Welcome everyone to today's webinar entitled Beyond Hospital Employment, Navigating the Path to Independence. And maybe we should change that to Back to Independence, given the circumstances that you're about to hear about. My name is Joel Sauer. I am the EVP of Consulting for MedAxiom, and I am pleased to be your host and moderator for this afternoon's discussion. And before I get into introductions, I do want to emphasize that this is meant to be a dialogue. This is meant to be an interactive Q&A session. So we welcome your questions, and I'll get to how to, well, I guess I'll do that now. So our Q&A happens in the Q&A box that you should see. There's a button on the bottom of the Zoom screen for Q&A. That is where you will type in your questions to any of the panel members. And you can do that at any time. We do not need you to wait until the end of the broadcast or at the end of our session. You can type that in at any time. If you are having technical problems, such as a problem with the audio, the images, the slides, et cetera, please type those into the chat box, because that is the area that our technical team is monitoring and they will be able to help you. The chat box is also where you will find a copy of today's slides. There's a PDF version that you can download if you are interested in keeping those. So now I would like to make introductions this afternoon or morning, depending on where in the country you are. We're joined by Dr. James Flynn. He is the managing cardiologist for cardiovascular specialists of New England, or CSNE. You may see that acronym throughout the broadcast. Dr. Flynn is going to be telling us about their journey from hospital employment back into an independent practice. We're also joined by Jason Gunderson. He is the CEO and co-founder of Cardio One. Cardio One was the organization that provided the support for Dr. Flynn's practice as they made that transition. And joining Jason on from that team is Carol Ann O'Sullivan. She is the vice president of operations for Cardio One and specifically for the CSNE practice. So with that, I am going to turn it over to Dr. Gunderson, who is going to take us through some background of what happened. Excellent. Thank you, Joel, and thank you, everyone, for joining us. And most of all, thanks to Dr. Flynn and his team for trusting us as a partner to work with him on the liberation and path to independence. So I'm really excited to kind of move into the Q&A and kind of hear directly from Jim and Carol Ann, who are doing this every day. But I wanted to provide a little bit of framework on kind of how we got here and a little bit about where we think the direction of the market is going to go. So we'll click to the next slide. One thing I think we all know is, is there has been a just absolutely meteoric rise in the employment of cardiologists across the United States. I liked a kid back when I was a resident, which was getting to be a while ago now. Most of the docs I worked with were private docs, even though it was an academic medical center. Interesting little fact, Jim and I actually both worked at UMass at the same time many years ago. So it's a great kind of reconnection, but really an incredible rise in consolidation by hospitals into this kind of employed model. And I would put in that model integrated, which are really like the payviders, like the opt-ins, but we're approaching almost 90% of cardiologists are employed. One thing we have seen, and this is from a study that was funded by the American Independent Medical Practice Association through Avalere, that model has actually caused a rise in total cost of care across the health system. So it's not been good for the health system. It has actually driven the cost of care up. So this was a study that was done by Avalere. It looked at five specialties, and it looked at the movement of physicians from independent or PE-backed kind of management services organizations into hospital and corporate employed entities. And if you look at that study, it was pretty fascinating. This was Medicare only. We are working on a study for the more commercial side. I am on the board of AMPA along with a number of other physicians. That has led to a cost of Medicare of about $4,000 per Medicare beneficiary per year. Just by moving into that hospital model, we know that there's hospital outpatient department charges. It's expensive. It's hard to get in. Utilization goes up. So there's been a big movement there. It's not been great for the health system, but it's largely been driven by really aggressive moves by large health systems. And it's just difficult to be an independent doc today. I mean, it's complex. Payer relationships are complex. You need scalability. There's capital. There's technology. There's resources. There's simple things like just hiring and maintaining staff. And so that kind of administrative burden and challenges, I really think, has driven that move. We're excited to see that move start to move the other way. We'll click to the next slide and talk a little bit about kind of satisfaction. Here's some data on here. We've seen that move to employment, but we've actually seen that move to employment lead to more physician dissatisfaction, so more of a negative view of their work. So you'll see independent versus employed on the left. And they're really citing a lot of burnout. A lot of physicians do consider going to private practice on this study. Many don't know how to do it, but the biggest reasons they cite for that are autonomy, control, the ability to kind of really control is the big one, control over patients, control over hours, and the ability to kind of, you know, profitability and pay is a component of it, but it's really about driving the direction of that and having more control over it, rather than some administrator coming in and saying, oh, we're changing your staffing or, oh, you're low on a certain number of test procedures or, you know, your schedule changes. You really don't have control over the clinical direction or the way you want to kind of work with things. And that's really been a big driver of it. And I think we'll hear directly from someone that wanted to do it in just a minute. So we'll click to the next slide. So for those that are in cardiologists today, there's really three paths, right? There's the employed model, which as we saw is about 90, you know, pushing 90%. So very stable. You get a salary. Although I would say that that stability is starting to get a little bit not so stable as health systems are coming under pressure and movements in the market. But less administrative burden, you get a salary, maybe you're on an RV modeling before, but very little autonomy, lack, you know, a lot of bureaucracy, and you really don't control a lot of your income. You're really driven by how the hospital works. We do have private equity companies. A number of private equity-backed companies in the space have grown really rapidly over the last several years. I think that's been an option for a lot of physician practices out there. And, you know, I think that it is an option. I