center, especially if you integrate them well into your practice. They are reimbursed on average 85% of the physician's fee schedule. They can go higher depending on if they are, if you're billing incident to, like if you're in the building. And Medicare, this is something I didn't realize. So if I am acting as a second assist surgeon to the primary surgeon, Medicare will reimburse me 16%, but the PA will get reimbursed 85% of that 16%. So it's a no-brainer. It makes sense to have a PA there, unless you certainly need the surgeon as a first assist. To get the most from your PA or NP, you wanna first hire the right person. You know, is a new grad the kind of person that you want, or do you want a seasoned veteran? You wanna make sure that you define their role. All right, are you gonna use them in the clinic only? Are you gonna use them in the OR, for call, et cetera? I found that one of the most important bullet points on here is to make time for on-the-job training. So it doesn't matter how seasoned this veteran PA or NP might be. It's unlikely that they know how to treat a foot and ankle surgical patient the way you do. And for example, let's say they came out of North Carolina. The way I practice my foot and ankle, you know, surgeries and clinic, et cetera, it's not exactly the same way as Dr. Cohen might. And then take full advantage of their scope of practice. Right, so they're there to be an extension of you. So if you keep them only in clinic, without the expectation of going into the OR, they'll probably be unhappy, and you're not maximizing the return on that investment. So you wanna make sure that you take full advantage of their scope of practice. So what can they do, right? So in my practice, so my PA is directly associated with my P&L. They are involved in the full scope of ER call coverage, the operating room setting, and the inpatient setting. And what that means is, you know, they will feel the call, they'll reduce a simple fracture, they'll get the patient positioned in the OR, they'll see the post-ops, they know what the wound should look like, and they know things based on my preferences and my practice. The typical PA or NP utilization models are listed here. So there's a dyad model. The dyad model is one where the physician and extender split the clinic patients. And, you know, there's also an observation model where the extender handles most of the patient management and billing. It's an efficient way to utilize the extender and allows them to work at their highest level. So that means that they're in there, the PA or the NP does all of the work, and you're not, you know, going back and, you know, sort of verifying the plan because they already know what to do because you trained them from the onset. So the observation model is really efficient. There's an admissions model where they primarily work in the afternoon or in the evening, and they're helping you in the hospital setting. So the most efficient model is one where the PA has, you know, their own clinic and space with staff. The PA or NP will see the patients on their own and they'll ask you questions for management. The least efficient one is where you follow up and see every patient that the PA or NP has seen. They're highly inefficient, and, you know, it's just not gonna help your clinic flow. So again, you want to integrate them into your team and make sure that they're involved in every stage of patient care so that when the patient calls and says, hey, I think my wound is a little erythematous or my toes are swelling, then the PA or NP is gonna know exactly what to say based on what you've taught them. All right, so let's move on to billing. Am I going fast enough? Okay, good, all right. So billing optimization. This one is highly, it's a little convoluted, right? So whether or not you're in private practice or in a hospital-based setting, knowledge of how to bill your procedures is critical. So you have to keep the revenue flowing without delaying your payments and obviously reducing stress. As I mentioned, it's highly convoluted and it's overly complex. Just this year alone, there were changes to the E&M codes, so now you focus more on medical decision-making as opposed to hitting points for your history and physical exam. In 2021 alone, again, now there have been over 490 ICD-10 codes, right? 58 deleted codes. And when it comes to the CPTs, there are 329 editorial changes, 206 new codes, 54 deletions, 69 revisions. I mean, it's all over the map. So, I mean, in reality, you should have a degree or some sort of certification to get it all done right, right? So ICD-10s have to match CPT codes. There's modifiers that, you know, Dr. Ardoin talked about. They're all over the place. You know, global periods are not always 90 days. If you look at wound abreviants, they go anywhere from zero to 10 days. CCI edits, you know, you can't double, things are bundled. You can't do this code with that code, et cetera. And then there's this HCPCS where these are the codes where you use to get reimbursed for supplies, equipment, drugs, et cetera. So now, if you submit a code and it's not clean, meaning that