really looking forward to bringing you all today's webinar on Joint Venture ASCs, looking back and looking forward. So before we do that, what I'd like to do is explain how the system will function for you as an attendee today. So if you would like to access the slides, you can do that through the chat button. So all that's going to happen in the chat today is the slides will be posted. We'll be posting those same slides throughout the presentation. They're not going to be different or updated, but as more people join, they can't see the history of the chat, and we want to make sure that they have access to the slides. So you'll see that happening. If you want to communicate with us today, you will do that through the Q&A button on the lower right-hand side of your screen. And the Q&A is where you will send questions to the presenters. In almost all cases, we are going to hold those questions until they've had a chance to present their content, and then we will spend the majority of our webinar on Q&A today. If we do feel the need to interrupt the speaker because we feel that it's a clarifying question that would help, we will do that as well. So thank you for that. And so let's talk about today's webinar. So Joint Venture ASC, looking back, looking forward. Some of you may remember this same crew as this webinar was done almost two years ago to the month, and we had the same exact set of speakers. And with us today is Lori Duvall, and she is the Practice Administrator of Cardiac Solutions, which does have a Joint Venture Cath Lab, and Christy McShea, who is the AVP for the Cardiovascular Service Line at Banner Health, who has multiple Joint Venture ASCs as well, and Mark Toth, who's the Market President of Cardiovascular with Atlas Healthcare Partners, also involved in multiple Joint Venture Cardiovascular ASCs. And so where we were in this country two years ago was at a very different place than where we are today in terms of the evolution of ASCs. What were we thinking about ASCs at that time? How we wanted to engage around doing it ourselves, doing it with partners? How do we do it with a hospital? Do we work with a third-party company? What does it take to set up, etc., etc.? The folks on this call are now multiple years into their journey. So as many of us are still figuring out, are we going to do a new site, attach it to the office, put it in an MOB somewhere that the hospital owns? How are we going to partner still? They're now further along in their journey, and we wanted to bring back this same group, and they graciously agreed, so that we could then ask newer questions about what their evolution has been two years into their timeline. So I certainly am appreciative of all three of you. So Mark and Christy and Lori, welcome back. Thanks for sharing your expertise and your experiences with us today, and I'm just looking forward to diving right in. So Mark, I think it would be nice if we just did a quick introduction of each of you. Let's take 30 seconds to a minute to do that, and then we'll turn it over to you to maybe get us started with slides. And after you present each of these three stories that we can share, I'm sure we'll have a ton of questions from the audience that we can then provide some of our expertise and insight. But Mark, I'll turn it to you to do your own introduction. Sure, Joe, thanks. Joe and Ben, thanks for having us. My name is Mark Cote. I'm with Atlas Healthcare Partners, and we want to update, as Joe said, the joint venture relationship we have with Banner and Cardiac Solutions. We'll also touch a bit on the joint venture relationship we have with MedAxi. So without stealing any thunder, I'll hand it to Lori for her introduction. Thanks, Mark. I'm Lori Duvall. I'm the Practice Administrator for Cardiac Solutions. I represent the physician group that partnered with Banner and Atlas Healthcare Partners in the formation of our joint venture, ASC. Yes, hello. I'm Christine McShay. Thank you again for having us. Pleasure to be here. I am the Cardiovascular Service Line Leader for Banner, and in that role, my focus is really on strategy and growth that really drives improved performance for the service line, and have worked really closely with my two partners here, Mark and Lori, in advancing that through our ASC strategy. Wonderful. Well, Mark, let's turn it over to you to show people that sometimes the movie sequel is better than the original. Yeah, again, on the opening act, really, Christine and Lori are going to give the details of what this relationship looks like, what went well, what didn't go well, and what we learned from it. We throw this term joint venture around, and I saw this definition, which I thought made sense. It's a business arrangement where two or more parties pool their resources for the purpose of accomplishing a specific task. So in this joint venture, Cardiac Solutions is really good at delivering new cardiology care. Banner is really good at being a health system. They have an insurance product, and they have lives, and they have hospitals, and Atlas is good at running surgery centers. So pooling the three together makes the whole greater than the sum of the parts, and that's what this joint venture is all about. If you go to the next slide, to further complicate things, we have a joint venture with MedAxium. We call this company MedAtlas. It was created about a year ago. The goal is to bridge the relationships between what I call the MedAxium community, which is service line leaders, hospital leaders, cardiologists, employees, and to advance ambulatory strategies through this ASD partnership and really set the standard