think it's an option that people should consider. It does come with capital infusion, business expertise, potentially higher earning potential because you're kind of in control of that. You do have some loss of control, a little bit more drive on profit, and then there's always this kind of how private equity thinks about the next turn. In other words, how do we move from sale A to sale B to sale C? That's kind of how the model works. And there is a little bit of loss of control in how those come together. And then there's independence, where you kind of work on your own. It's personalized. You can make it there. There is some higher earning potential because you're not paying as much, but you're also getting a lot of pressure from payers. Payers are, I'm going to use the bold term, held a bit hostage by the health systems because they've gotten so large that they can demand extraordinary rates. I like to tell stories. I had a $5,200 echocardiogram in Denver, Colorado, because that's how the health system billed the payer. And I ended up with, I think, almost $285 out of pocket, which is pretty crazy when you think about the cost. A lot of the independent docs kind of have the high administrative burden and need some help moving forward, like the economies of scale. And I think there is a path forward on that. So we'll click over to the next slide. I'm just going to, I'll tell you the view of the CISNY. And we use CISNY as our abbreviation because cardiovascular specialists of New England will take us a lot to say over and over again. And I'll just kind of give the summary and then I'll, we'll hear directly from the story about Jim and his group were an amazing group of docs working in New Hampshire, nine cardiologists, there were five interventional, four EPs, three APCs, looking to kind of reclaim their independence, some changes in the hospital, wanted to move out. We were introduced in February, got to fly up, have dinner with the group and really kind of align on what they were looking for. They wanted some help with partnership. Really, you know, the group's amazing to work with. I'm excited every time I'm on the call with them. They have a lot of strategic direction, a lot of interest, really a big drive to drive the business, but really needed help kind of like coalescing and pulling all that together. So we did our intro component, got our contract signed and we launched into implementation. So we put together eight work streams, hired local leadership with Carol Ann being an amazing resource to have there. We were able to bring in 53 practice staff, financing secured. We had contracts secured about 94% were secured a month and a half pre-launch and we were a hundred percent contracted when we launched. And day one, September 3rd, everybody was seeing patients. And so they are now a fully equipped practice with two sites, full capabilities from ultrasound, PET, treadmill, device monitoring, the rest and growing very rapidly. It's been a thrill to be a part of it. And it's a model of success to show someone that you can move and be independent and have control over your own practice. And we'll click over the next and I think we'll hand it over to the panel discussion to hear directly from Dr. Flynn and Carol Ann about their experience there. And looking forward to questions and Jim and the CISNY group have really been pioneers in this. First group to really lead, first group ever to lead fully employed to go fully private, have their own entity, not employed by anybody and really driving the business. So hand it back to you, Joel, and we'll answer questions and go from there. Great. Thank you for that, Jason. So Dr. Flynn, let's start at the very beginning if we will. And thank you for joining us this afternoon. What was the motivation for your group to say, we're going to go private? Was it a singular aha moment, a singular event, or was it death by a thousand cuts that there were things happening you just didn't like to see? What motivated you all? A little of both. I think the group, very talented group of physicians at the time, the entire group was 26 docs and 23 APPs. The system, the hospital system has been challenged, I say, for a little while. And I would say that the group outpaced the hospital in terms of where it was going. And it led to a lot of long-term frustrations in terms of patient care, the basic stuff, answering phones, following up with patients, getting people scheduled. All that was becoming a big challenge. And then the hospital system, as it devolved, it started losing quite a bit of money, ended up being acquired by a for-profit. And when we got wind of that, we made it known that we weren't in favor of that. And in the end, we made the choice. We felt like, I think a lot of people are feeling that loss of control and loss of feeling valued. And the group had been stable for many years, decades actually. And for the first time, a couple of the physicians left and that really had never happened before. And that was a big red flag. And so we saw it falling apart. We saw people leaving. And from the standpoint of our group now, we saw this as a way to kind of keep the talent together. We had developed really very, very strong interventional programs, EP programs, structural programs. And we felt like we liked each other. We liked working with each other. We thought that it would be very hard for any of us to reproduce that in another situation where we had the amount of talent and just collegiality that we had. So, we sort of saw this as a way to sort of build a vision, to fulfill our vision and sort of deliver the quality of care that we wanted and that we felt was lacking previously. So, it was nice. We had autonomy. We were freed from the bureaucracy. We freed from the dysfunction we were experiencing. And it's really been exciting. Great. So, you mentioned the loss of a couple of physicians prior to the decision to go private. That decision is a heady one. I mean, it's not an easy transition. And we'll talk about that coming up here in a little bit. What was the reaction of the group? Was there a lot of cohesion? Did the troops rally around this? And did you have to employ any strategies to keep that cohesiveness as you went through this difficult process? So, I think first you need to identify your core group and honestly look in the mirror at yourself and then look around and say, who are the individuals that we feel would be best served in this model? And, you know, we knew we had the talent. And I also knew that, you know, you'll have in any large group, you know, you'll have some people at a risk of birth. So, you know, I told everybody at the beginning, you know, we're going to lose probably one third of the people, you know, in this group that are talking right now. You know, we had a lot of nights where we got together and had discussions about it and sort of formulated our ideas. And I think that was a big part of it. And we actually started with about 11. We did have two, you know, two people. I think that, you know, it was just, it was too much of a risk for them, too much of a leap for