there's a reason for denial, it's gonna cost you about 25 bucks to appeal that, you know, just as far as manpower and paperwork, et cetera. And about 50 to 60% of the denials are not even worked up. And in every rejection or denial increases the risk of never getting paid. So it's interesting, you know, Dr. Ellington back there was talking about the nuances of this industry. The reality is you've done the work and now they're telling you they're not gonna pay you. I mean, there's no other industry or their service sort of provide, you know, I can't even imagine anything else where you do something and don't get paid for it. But the reality is this is what we're doing. So you should code it right the first time, right? So your goal is to submit a clean claim and get paid without denial. ICD-10 is both your friend and your enemy. Use the correct model files and don't upcode. That's an obvious thing, but also downcoding is not right either. So that can get you in trouble. So what I've done is I use a certified medical biller. There's a person who works in Oregon. Remember, I'm in Florida. And I pay this person a reasonable fee to get me multiples back from what I've paid her, right? She's a trained professional. She stays on top of this. This is what she does for a living. So it doesn't mean that I don't know which codes I'm submitting, but once I submit the codes, she goes through and she makes sure that she bills it properly, submits it properly. So that way I get paid on first pass. And if I don't, then she tells me exactly what documentation I need to resubmit and get it back. So they're in this process, right? You can imagine that it's really important to quickly reply for the request of additional documentation from the payer. And you want to log and prioritize the things so that way you minimize delays and denials. The reality is that someone up here in the panel said this, that the payers are probably your enemy, they're not your friend. And so there's this something called underpayment. So despite the fact that you've negotiated, let's say, I don't know, 500 bucks for a bunion, they may pay you $300. It doesn't mean that you didn't submit it properly. It doesn't mean that it's not a clean filing, but they don't realize, well, rather I should say, they realize that you don't know the contract as well as you should. And so if they give you 300 bucks and then you go away and that's perfect, right? So they've underpaid you. So it's not that you're doing anything properly, it's that the payers are quote unquote misreading the contract. So you should be aware of your contract, excuse me. You should review your data so that way you know what's going on and that you shouldn't let these underpayments go unnoticed because you've done the work and you should get paid appropriately, especially if it's a contractual obligation. Denials will happen, but they need to be, excuse me, I don't know what's going on here. So, okay, so denials will happen, but they need to be managed effectively. They put pressure on your cashflow and they're worsening your accounts receivable. The best strategy is to prevent this from happening in the first place with clean claim submissions. And like I said, I use a certified medical biller and that's something I would recommend for everyone. And the best strategy again is to identify and resubmit quickly if you do have a denial. You should be on top of your data, right? You should know what your AR trends are. If your AR days outstanding are increasing, you should know why. You should track your follow-up correspondence because you've already done the work and you should be compensated appropriately. So let's go to ASCs. So ASCs, we've heard this from multiple people on the panel. The growth is projected to be over 26% by 2026, largely driven by an aging population as well as the elimination of the inpatient only list. The proportion of orthopedic surgery procedures being done is increasing significantly. I think you mentioned this, 68% by the mid 2020s as far as orthopedic surgical cases. And again, I'll try to be brief here. So you should take advantage of this opportunity by if you're a part of the OSC, maximize revenue and minimize cost, right? So profit sharing is a good way from top to bottom to incentivize everyone to align themselves with the same goal. Get as many cases done, finish quickly so everybody goes home, the patients are safe, et cetera. You wanna do a lot of patient outreach, market your surgeons. If you have any unique offerings, robotic assisted, whatever, any specific procedures that people don't otherwise offer, you wanna make sure that your patients know that, market the heck out of your great surgeons. You wanna know your costs down to the penny. That's particularly important for people in private practice. And pick the right patients. Minimize readmissions, optimize outcomes because if you do it right, then it's gonna generate more referrals from either the patients themselves or from the surrounding referral docs. And then very importantly, you wanna invest in enterprise software, right? So no longer should it be doing accounting