for quality, efficiency, profitability of surgery centers. We look back through surgery center history. In the 90s, we thought ophthalmology really shipped. Then in the 2000s and the teens, we saw ortho ship to the surgery center site of service, and now with PCI being approved a few years ago, we really are seeing a strong shift out of the hospital into a value-based side of care to a surgery center for cardiology. So we were flattered when MedAxium approached us and we put this deal together, and in setting that standard of data collection and appropriate use criteria, patient screening was really key to us, from MedAxium to the ACC, and we're really going to be the leaders in that data collection and benchmarking. So next slide, please, if you would. This is a busy slide. I just want to take a moment to talk about what is a joint venture strategy. If you're a health system or an independent practice, there are really four things that Atlas is focused on in a joint venture strategy. One is access to high-quality, convenient, affordable care for the community. That's ASD network development. Where do we put up? How many do we build? How many rooms? How many prep and recovery beds? How does that fit into the health system network? Physician alignment, and this is key for employee health systems. It's recruitment and retention of employee cardiologists, and with independent groups, it's alignment, creating long-term relationships with these independent physicians, which we've done here with Cardiac Solutions. The health system integration strategy is really connecting the dots across the continuum of care, and again, enhancing and increasing that patient accessibility to a value-based side of service. Finally, market share gain. I mean, let's be honest, it's a business, so the health system wants to increase market share. The cardiology group wants to increase market share, and having a tool, oftentimes being a fast mover and first to market, can really help increase that market share, outpatient market share in the cardiology space. So next slide, please. So we want to talk about the Banner Cardiovascular Center that Lori and Kristi and I talked about two years ago, and when we talked two years on webinar, we were six months into it. We were barely fully ramped and getting underway. We label our centers with a banner name, so they're called Banner Cardiovascular Centers, dash the market in which they operate. In this case, they're in a town called Sun City, which is a west suburb of Phoenix, and it's a planned retirement community. If you look at the picture on the building, it says Cardiovascular Center, West Valley. That's more of a generic term locally that people understand where the West Valley is. I didn't have a picture with the palm trees in it, but just to the left of the building, there are palm trees. So for those of you who are in non-palm tree locations, we have palm trees next to our center. This center is in a, I would call it a medical strip mall. It's in the middle of Sun City and it's full of medical practices, physician offices, and et cetera, and I think we occupy about 7,500 square feet. So far this year, we've done about 1,900 cases. So we're on pace to do about 2,200 per year. That's a big growth over last year. Our net revenue per case, and I highlighted this because surgery centers are often, one key metric is what's your net revenue per case. In a pain or a GI center, the net revenue per case would be dramatically less than 7,000 per case, and that's going to help get to profitability and EBITDA distributions faster. So we think that number will continue to grow as new cases are added to the surgery center with the patient and structural heart cases. Our EBITDA margins, I just wrote very healthy. We can't share all of our secret information with you, but EBITDA is a term for profitability, and that's what leads to distributions. Distributions are the first share of distribution. One would get it, they don't share, and our margins are very healthy. The physicians and the other investors, including Atlas and Banner, received all of the money we invested in about a year. So that's a pretty good return on investment from the future capital back in about 13 months. This center is interesting. It's 90% government and 10% managed care because it's Sun City, it's in the middle of a retirement community. This hurts us in the sense that we have the advantage of Banner helping us negotiate managed care rates, which are very healthy. So the more managed care patients we do, the better our margins. In this case, it's just heavily government, and we're still able to have a very profitable center. As I mentioned, the building was accredited and syndicated in 2021, and syndicated means we sell shares. So we open the offering when physicians and Atlas and Banner literally write a check and invest in the center. The building is small, really. It's 7,500 square feet. We acquired it from another group. So it was what it was. It was there, and we acquired it, and got the license about the time. We have 23 physician investors, and Lori can get into more of the details. I believe it's three or four EPE physicians and arrest interventional cardiologists. There's 17 full-time equivalents. They all work for Atlas. So we have a leader, we have a director of nursing, we have a business office manager. All that is run through Atlas. We plan to start doing right heart ablations in about 60 days. We'll get into that in the next couple of slides. They're not approved by Medicare, so we're able to do managed care patients and do ablations. So physicians that are on the start on the