them. Did they stay in the market, Dr. Flynn, or did they? They did. Yeah. They're now employed at another hospital system across town. And so, yeah. And in the rest of the group, you know, we saw some of the 26 original docs, you know, there was nine of us that went private and then, you know, a total of 23 left. There was only three left at the institution. So, you know, they went to various other places around the region. So, but the core group, you know, we identified about 11 that we thought, you know, would be a good fit, a good fit for the group. And so, yeah, we, you know, we had to always make sure that, you know, everyone was on the same page, took a lot of, you know, commitment, keeping the talent together. And, you know, very important that each person, you know, given opportunities to voice their ideas, their concerns, their vision, and give everyone, you know, a feeling that, you know, they're obviously their opinions were valued in the group. And so, yeah, we're lucky that as we started, you know, we kind of started with when we finally made the decision was it was just nine of us that made that final decision. We're fortunate that everyone kind of stuck together and stuck with it. And it's been great. So, Dr. Flinton, you use the word commitment, you know, and there's the commitment I pledge. Did you ask for anything more tangible like, hey, everybody, we got to pony up some money to really put some skin in this game to keep us all? So, that comes with it. I didn't initially. It's sort of my personal style thing. I feel like that if, you know, if people are going to do it, they got to want to do it. And so, I felt like if someone wants to walk, they can walk. You know what I mean? You want to end up with a committed group. And so, we didn't really have that in the beginning. Now, as we formed the LLC and we're looking for financing, you know, in a line of credit, then we did have to obviously come up with some, you know, some amount of money that we all put in as a group. And even that we kind of adjusted a little bit. You know, we had a couple of young partners and we kind of covered for them to get it going and made it a little bit more palatable for them. But in order to get, you know, a line of credit, you know, in the financing, it did require a little bit. And so, yeah. So. So, Jason, I'm going to turn to you now for a second. And you touched on this. I mean, we saw that big transition from private groups to employment. What do you see happening? You have more of a national view. What do you see happening in terms of the industry? And what's your prediction going forward? Are we going to see this disintegration trend, which has been a big topic of conversation at the MedAxium meetings over the past five years? But the numbers have largely held steady. What's your over under? I think the disintegration trend is going to continue. We'll pick up steam over time. I'll tell you, we are working on our second group, leaving hospital employment or not hospital employment. They're actually employed by Optum. So they're moving to go private with us. There's been a couple other instances where people have done it with some of the PE back folks. I think that there is a lot of interest. We get tons of questions around it. I think there's some anxiety around some of the non-compete, non-solicit language that hospitals have and some concerns around that. I think we have to figure out a way to overcome that. So I think it's going to continue. I think there's a lot of interest from physicians. And I think hospitals have to figure out how they can partner with physicians without this concept of having to own them. Every time I hear them, they have this idea that I own these physicians and then I'm going to get them to do everything I want. It's really not how our healthcare system was built, designed, or how any of us decided to go into this. And so I think as we start to think about it, I think that there's ways to do this in a complimentary way. I would say that the CISNY docs have been very partner-oriented with the health systems in the market. I mean, you guys still cover STEMI call, procedures, very supportive, and this is a model where I think we can all – fundamentally, I think the patient's awareness, and so I think we need to drive it. I think the barriers are largely the, you know, restrictive covenant, non-compete language that health systems have, and frankly, health systems have payers really in a difficult position just due to their size. Think about how big the health systems are becoming now. I mean, they kind of metastasize on a regular basis. They just continue to buy and grow, and that becomes a monopoly, and that's driving health care costs up like we're seeing, so I think we need to think about how we start to move that. I don't know if that answers your question, but we have a lot of interest there. We are trying to solve for it in any way we can on our side to provide contracting, staffing, technology, resources. We've been working on financing opportunities and really providing the tools to let the physicians decide the direction of their practice, but we can provide the services. We give the scale of a big company without being owned by a big company. That's how we built our model, and that's what we're trying to do. Great. So, that's a good segue, because you kind of mentioned that, you know, oh, if I employ you, I control you, and, you know, It makes me laugh when someone said that. I was like, really? I did. I employed a lot of docs in my former careers. I'm like, I don't know about that, but if you think that works, go for it. Yeah. So, along that line, you know, the reason the hospital does that is for that perception of control, and this could feel like a loss of control. This was on my list coming up, but the audience has already zeroed in on it with their questions. Dr. Flynn, well, or Jason and Carol Ann, rarely when this happens, and I know it's still a very new thing, so we can't talk about it in any, you know, with any science of numbers, but the hospital's not going to sit idly by, right? When they lose 23 cardiologists, that's got to be a big deal for them. What was the hospital reaction, and what does it continue to be now that you're four months into this? Yeah. I mean, I think you can, you know, universally expect a negative reaction from the institution, and I came into it with a little experience back in, you know, this was 25 years ago. The practice I was in built a cardiovascular hospital, and we originally approached our institution asking to joint venture it with them, and we sat down in the board meeting, and we were basically, they looked at us and said, you know, we have $130 million in the bank, and we are going to bankrupt you and ruin all of you, and they just sort of said it right to our face, and we said, we kind of walked away and said, okay, well, we waited six months, and we still did it, but, you know, it was, that was the reaction we had. So, I was kind of prepared for a negative reaction. I would say that they're just not going to be happy about it, right, because I