and billing on paper. Collections shouldn't be done on paper. These are things that you should have access to the data to and you should be able to do it pretty quickly and have it right on your desk as soon as you ask for it. It goes without saying that you should minimize vendor exposure. Nothing against any vendors in the room, but a single vendor system has been shown to lower implant costs, but otherwise make multiple vendors compete between themselves so that way you get the ASC the best price. Negotiate the right contracts, right? So I know a case study of a surgery center where they did not have a total joints program. They went to implement the total joints program and realized that they're gonna lose money every time they do a joint. Well, why? Well, because they didn't negotiate the right contracts. So that goes against everything we were just talking about. And then you've already touched on this, Bruce. Negotiate a high surgeon fee, right? The surgeon's fee, negotiate a higher surgeon fee for cases done at a surgery center versus the hospital setting because you're saving them a ton of money. You wanna, again, get intimate with your revenue cycle management. Collect upfront, preauthorize cases. That's very important. You wanna code accurately, bill and collect in a timely fashion, and then obviously be transparent with your patients with respect to how much it's gonna cost them. And I already mentioned this before, a data analytics platform is key. It gives you an idea of your costs down to the penny when you have to improve on your supplies, physician block utilization, et cetera. And if you haven't heard, right, total joints, spine, very lucrative for a surgery center. So I encourage you to encourage your total joints and spine partners to do their cases at the ASC because it will significantly improve the bottom line. Thanks, guys. Thanks, great job. Okay, now I owe you two beers from industry. We didn't open it up for bourbon. We're up to bourbon, bourbon, okay, yeah. Just go to the bar and just use Greg's name. After your talk, the name is Burlatt. Just put it on the Burlatt tab. Okay, so Casey Humbert's gonna talk to us about how do we deal with trouble and difficult patients. Thank you so much, Bruce. I'm getting to give the talk on getting sued. I'm not sure why Bruce thought I was the right person to talk on that topic. I haven't been sued, so it's a real short talk. Also, everybody deserves a drink after this great lectureship, but there's a lot to digest here. I have to think about private practice after RJ's persuaded me. So who gets sued? These are all physicians, and about a third of all physicians have been sued. When you look at surgeons, it's a bit higher. You'll see here that the men are about 40%, and women are 23% amongst orthopedists. Men are more likely to be sued by women. This might be a selection bias, or it might be that women are just more awesome. You decide. So I talked to a hospital-based attorney, because I haven't been sued, and I said, tell me, what would you want to communicate to folks? You do risk management, you deal with disasters. And she said, patients don't sue people that they have good relationships with. And maybe this is why Bruce wanted me to give the talk, because I very much value the relationships I have with my patients. I've been teased for being overly sweet and sensitive with them, but that's where I get my joy, and hopefully that's where they get their positivity for seeing a physician. Also, hurt people hurt people. So if you have someone who has had a miserable outcome, and they're not only feeling physically hurt, but emotionally hurt, and they feel that you're dismissive, that is a setup for a lawsuit. So overwhelmingly, when it's been studied, the breakdown in the relationship, rather than a poor clinical outcome, it's the relationship breakdown that predicts what, why patients get sued. It's a good way to get you to listen when they feel that you haven't been listening. So these are some of the things from an article, it's a, I have the reference there, sorry it's so small. So the feeling that physicians wouldn't listen, they wouldn't talk openly, they attempted to mislead them, they didn't warn them of long-term issues in their newborn stuff. Other things, that they felt deserted, they felt that the physician wasn't available, they felt that they devalued them, or their personal family views, that information was given poorly, or they failed to understand. So step one to avoid bad things is to develop a relationship with your patients. Step two, don't go in distracted. I talked to a good friend who works at Johns Hopkins, I said, tell me about your unsuccessful things, where have you had to pay out lots of money? She said it was people who didn't avoid malpractice behaviors in the first place, and she said in almost every incident where it was a surgeon, someone was going through a divorce, there had been a recent death, a kid had just gotten a cancer diagnosis, these people shouldn't have been operating, and they went in and did it anyhow. So she said, don't go in distracted. Be present, pay