right side of the heart. In the Phoenix market, there are about a half a dozen surgery centers doing ablations, both right and left heart, and they're all with managed care patients. We have 12 pre-emptive post-op days. That's important to note, because the throughput in your cath lab will be choked if you don't have enough recovery dose. So 12 is a little tight, to be honest. This center, this side, can probably do with 14 or 16, but we've got 12. We have three labs. We have a fixed unit in one, we have a mobile unit in the other, and the third room we use for non-imaging cases like lupicordial infarction. So next slide. We really live by our culture and our mission, vision, values. We have to make sure these centers are run with those mission, vision, values in mind, and we measure them. As a company, we have about 30 surgery centers. All of them are rated monthly on a GPS score, global performance score, as you can see on this side, it's 8.55. This is a measure of what we call the ASC's health, and we measure categories of culture, service, growth, and profitability. And I'll brag on Lori and Christie's center, when we rank our 30 centers, BCC West Valley is typically first or second. So very well-performing, and that's not just how much money it makes, that's the culture and the position and the patient satisfaction score. So on the left, you can see some of the metrics we use. Same day cancellation rate, we're at 2%, which is good. Average room turnover is 10.9 minutes. Actually, our goal is 10. So we have some room for improvement there. Half-life utilization is about 50%. We have a great room for growth. And then really provider and patient satisfaction scores are key. We use a third party to distribute surveys to patients and providers, and we're really proud of our scores there, 92% and 100% for those satisfaction scores. So I've got just one more slide I want to touch on before I hand it off to Lori. And we get asked all the time, what's next in the CDASC? You know, today we're doing diagnostic caps, PCI, PAD, CRM implants. And on the left side of the screen, I mentioned ablations are currently being done, and we expect approval soon. It's not going to be 2024, but we think in 2025 or 2026 that we'll see Medicare. There's a lot of activity with HRS and ACC and some lobbying groups trying to figure out to get the ablations added to that covered procedure list, which would mean Medicare would pay for them. This year we had two wins. We did get approval for what we call a complexity code. So now if we use IBIS, we get paid more to cover the cost of the catheter, both coronary and peripheral. Prior to 2023, if we used an IBIS catheter, we didn't get enough charge. Now we have a complexity code. We think structural heart is kind of in the crosshairs of what's going to ship next. And when I say next, maybe three to seven or 10 years. I'm not saying that Watchman's and Tavers and AAAs are going to ship next year, but there will be an appetite to ship those cases out in value-based care. And I would suspect, like I said, in the next three to 10 years we'll see those. I put renal denervation on there too, because most people know that was just recently approved. It's got a ways to go. It's got to go through the hospital and then outpatient, but those seem like really safe and maybe have no basis for a surgery center. Lastly, I just want to touch on what you call ASE-adjacent. I'll give Joe Sasson naming credit for this, because I think Joe came up with the name ASE-adjacent. But for ancillary technology like imaging, you can't get paid in a surgery center to do CT, MGO, or PET. So one strategy that seems to be gaining traction is having a CT or a PET scanner next to, adjacent to the surgery center in the same complex, one suite down or across the parking lot. We also think that these centers eventually will be more than just episodic centers of care, where one would go to get a stent or a pacemaker, but maybe it's virtual cardiac rehab, or the IOMT is the Internet of Medical Things. So maybe we're doing wearables and remote patient monitoring device clinic, maybe a wound clinic. So we think there's a lot to making these more than just a center for your procedure. So there's plenty of time at the end for questions, so please feel free to type them in to the chat. And with that, I'm excited to introduce Lori Duvall. I'll give a little background before Lori jumps in, and Lori may be wrong, but I think Cardiac Solutions is a 30 to 40-year-old practice in the West Valley of Phoenix, and it is literally ranked as one of the best practices in town. And I say that not just to tell Lori they're great, but when we talk about practices in Phoenix, there are a lot of independent groups in Phoenix. Cardiac Solutions always has had the reputation of just being a notch above as far as clinical and compliance and doing the right thing, and we're thrilled to partner with them on the center. So with that, I'll hand it off to Lori Duvall. Thank you, Mark. I think one of the things that does set Cardiac Solutions apart is that we put the patients first in everything that we do, which was also one of the main decisions and why we decided to partner with our joint venture, ASC. So next slide. Just a little background about who we are. We have 22 physicians in total. We did elect just to have our EP interventionalists and invasive cardiologists actually partner with the venture. We have three electrophysiologists, five non-invasive. We have one invasive cardiologist. Actually, that should be updated to two. We have 13 interventionalists. We have 22 advanced practice providers. So we currently, our