think that administrators generally value control over anything, even money. Like, they'll value control over all else. So, you know, what I said to everybody was just make sure that the hospital system doesn't become a distraction to what you want to do. I said, you know, focus on what we're doing, focus on the practice, and sort of everything else is just kind of background noise, and, you know, with that said, we really did our best to kind of preserve collegial relationships with our main hospital and all the other hospitals. You know, we did have legal counsel that we had worked with, and, you know, and that was very helpful, I would say, and not in the sense that, like, your lawyer's not going to go in there as sort of a, you know, someone trying to force issues. The lawyer really was very helpful in kind of helping us to say, look, you know, here's the vision, here's where we want to get to, you know, with the system. And, you know, we might not get all the pieces, but let's try and, you know, knock off each piece that we can. So, you know, we were able to sort of preserve some collegiality. Yeah, able to get call agreements in place, able to get, you know, able to get agreements about hiring staff, you know, if staff came to us that we wouldn't be considered, you know, breaking that contract by hiring people. Some ability to contact patients, we had some agreements about that, so we wouldn't be considered, you know, soliciting. So we were very careful about that, and I think working with them, you know, sort of in a positive way was helpful. You know, it's never going to be good, and I don't think you should be fooled for a minute that you think the hospital wants you to succeed. They don't want you to succeed. So, you know, it's one of those things. But again, it was just, you know, let's not let this become a distraction to what we're doing. And so it's worked out okay, I would say, with the hospitals. Great. Caroline, you have an interesting perspective because you have been on the hospital side of things as an administrator, operational director. Now you're on private group side through Cardio One. How have you seen physicians' attitudes change over time? Well, it's been interesting. You know, I've worked with physicians for over 30 years in a variety of settings, academic medical centers, community hospitals, almost always on the kind of physician enterprise side of the hospital system. And I think that, you know, physicians over the course of time, I think, share and endure one common goal, and that's to provide the very best care that they can provide for their patients. And I think that, you know, their ability to do that has been constrained for a lot of the reasons that Jason and Jim have outlined. And, you know, I think that as that's happened, that's, you know, they've been frustrated. I think that physicians, you know, generally speaking, are independent by nature, and they do want control mainly just over how they can provide care. And as those things become constrained, that's what elevates their frustration. And as Jason mentioned, you know, it's just the hospitals want to control how many patients they see, how they see the patients. And there's, for a lot of reasons, hospitals, you know, having their own set of financial challenges and constraints. It's just been a relationship that has been increasingly strained. And as physicians, they've had to look for other solutions for themselves so that they can continue to achieve that goal, which is to provide the best care they can for their patients. And, you know, there's been more burnout. There's been more, I mean, the job of a physician, I think, has, irrespective of where they're doing that job, the job of a physician has become increasingly difficult over time. As we look at insurance regulations, the way that insurance pay, the way that all of the electronic medical record has evolved and is, you know, presumably was designed to help patients, it is in some ways more cumbersome for physicians. So physicians, to achieve that one main fundamental goal, it's been a hard road for them. So, you know, looking for solutions that go back towards their roots of being independent, having the support that they need in this very complicated infrastructure, that I think I agree with Jason, there'll be more and more movement towards disintegration as viable options are available for them to do what they love to do. So there may be more than one elephant in the room, but certainly one of them, and this is a question from one of our audience members, you know, when you look at MedAxium data and corroborated by other surveys, private physicians, private cardiologists tend to earn significantly less than those who are employed by a hospital or health system. I'll start with Jason on this question, but what does Cardio One do about that differential? And then I would love to hear Dr. Flynn's reaction to the same question from the group's perspective. Yeah, so a lot of that boils down to payer contracting, one. So working to get payer contracts aligned, it's a bit frustrating because payers are so focused on health systems that they do pay, you know, $5,000 for an echocardiogram where they are really not incentivizing and working with independent physicians to maintain independence by, you know, working with them on rates. So that's priority one for us is working with payers to try to better handle payer rates because it's just very lopsided right now. Obviously, working with payers is challenging because they move at a different pace than other folks and there's a lot of bureaucracy there. So payer rates are there, but I do think there is a significant opportunity to reclaim the economics that a true, like, independent doc that's maybe not partnered with someone like us. We have economies of scale on everything from IT technology, recruitment costs. So there's a lot of those expenses that an independent doc would have to absorb that we're able to manage at a far lower cost and scale, which helped improve basically the bottom line to the practices. And then bringing in additional ancillary services and testing, which are, one, more convenient for patients. Two, uniformly lower cost for patients than going to a health system. All those will drive revenue to the practice. So I think it's three major levers, which is working on the payer side on contracting, two, economies of scale around all the services we're able to provide in one felt solution. And then three is bringing in-house all the testing capabilities, which drive revenue, drive the patient experience, and fundamentally lower costs for the health system. I think all three of those come together to really provide the direction for the docs that are looking. Hopefully that can play. Yeah. I'd like to add one thing to what Jason said, if I could, as he talks about economies of scale that you know, solutions like Cardio One provide, I think the other thing that goes hand in hand with that is the expertise, you know, physicians, the services that Cardio One provides, you know, those are services that physicians aren't