attention, and if you can't, you need to cancel and reschedule. Nobody should be operating the day after their kid gets cancer, nobody should be operating the day after their wife says she's leaving them. She also said there's all types of systems in place to help prevent these things. Marking on the side, taking a timeout, don't ignore the systems that are in place. These are hand over your wallet lawsuits when you operate on the wrong side, especially because no one's gonna back you up if you ignored the nursing, wait, wait, wait, you're on the wrong, don't go in distracted. So step one, have good relationship. Step two, don't go in distracted. Step three, know your team. Know your team now before you're sued. I've reached out to Penn Medicine, HR, I'm sorry, not HR, Risk Management, just to say hi, just saying, I just wanna know you before I need to know you. Because I happen to know the Hopkins attorneys, because my other hat is I wear the ethics hat, that's a lot of work I do, so I actually would talk to Risk Management with devolving patient relationships, and them coming in saying, can we just run this by you, we want your advice from the clinician end. So I got to know them really well, they're a tremendous resource. So know your team now, because if you get sued or there is a threat of a suit, if someone says, I'm going to sue you, your first step is to call your lawyer or legal team and do whatever they tell you to do. Most importantly, and this to me is relatively intuitive, but she said that in her experience, in her experience, about half of physicians reached out to the patient, don't reach out to the patient. Once you have been sued or told you're going to be sued, don't call the patient, don't say, how could you do that to me? Don't have that with a patient who feels that you haven't been communicating with them. Be the first communication they feel that you finally paid attention to. So these are my steps for avoiding and managing trouble. I made up a three point because we can't ever remember more than three. Have good relationships, don't go in distracted, and know your team in case you need them. And now here's my sensi side, because this is who I am. In terms of the experience of being sued, only 2% of people said that it was not as bad as they thought it would be, and only 2% were neutral. Everybody else was pretty miserable, and if you look at the bottom two, very bad, disruptive, and humiliating. And then the bottom one, which is a quarter of all orthopedists, it was horrible, one of the worst experiences of my life. So to that end, share the pain. If you get sued, we know that we have really high rates of physician suicide. We know that folks struggle. This is an intense, wonderful profession, but super intense. So make sure that you have resources. Peer support is key. Spouses aren't actually super supportive in these, unless your spouse is able to be a physician and can also dissociate from being married to you. So I think peer support structures are really important. We have somebody else who can give you that perspective. My favorite story of peer support is, I called my husband after one of my first cases, where I broke that little chip off the back of a fibula fracture. I was like, oh, I feel so bad. I lost this, this piece broke. And he was like, oh my God, did you ruin their leg? Are they gonna be able to walk again? Don't call a lawyer when you're upset about a surgery, is the lesson there. And then I called my dad. I was like, you're not helping. So I called my dad, who's a retired orthopedic surgeon. He said, perfect, more bone for healing, which is the correct peer support response. He said, is your reduction perfect? I said, yeah. And he says, who cares about a case, move on. So peer support is key. Make sure that you have a support network so that you aren't in that worst experience of your life, or if it is the worst experience of your life, at least you know somebody is down in the trenches with you. There are some resources, the AOA, AOS, have a lot of resources for physicians being sued. Also an excellent book by Wayne Sotilo is A Resilient Physician. I said I'd keep it brief. That's awesome. All right. So my apologies for running late. I think we're just all passionate about these topics. Thanks, everybody. The panel can stay around for a few more minutes. If you guys have any questions. If not, the beer is on me, and the bourbon is on Burlett. Just tell him to put one on his room tab at any hotel in Charlotte. But thanks, everybody. Give us some feedback. We want to know how to deliver such a broad topic in a more concise way or a more detailed way. Because I think this, hopefully this format of the ICL, which we really want to hear some feedback on, I think it's here to stay. I hope. At least that's my impression from today. But give us some feedback so that we can make this better. This is the first time we've done it this way. Thanks, everybody. Enjoy everything tomorrow.

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practice revenue

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surgical procedures

billing optimization