service area is in the western region of Maricopa County. Maricopa County is what we basically refer to as the entire valley, which most people just refer to as Phoenix, but we're actually, we are in the western suburbs of the Phoenix area. We have four office locations, which are divided into three distinct markets, if you will. We have two offices in our Peoria and Sun City West area. As Mark mentioned, they're predominantly retirement communities, but with a lot of growth with younger commercial patient population as well. We have another office in Glendale, and then we're just reopening an office in the Southwest Valley of Phoenix. So we currently service four hospitals. You'll notice three of them are Banner facilities. One is an Abrazo facility. We'll soon be adding a fourth Banner hospital, Banner Estrella, and then our joint venture ASC. I think it's important to mention that, you know, I feel like it was probably two years before we opened to ASC, we started conversations with Banner and figuring out how could we partner best together. Mark had mentioned that they do have a health plan as well, and they are, you know, a very large health system in Maricopa County. So for us, you know, the joint venture for the ASC, we do also have a co-management agreement where we collaborate with the cardiovascular service line at the facilities that we go to, as well as looking at the relationship we have with the health plan. So for us, it was about making the right decision for our patients and not necessarily carving out just doing a joint venture, but it is about the true spirit of collaboration. Next slide. So, you know, we've been doing this for two years. When we first met with you a few years ago, it was all very new and we really didn't have a lot of experience to share. You know, today I hope we can share some things that looking back maybe we should have thought about, which would have made things maybe a little bit easier. But when I talk about keeping patient satisfaction at the core of everything we do, you know, Banner included, our patients love being at the ASC. That was, you know, whether it's a reduced co-pay that the patients experience, or if it's just walking, you know, 30 steps into where their procedure's going to be, little things like that make a difference. You know, if you've ever had to navigate health care for a family member, you know that when you go to a hospital for a procedure, you have to be there a couple hours early because you have to go through admitting and then you have to get taken to where the procedure is. And it's a whole big ordeal. Oftentimes if you have a cardiac condition, you know, walking a short distance is a significant improvement in the quality of care that you're perceiving, that you're receiving. So our patients feel that it's more personalized. They feel like they get to see the physician before and after the procedure. The family has spoken with the cardiologist after he's completed the procedure. So really our patients, while they weren't necessarily nervous in the beginning, there's always some that question, you know, receiving the care in an outpatient center versus the hospital, but, you know, they've quickly adapted and we really, the patients just absolutely love it. The decreased total cost of care is huge. You know, partnering with a health system that's able to negotiate these payer contracts, you know, having health plans reach out to us saying, you know, you really need to take your patients to an ASC because it reduces your total cost of care. You know, we're starting to get measured on our performance for that. It has been, continued to decrease our total cost of care, which helps keep us desirable as a cardiology group in forging these new contracts and hopefully risk-based contracts in the future. When we look at financial opportunity for investors, I mean, that's always a motivating factor, but there are other financial opportunities more than just the dividends that are paid out on a quarterly basis that you all hope for your return of your initial investment. When you look at the financial opportunity for garnering risk-based contracting, as it relates to your total cost of care, that can be huge in some markets. When you look at the financial opportunity for growth, you having an ASC and also having an ASC that is a joint venture with a health system shows those physician groups that we don't have to be acquired by the health system, that we truly are partnering. And as physicians look to join us, it's more entertaining to them that it would be a group that perhaps down the road would be getting acquired or bought out. So, you know, being able to attract physicians from other local groups all across the valley for us, the ASC has really made us able to leverage ourselves to be desirable from that standpoint. And then just the financial opportunity of being aligned with the health system, whether it's through having common goals, looking at patients that are coming to the ASC, collaborating with driving increased volume through the hospital that perhaps that was lost to the ASC, you know, just that collaboration has been a huge opportunity. And then most importantly, as it affects the physicians specifically, there's always hesitation in the beginning because you fear the unknown and you don't know what it's going to be like to partner with a health system. For many, certainly for us, that was brand new. We collaborated, but we'd never partnered. And so, when you look at the autonomy and freedom that the physicians have experienced, their work-life balance has definitely improved. The ability to see