necessarily subject matter experts on. So that leads to, you know, it's directly related to what their income level will be in private practice. So being able to lean in to folks who can provide the support with expertise also has a very positive impact on the physician's income. Okay. Dr. Flynn, when you made this, were the physicians expecting, okay, guys, at least in the short run, we're not going to make what we made in 2023, or was that not the expectation? Yeah, I mean, I think there was a fear that we might not make anything, right? That we might not make it. I mean, there was, you know, can we get the financing? Can we get the referrals? How do we manage the business side? You know, how do we get the line of credit? How do we get the site built out? How do we get our insurance and Medicare contracts? Who manages the human resources? Who does the marketing? Which electronic health record do we pick? You know, how do we get our malpractice benefits, our insurance benefits, you know? And then once you start working through that, which is about a year ago now, we were working through all that. Then you start to look at it and say, you know, look, should we do this piecemeal? Or should we, you know, get a comprehensive management company? I think that's how we, you know, we found Cardio One. And it is helpful, very helpful, because the economy is scale. You know, you can get, you know, potentially better malpractice contracts. You know, you get some access to their marketing group. And the insurance and Medicare contracting was huge. I mean, that was just a big lift that was just taken off of our hands. And, you know, health record, you know, you never know what you're going to get. Because until you test drive something, which you can never do with these EHRs, you know, you just don't know. So that was helpful. And then, so I mean, all that, all that made a lot of sense. And when you added up the value of everything put together, you know, you know, from our standpoint, you know, Cardio One was, you know, very, very beneficial for us. And also, I would say, very transparent, you know, I think the contracts that Jason sent us were, you know, easy to read, easy to understand, we knew where we all, where we all stood. And so that was actually very helpful from our standpoint. You know, we looked at terms of income, you know, we looked at private equity, you know, and that does appeal to people when they're first starting out, right? There's a lot of capital behind it. There's some upfront, you know, offer and everything. But in the end, you know, I was glad when the group chose to stay independent, because I think, you know, again, it preserves your vision, what you want to do. You know, I think, I mean, I just personally think there's just too much sort of people on the money side running medicine right now. We need more doctors who are facing patients every day, you know, in making the decisions about what gets done. In terms of, you know, in terms of income, you know, we definitely, you know, we just plan for less income. However, it's interesting, you know, just starting a business, right? The first year or even two years, you know, you're showing a loss overall in the company. So just, I'm not an accountant, and I can't explain it all to you. But, you know, the distributions you are making to one another are often tax-free, right? So you're taking a big reduction in what you're drawing. But in the end, if you don't take taxes out of that money, it's actually, to us, almost feels about the same, you know. So it hasn't, we've been fortunate, you know, we haven't really felt a big hurt on that part of it. It's been very smooth, actually. So we're happy with that. I would say in terms of how we preserve that, you know, I agree the ancillary part is huge, because I think, you know, we, since all these practices have been acquired over the last 20 years, there's this assumption that sort of hospital systems sort of had the rights to outpatient testing, you know. And you ask why, you know, an inpatient facility doesn't necessarily have that right. Like, we can do this, all this stuff for much, much, much cheaper, you know, anywhere from, you know, 50 to 90% less in cost, you know. So it's, and I think that the more comprehensive outpatient services, you know, you provide, then looking forward over the next five years, you know, with value-based care and ACOs, the more ability you're going to have to, you know, contract with insurers and whatever Medicare comes up with for, you know, for a plan for value-based care, and be able to manage a lot of this on the outpatient side. And so I think, you know, that, I think that's actually the future. So right now, it looks like a big lift. But as you look forward, if you're in that, you know, if you're, if you have mastered that whole process of managing the outpatient side of medicine, you're going to be way ahead of the curve. Because right now, hospitals still are in a mindset from 20 years ago. And, you know, in their vision of how they're going to generate revenue for themselves. And it's not, you know, they talk about aligning with physicians, but it's not really aligned with patients and physicians in the system. It's a misalignment right now. So I think that, you know, I think the more you can do to provide a comprehensive outpatient service, the better. I can see, based on the time, we're going to get through a fraction of all the questions that all this conversation begs. But Dr. Flynn, you brought up referrals. I'm curious, five months in, did the referrals follow you? And when we did kind of the demographics at the beginning, did the hospital employ a lot of primary care, or are they still quite independent in the New Hampshire area? Almost everybody in the Hampshire area is employed by a hospital system. So we, yeah, there was some worry about that. But, you know, it's interesting. Number one, I think, you know, we did have the talent. And the, we've had referrals from just about everywhere. Number one, Medicare patients can choose where they go, right? So that's number one. That's number one. And there's actually more independent practitioners out there than we realized. You know, we thought everyone was in a system, but in truth, it's not necessarily the case. And those independent physicians are really interested in working, you know, with us. And even in the hospital systems, the waits for service are so long. And patients are not getting, again, not getting their testing done, not getting called back with results, not getting appointments and waiting and waiting and waiting. And they're just calling us up. And, you know, I would say that anywhere from 20% to 40% of my patients every day are new patients, you know, so they're just consistently coming in. And, you know, I think you have to expect it's going to be a process for a couple of years, you know, as you do it. But, you know, it's definitely doable. So one of the things that we have touched on is the significant differential in cost and reimbursement between a hospital outpatient department or setting, and then what's done