twice or to complete twice as many procedures, I mean, a 10 minute turnaround, 10.9 minutes, Mark didn't like the 0.9 minutes, but I'm sure you all know what the turnaround time is in the hospital. And I think they shoot for, I mean, don't quote me, I think it's like an hour or 90 minutes or something like that. 10 minutes, these physicians are able to do twice as many cases in a short amount of time. They're able to know the staff very closely. They anticipate their needs. They work very closely together. There's really not a lot of turnaround time. And just being able to control when they're at the ASC, the types of patients that they're taking there truly does give them a sense of autonomy and freedom. Next slide. So, some of the obstacles, there's many listed here. I'll just focus on a few, but it truly breaks down into clinical, financial, and operational obstacles. Really, the clinical in the beginning was focused on what is the right patient to take to an ASC. And I had different physicians with different philosophies. They thought, oh, I'm not going to take a diabetic patient because they'll probably have multivessel disease, or I'm not going to take a patient who's had a cabbage in the past because I might not be able to intervene, or they all have these philosophies. We met quarterly to discuss clinical scenarios so everybody could banter back and forth about their own personal experience. And what they collectively decided is whatever you think you're going to anticipate about the appropriate patient for the ASC, you're going to be wrong every time. So, just be of the mindset that these are diagnostic paths, and if it needs an intervention, you're probably prepared for it. But if it needs more technology that you don't necessarily do at the ASC, then you'll just do it at the hospital. And so, honestly, most physicians clinically, we have, obviously, there's size limitations and some different, you know, somebody who can't lay flat or some true clinical indications that you don't take patients to the ASC. But for the most part, they take all their patients to the ASC. If they don't, they're actually indicating in the chart note what is the clinical reason why, which has kind of helped them formulate who is the appropriate patient for the ASC. But it was an ongoing collaborative approach. An obstacle that we've overcome is how do you communicate with the physicians who are taking cases to the ASC in the manner that they best respond to? And so, remember that the ASC team is new in responding to a bunch of physicians, and we know that communicating things to physicians is a delicate balance between what are they going to read, what are they going to disregard, what's truly important. And so, collaborating with the team and the best way to communicate or mass communicate with the providers was key. And for us, you know, whether it's through, you know, mass emails, whether it's through work groups, we kind of had to figure that out along the way. Financial, I think that figuring out what financial performance metrics the organization wants to see, what they understand, how's that communicated, at what level of detail, that's taken a little bit of time because everybody's financial reporting is different. You know, the type of accounting that we do is different than the type of accounting that we see through Banner and the ASC. So, we've kind of had to, I've had to reteach the physicians and move them away from our accounting methods. When we look at collaboration with the billing office, that came a lot later that we probably should have done at the outset. We needed to align the goals of the billing department for the ASC to make sure that they fit with what we were doing from the time the patient got scheduled. So, for instance, not scheduling an outpatient ASC within seven days, no sooner than seven days unless it's a stat. What we found is we actually needed more time to make sure that we were getting the insurance prior off and that the billing office for the ASC had everything that they needed. They had some requirements that they need for their health plans in terms of like old-fashioned paper documents. We didn't know that. And so, collaborating with their billing office and our billing office and schedulers to make sure that on the front end all the claims were going through clean and that we were both achieving the metrics that we wanted to. We see the Banner Atlas billing office as our billing office because we're really just an extension of the ASC. So, that collaboration was huge. When we look at growth opportunities and new procedures, Mark mentioned some of the things that we're looking at. Always looking at new procedures that we can add and how do we best roll that out. Operationally, I think the biggest thing was how do you add a new place of service for physicians who already have an established workflow? And so, for us, we had to coordinate that with maximizing as much volume as we could at the ASC while making the physicians, not making, but creating an environment where the physicians actually enjoy making that extra stop at the ASC. And so, the block time as we move forward. And even to this day, we're constantly looking at, you know, what is our resource limiting factor? And as Mark had mentioned, for us, it's probably going to be the 12 pre and post rooms because as we continue to grow physicians, we know that we're just bringing more volume there. But the question becomes, when do we max out with the volume? And I mean, I don't think that's that far away. And, you know, only being two years in, I think that's a pretty phenomenal achievement. So, next