in the physician office. Jason, what we've heard from our membership, and I'm zeroing in on a case in the Midwest, the group followed a similar path and they were expecting open arms from the payers for their much lower office-based reimbursement. But they didn't necessarily find that reaction, far be it from us to expect rational behavior from a large payer plan. But what has been your experience both in New Hampshire and then more broadly nationwide? I think New Hampshire has been slowly receptive around it. I think we've been working more on the national level around it. I would tell you that on the national scene, everyone's like, this is great when they look at the numbers and everything else. But it's almost like they don't know what to do with it. I don't mean to make it sound so simple, but like, we're like, this is lower cost of care and they're like, that's fantastic. But then the inertia is so driven towards health systems that they almost don't even know how to- Do you think the hospitals and health systems have like most favored nation clauses or- No, I think that they're just stuck with each other. And I think that like the hospitals need the health systems and the health systems have gotten so vague that the payers need them. And so it's just that they're frankly, I think, they're not really paying attention to it. I think like this is very obvious, right? It's lower cost of care at Jim's point, it's more accessible, it's cheaper for patients. You know, it's been studied to be lower cost. Why would we do it? But I think there's this fear of like, oh, I don't want to upset the health system or there's going to be a problem. And so I think there's just angst around it. And I almost feel like it's we've gotten health care in general, like so many things, like once we start doing a certain way, we get this momentum and then people just keep doing it. And then trying to get the turn on it is hard because there's a massive machine in the United States that is built around these big health systems and payor relations. So there's interest. I think people are trying to figure it out. I would tell you that there's. You know. Our view of it is to move towards this value approach, which I think we have seen grow well in other specialties like kidney, oncology, musculoskeletal, where there are kind of well-defined governmental and commercial value based arrangements, where like, for instance, at CISNY, were we to have a like an AFib bundle or a heart failure bundle, they could definitively jump into that and demonstrate lower cost of care, significant revenue savings, both right into the practice, but we've had trouble making the leap for cardiology into the value side. So there's two paths. One, you go and you try to like kind of like demand higher fee for service rates. You know, it's hard to do when you're small. Payors are kind of stuck on that side. But moving to the value side is something we've seen in other specialties. And I think, you know, being able to go in and like demonstrate that like, you know, Jim and his team could do pretty much everything they need from a testing standpoint right in the office, much more convenient. So that's where I think we have to build them all. So payors in New Hampshire, smaller market have been reasonable to work with. But payors in general almost don't know what to do with this opportunity. Like, OK, this is great, but like, I don't know how to get there. And that's been the challenge. I don't know, I'd be interested to hear your thoughts, Joel or, you know, Jim, but that's where like you talk to payors, you're like, yes, but then they don't know how to move it forward. Yeah. Somebody told me, actually, I think I read it in an article, they have no motivation to bring costs down because they actually can make money on the arbitrage between their premiums and the cost of care. And if the cost of care goes up, they simply increase their premiums and they can even squeeze out more arbitrage in that differential. And I think that, you know, I think most of the people on this webcast would find that absolutely obscene, that that is how our health care system works. But it is. And that's the reality. And I wonder if that's part of the disconnect between what we're just talking about. Well, understanding how payors work baffles me. So not being sarcastic, but it just it's just the way they work. I mean, I think we and Jim and his team and the docs that are doing this on their own are definitely pushing the trend, pushing a little bit of the, not a little bit, you're definitely pushing against this role towards consolidation. I think we all have to look at that and say, is this a good thing or a bad thing? And I'm very concerned. I'm going to take one pivot. I'm very concerned about a lot of the regulatory and legislative actions that have been occurring at the state and federal level that are trying to block. MSOs like us or some of the companies from supporting independent docs and driving that business, we see its lower cost of care and its quality there. I think there have been some bad actors in the space, and that has now resulted in a pretty significant, complete movement against it. No one's talking about the consolidation in the not for profit space or even in the for profit health system space. I mean, if we. I think Jim and Caroline would say, like, Southern New Hampshire is not necessarily like New York City is not a huge market, but if you go there like we were at a dinner, the amount of talk of all these not for profit, all these big health systems and who is going to take what was really, frankly, alarming. But that is not being addressed in the regulatory environment. So sorry for my soapbox, but I feel like we're beating up one side and everyone's like, oh, it's OK, we'll just keep letting them do it. I think that consolidation should concern people. I do think that we have to continue to leverage patient choice. And Joel, as you said, the insurance companies can just pass the premiums on to employers, then employers pass costs on to patients. And we all know that deductibles and out of pocket costs are going up and up and up for people. So I think we have to kind of stay the course and fight the fight of letting patients know why this is a good value for them. The clinical care is there, the cost is lower, and it directly benefits them in both ways from from that standpoint. Caroline, what with this question from the audience, what imaging services does CISNY offer? What are the imaging modalities that are part of the private group now? We provide ECHO, you know, ultrasounds of the heart, obviously, we provide ECHO, nuclear stress testing, regular stress testing, PET scans, we were the first community hospital in the region to provide ILRs, internal loop recorders right in the office, a very quick procedure that patients historically have had to go to the hospital for a procedure for. We provide all the wearable devices, Holter monitors, all the monitoring devices. I forget, nuclear stress testing, if I say, yeah, I mean, vascular, you know, vascular testing, vascular