slide. Next steps, we talked about new procedures. For me, I cannot tell you how much the ASC has helped me with recruitment and retention. You know, when I look at being in three different markets across the valley and having have experienced physicians, you know, leaving the group, when we look at the addition of the ASC as a retention tool, physicians want to stay because they feel vested. But physicians also want to come because they see the collaboration that a private practice group well-established has with a big health system. And I really think that gives potential recruitments comfort in knowing that we can coexist side by side and not necessarily need to be purchased or acquired. And then market expansion, you know, this just opens up the opportunity as we grow into different markets, what that looks like with future ASCs. So, that's definitely something that we're always considering as well. I think that's all I have. Okay. I will try to get through my slides pretty quickly here so that we can get to more discussion. Next slide. I know everybody on this call has a slide something like this for their organization. And it's not my intent to go through a deep discussion of banners. But really just to emphasize that two years ago, actually probably four years ago, as Lori said, we started talking about this well in advance of opening our doors. It was really important to us to make sure that we embraced ASCs for the right reasons, that it helped us further our greater mission in this service line. And I think we have done a really good job in being organized and thoughtful about how we link our specific ASC strategy and the development of ASCs back to this every single day, every single discussion that we have with all the various stakeholders. And we'll continue to do that as we move forward. Next slide. So really specifically thinking about how does the ASC further our overall service line strategy? It supports growth, which is obviously important and key through physician alignment and partnership. And it certainly, as Lori just said, is a less costly way for us to enter into new markets, in markets where we have strong physician alignment opportunities, whether those are with independent groups or our employed cardiologists. It's a way for us to create a presence and a base without having to build, for example, a significantly more costly acute care strategy. And we know it's a payer-friendly strategy as value-based care and even risk-based contracting becomes more and more important. And I will just say as a little sidebar here, for us in our market, I think Mark and I periodically count how many ASCs are in the Phoenix area. Are there 12 now or 14 cardiovascular ASCs? 14. 14. So we're in a very competitive market. This is a significant growth area. And so that means there's a defensive element to our strategy for all of us, for Mark, for Lori, and for me and Banner. We know that if we don't provide this service or this offering, somebody else will do it and take our business. And we also know from a value-based care and cost perspective, if we can't compete with ASC margins, ASC net revenue, ASC cost profiles, we're going to be asked in the hospital setting to take care cuts to mimic that. So again, very much a defensive element to our strategy. It also improves patient access for all the reasons Lori went through, much easier for patients to schedule, to navigate smaller parking lots, smaller facilities, step right in, have their procedure, go home. But we also do believe it supports clinical quality and performance. And so the important things around that goal are the formal governance structure that all of our ASCs have, that it really truly is 50-50 between the two owners of the ASCs, that's Banner, Banner Atlas, and then our physician partners. And that group really is charged with identifying metrics and KPIs and continuous monitoring, not just of the financial status of the ASC, but about the care and the quality that it brings to our patients. And Mark talked a little bit about that when he went through the pillars that Atlas looks at there. Next slide. So some of the things that we've challenged ourselves with over the last two years as we've built and developed and ramped up our cardiovascular ASCs, are we confident that the business model that we have in our ASCs supports, as I said, our overall service line strategy for the health system, the strategy very specifically that our hospital leaders have to grow and expand cardiovascular care within the acute setting, and then the ASC strategy itself. So you all can imagine, I know you've gone through these conversations in your own organizations, it's a difficult concept for a hospital leadership team to embrace. Why would I do this? Why would I support cases leaving my hospital? What will I do to backfill those cases? What will that mean to my hospital's census and program development, et cetera? So we really kept that top of mind because for a strategy like this to work, every stakeholder has to see a win somewhere in it for them. And so in terms of looking back, the questions that you see here are those that we asked ourselves. And it's a little more organized at this point, kind of being able to look back and utilize that whole learning process. We didn't walk into this knowing all of this on day one. So it's very much been a learning curve around, do we have a sufficient knowledge of ASCs, ASC resources? As Mark mentioned, and Atlas is our partnership expert in this, it's a different business model, different reimbursement, different cost profile around everything from staffing to supplies to the