testing. Yeah. Did you guys look at cardiac MR, some of the advanced, so your CT solution is PET CT? Yeah. Yes. So we had a lot of experience with cardiac MR in the big group, and we have not chosen to do that in the outpatient arena just because logistically, I think it's difficult to do in a private practice, at least the way we did it. I mean, there may be other ways of doing it, but we had our MR specialist in for each study, sitting there at the console, customizing it for each patient, and it was an eight-hour day doing six or eight scans, and it was, I don't think it works that well in an outpatient arena, especially with the cost of the MRI, the scanner and everything. But I mean, that may change over time. We just, from a startup standpoint, it didn't, I don't think it, we didn't see the need for it. Other programs that can be provided in addition to the testing is chronic care management, intensive cardiac rehab. Dr. Flynn has been really at the forefront of ensuring that patients can receive comprehensive care in the outpatient setting from risk reduction through procedure and post-procedure care. And I think that those are programs that can also be provided very well, very efficiently in the outpatient setting. Yeah, I think that ties into the value-based care in the future. And if you can show it, I think you have to work with individual insurance companies or individual health plans to show the benefit. But, you know, like I look at the model of like, I'm actually board certified also in lifestyle medicine and the lifestyle medicine treatment model of shared medical appointments and the education and the nutrition and all that, I think is a very good model for like, you know, for chronic heart failure management. And I think, you know, if you can get a comprehensive, say, comprehensive outpatient heart failure program going and you can show how much, you know, it saves these insurers and health plans in terms of re-hospitalizations, you know, I think that's a, there's just sort of low-hanging fruit wherever you look. There's just so much expense of patients going in the hospital and everywhere you turn, there's a program you can do to save a ton of money with the system and, you know, we'll see how, we just have to see how insurers react to it. Sorry for the quick change there, Mike. I realized the outlet I was plugged into wasn't working and I was running out of battery. Carol Ann, one of the things, this is my experience and, you know, we've been engaged to do some analyses for these kinds of transitions in the past, one of the kind of hidden costs of these transitions is in the opening slides, Jason noted that you guys were, you started five months before the group went live. There's a lot of work that happens in those five months. Can you talk about that? Because I think groups often, they're working full-time during that five months, there's nobody to do the work. Sure thing. So I, that's absolutely true. And, you know, I think that this type of transition really validates the phrase, it takes a village. And so, you know, I think when you start with a group of very committed physicians, like we have at CISNY, you know, they worked, they did a lot of pre-work, you know, making decisions, what was their vision of the practice? So a lot of those things are super important for the docs to come together on. And then, you know, it really couldn't have happened without the support of Cardio One in that short of a timeframe. You know, again, I think the way that they took care of, Jim mentioned earlier, the credentialing, the contracting, the recruitment of staff, the hiring of staff, the, you know, getting, working with the lawyer, the lawyer that the practice had on the, and the accountant on practice finances, compliance, all of that. I mean, setting up a benefit plan, setting up a retirement plan, a 401k plan. You know, Cardio One provides all of that. So they really, you know, the doctors found space, they found, you know, they formed the LLC, but then Cardio One, they have this implementation project team and plan that these meetings happen regularly. And there are, Jason mentioned early on in the work stream. So leaning in and, you know, leaning into that level of support that can be provided, that really enabled that Cardio One, the doctors, you know, coming together to really work as a team and have those constant communications and organized structure of what had to be done, what's the list, how's it going to be, you know, divide and conquer, and then coming back together, that, that's really how it, how it was able to happen. Dr. Flynn, when we went live, I'll just add, when we went live, you know, there's always the kinks, right? You know, the opening things. And it was like a swarm of like hand to hand with the Cardio One team that came in and, you know, the doctors had somebody at their side, the front desk people had people at their side to kind of work through it all and those early weeks and months. Dr. Flynn, you mentioned getting a hospital call coverage agreement with the hospital, not getting into specific dollar amounts, cause that's probably inappropriate, but are, what other forms of financial support will categorize it as, are you getting from your former hospital employer? Well, you don't, there's not a lot. I mean, there's a call coverage, which you work out and then there's some, you know, management agreements like, you know, cath lab director, EP lab director, that kind of thing. But it's, it's usually not, I mean, it's gotta be fair market value, right? So it's, you know, it's just a standard amount that probably people get already around the country. Other than that, you know, the support, I would say that the support was, you know, in terms of like inpatient support was I'd say less than adequate, you know, in terms of the hospital, in terms of the amount of volume that we do in the hospital. And, you know, we tried to make that point to them. I would say that, you know, look, if we're, you know, if we're doing all the stuff out of the EP lab for set, you know, say, and we have to do, you know, two less ablations a day, it's going to hurt the institution more than us. But, you know, it was, that was one of those agenda items we never quite could see eye to eye on, but it's interesting now that the hospital, you know, finally in this past couple of weeks has changed hands now to the, you know, for profit, which we were, you know, kind of initially not enthusiastic about, but actually they seem to be much, much more willing to help us be efficient. So in, in as many ways as possible, as you would probably expect. And so, you know, I suspect we're going to be seeing a little more support, you know, and I'm not talking monetary support, just like, you know, hospitalist support and that kind of thing. And just to make the day easier when you're in a hospital, because when you're in a private practice like this, it's almost the formula changes a little bit. It's almost like, you know, you're, you're better off in the office, you know, spending, you know, when you're in the hospital, I mean, you know, PCI