facility itself. We know as a system, and we've talked about this again today as well, that what we see today in the ASC setting is very different than what it might look like in six months, in a year, in five years, in 10 years. So as we think about what our hospital backfill strategy might be, what the out-migration impact of cases on our hospital might be, we have to take both a short term or immediate view, but look long-term as well. So for example, very much top of mind within Banner now is what will the impact be as CMS approves ablations in the ASC setting, which are very profitable procedures for us, obviously in the hospital setting, but will certainly migrate because at some point they will be approved. And we have some experience with that in a little bit of a limited way. In Phoenix, we are doing ASCs in some other settings, some other ASCs in the area, because commercial payers will pay for ablations in the ASC setting. So just kind of an example. And when Mark mentions Watchman or TAVR or Structural Heart, just again, more examples of reasons that you really need to be prepared for what the future is going to look like. I talked a little bit about all stakeholders. Do they all support the ASC model? And really for us, this has given rise to a lot of very, very detailed conversations over a period of months with all of those stakeholders you see there. and it just really emphasizes the importance of having that open and transparent communication around what we expect, what's going to move, what's going to be left in the hospital setting. How do we work together, including Lori and her physicians as our partners, to help backfill and mitigate the impact of the ASC in the hospital? Because it's not in the physician's best interest to see a weak program in the hospital setting. So we're all part of that conversation together. And at Banner, we've been really fortunate in Mark and in Lori and in our other physician partners to have a really strong and cohesive group that's dedicated to working together to make sure we all stay strong through this. And then I really think importantly as well, remembering that at the heart of all of this, I'll just say this really, really briefly, is our concern for our patient, that in Banner we call Sophia, that's our representative patient, and really are we doing what's best for her and for her family, which is to provide care in the most efficient setting possible at the highest quality. Next slide. So there are some things as we develop this strategy, and I think it's been only emphasized as important over the subsequent two years that we've been moving forward in this area, that are really important for us in terms of standards for the ASC. And I think the first one's pretty obvious. But we also wanted to make sure that our ASCs, as much as possible, functioned as independent entities. So the governance of the ASC is, although it involves Banner and involves Atlas and involves Cardiac Solutions, is very much separate and distinct from the governance of each of our respective organizations. We do have credentialing and privileging processes and policies that are very similar, actually almost exactly the same, as what you would find in the hospital. They're open staffs, so non-owner physicians can participate if they can meet the privileging standards. We do ongoing performance and quality reviews. And I think it's been very much a process to develop that shared governance model. And that has probably been an area I think I've been most grateful to see and observe. And I do sit on the board of one of our ASCs. But in that governance setting, that's really where the owners come together and each brings their own perspective. But we all have to compromise from time to time for the good of the entity and the good of our patients. And that process has been really great to see. Next slide. So I wanted to give you a little bit of information around what the impact has been now that we've had our West Valley ASC in partnership with Atlas and Cardiac Solutions open almost exactly two years, I think, Mark, is that right? So what's the experience been in the hospital setting? How have we developed and executed on a backfill strategy in the face of out-migration? And what's been the positive impact in some of the areas that Lori and Mark have talked about already? Really primarily physician recruitment and incremental market growth. So our ASC is in the neighborhood with two Banner Medical Centers. One is Banner Boswell. The other is Banner Dell eWeb. Banner Boswell is a tertiary center, offers almost every advanced service with the exclusion of heart transplant, while Banner Dell eWeb is a smaller community hospital focused on basic services. So two very different facilities in close proximity to our ASC. At Banner Boswell, the team developed a backfill strategy that was really focused on growing complex cases. So complex PCI, complex structural heart, complex EP ablations, knowing that low acuity cases were going to migrate to the ASC. But actually, the fact that that happened allowed the hospital team, in partnership again with Lori and her physicians, to really identify some opportunities. So we had complex cases that were struggling to find time to fit onto the schedule. And in working with the physicians and communicating that to groups, we were able to actually clear some backlog because those complex cases were able to be moved through the system much more efficiently. I think that not all of our challenges were solved by that, but certainly gave us the opportunity to really identify services that we wanted to grow, that were