can take several hours. Well, you're not, you're not getting a lot for, for those several hours, you know, or it's just, it can be hard, right? You're in, you're physically tired, right? So your, your focus is really on the outpatient setting and in the office. And so, yeah, the hospital, that's a, that's a work in progress. And, you know, it's interesting because I had a friend who his practice went private and for like three years, they didn't even have hospital privileges and everyone was worried about that. And then they turned out after a few years, they realized just how happy they were. And about three years later, the hospitals came begging them to come back in, you know, and, and, and help support. Thanks. And they, I think they ultimately did, but they were very, very happy just being in their offices. So it's kind of interesting. Yeah, for sure. So in the few minutes that we have left here, I want you to all to get your crystal ball out and we're going to attempt to predict the future here. A question from the audience, you know, year after year, after year, after year, they toy with the idea of site neutrality payments, where we close that differential between the hospital and the physician enterprise. What do you guys think? Is that inevitable? Is it going to continue to get kicked down the road? And if it does happen, what do you think that means, uh, for this whole discussions today? Uh, so I'm a believer that I think site neutrality is, has to happen. We cannot afford that as a country anymore. Um, the AMPA group that I mentioned, you know, we are out lobbying. I'm going to DC and, uh, like a month or so to meet with Congress members of Congress, you know, it's, it's just, it's a lot about the politics of it. But I mean, if you look at it, site neutrality, I mean, the hospital outpatient department rates are catastrophically high and not sustainable when that happens. Or if there is a movement on that, there will be such a rapid compression of hospital employment, i.e. disintegration because the hospitals aren't gonna be able to afford it. Hospitals are fundamentally able to afford what they're doing because of that HOPD testing. Um, it's a frustrating thing. It's under, it's hard to understand that. Why, uh, I, like I said, I got bamboozled into one. I walked into what looked like an office and they billed me an HOPD rate. I it's, it's very alarming to patients. It's not fair needs to go. Well, Jason, you're out of pocket was nothing. I have an HSA, that same echo cost me 5,200, but there's story. There's story after story in Denver, people walking in saying, I got an MRI. No one told me that the MRI at this building was going to cost me five times more than it would cost me at this building. Like, I don't know. I just go. And so that's, I mean, it just, it doesn't make sense. If Jim does, why, why Jim doing a PET scan in his office should get 70% less than doing it four miles down the street in an office that looks just like his the same equipment, but they snag an HOPD rate. I'll get off. That's actually, that's also an advantage right now, even with outside neutrality, because if word gets out, you know, that again, your test is going to cost a fraction of what it would at the hospital. And, you know, you can get word out about that people are going to be knocking on your door. So, so another kind of future prediction and we'll end here. Uh, cause we're at the top of the hour, but, um, the, what we hear a lot is the, the cardiologists coming out of training now aren't really interested in owning their own business, such as a private group. So even though those in your generation, Dr. Flynn, maybe are, you know, still have that entrepreneurial spirit. I predict your, you know, your analysis of the future is, yeah, we can, we can still be attractive to young talent coming out of training. Yeah. I mean, we were lucky that two of our partners were within a year of finishing their training and they stuck with it, you know, so, um, I think people can, um, see the value of it. I think that definitely, um, you know, younger people are going to be cautious coming out and I think they also underestimate their capabilities in their, in their options, you know, um, you know, uh, if you want to live, if you want to live somewhere, you know, a lot of times people go and apply for jobs, they'll be, oh, there's no jobs in that area. And they don't think like, I could just get a space and start a practice and be just fine. You're like, you can just live where you want to live, like go where you want to be, set up roots and you'll be fine. You know, a lot of people, a lot of young people don't think that way, but it's, you know, it's very possible. So I think there'll be a little watching, right. And seeing what people do, and there'll be a lot of following, not necessarily leading the, the surge, but following the surge. But I think that, um, you know, like any choice, I think, you know, young people, they also have the ability to take that risk and, and, um, and, uh, with some enthusiasm. So I think, I think there's some potential there. We get, we get questions all the time from fellows and residents about how to do it. Um, I'm married to someone who's one of the assistant deans here. And I think the generation leaving to graduating today and out there are very much not wanting to be told what time to show, like exactly when to work, how to work, what they have to do and the hours they're actually looking for the flexibility and the entrepreneurial spirit. So I'm optimistic, but we have to figure out is to show them that there is an option. They are trained in large academic medical centers, and they're told that private practice won't survive. They're told that anybody that has the word private equity or for-profit are evil. And so they're kind of driven that way. So we, I think we got to show them the option. I'm confident. Yeah, I agree. And, and, you know, most of the fear is again, starting a business and running the business. But, you know, like with Cardio One, if you have a comprehensive, uh, company around you with experienced people that know how to get it done, it takes, you know, it takes a lift out of it. I mean, as a physician, you know what you want in terms of a practice and you just need people to, to help you out, um, on the support side. And, uh, and I think that, uh, for a lot of young people, it'll, you know, it's, it actually not a, it's not difficult. It's, it's, it's, it, you have to be detailed, but it's not difficult. Well, Dr. Flynn, we'll let you have the last word here. Cause we're at the, uh, uh, end of our time. And I want to thank, uh, Dr. Flynn, Dr. Gunderson and Carol Ann. Appreciate you all joining us for today's webcast and special. Thanks to those of you who tuned in from the MedAxium nation. So thanks everybody. I hope you have a great rest of your week. Thank you.

independent cardiology practices

hospital employment

Cardio One

patient care autonomy

administrative challenges

insurance contracting

industry trends

site-neutral payments

young cardiologists

entrepreneurial spirit