appropriate for the hospital setting, patient acuity type of service, and focus on moving those through the system. At Banner Dell eWeb, the impact was much more significant as we had, again, primarily basic cases in that hospital. And about 30 plus percent of our outpatient cath and EP cases to date have moved out of this hospital. So as you can imagine, that created a pretty significant gap to fill. So we took a look at a couple different things, and there's no perfect answer here. So I think what's really important is to recognize this, to recognize it takes a lot of time. It's certainly a team effort to identify this. And you may find things that work or don't work, and you sort of have to pivot, go back to the drawing board. So we looked at, again, the same types of things. What kinds of cases could we find? Could we do peripheral vascular cases? That's the first thing we set on, and we found that that wasn't really going to provide the volume we needed. So recently, and literally in the last couple months, we've identified an opportunity working with our team at the hospital, our physicians, and looking at market data to grow vascular surgery cases, inpatient vascular surgery cases. So that will be our new focus. And I will say as well, in some of our hospital settings, because we have other ASCs besides the West Valley one, but in some of our other settings, it actually has been a fairly significant opportunity for us to provide resources and availability and capacity to support non-cardiovascular cases. So that's an area that we look at as well. Maybe there's a neuro team that desperately needs capacity and space, or a pediatric program. All of those things are kind of fair game. And again, remember, we're taking the perspective that not only is this the right thing to do, it's the right thing to do strategically, but also it's going to happen anyway. So we're choosing to lean in and embrace it and take advantage of it versus sitting back and letting it just happen to us. Next slide. So just to give you a sense of the existing centers and the partnerships we have, I think the point here is that there's really no one rigid model that can work in the ASC setting. We've seen success with our employed cardiologists, with our large independent partners like Lori's. We are soon to embark on a journey developing an ASC in partnership with our employed academic physicians who are part of our university care model. That's been a little bit of a different flavor, but a really interesting and gratifying process there as well. And that's it, Joe. Well, thank you all. That went, Mark and I were just texting to be completely transparent saying, this is going longer than we thought it would, but it was so valuable to hear the perspectives two years later. And I think you all had much more of your story to share than we anticipated. And I'm thankful for it. So I'll remind everybody again that at the bottom of the screen, there is a button, and we will take questions through there for any of our three presenters. And I do have some that will get us started that have already been submitted. And thanks for these folks who submitted for their patience. So the first question is a pretty easy one. And it's, does this 7,500 square feet in the ASC at West Valley include all aspects of the ASC, including procedure rooms, recovery bays, lobby registration, et cetera? And then also looking for clarification on, is that one, two, or three procedure rooms inside that facility of 7,500 square feet? So I guess that's a Mark or Lori, either one. The short answer is, yeah, that's all in. That's three ORs, three labs. They're not huge. They're each 400 square feet, so it's a little tight. 12 prep and recovery bays, lobby, break room, locker rooms, everything, 7,500. Okay. Thank you. And then the questions get a little harder. So this one is one that's dealt with by anybody forming an ASC. And it's about who can participate. And so is the joint venture ASC structured in a way that interventional or invasive physicians in the practice can share at all in the ASC profit? And so anyway, so that non-interventional or invasive can share. And Lori, I think from what I heard, the non-interventional do not, but the invasive does. And I'll let you make sure that we have clarity and answer that question for the group. Sure. So there's a million different ways that you can structure ownership in an ASC. And my first best advice is to get legal counsel that you're very comfortable with. And it's all about what risk are you willing to take should there be questioning of your ownership, right? And so for us, we actually explored two models. We looked at all physicians, invasive, non-invasive, interventional, and EP joining in the joint venture. And we just didn't have 100% majority vote in the comfortability, if you will, of what that would look like in terms of the regulations. So because we wanted everybody to be comfortable, we did opt to have just physicians who are doing procedures at the ASC can be owners, but there is no one way. It's whatever works for your organization. And you just have to make sure that all the physicians are on the same page with the level of risk with how you set up the venture. Yeah. Excellent. Thank you for that. It is based on your risk tolerance without a doubt. That's what we come down to. So next question is, is the ASC staff dedicated to this facility or do they come from any of the hospital cath labs? And I'm assuming that question means are they coming back and forth from the hospital, not did you hire some that used to work in the hospital. So are you seeing a job share, if you will, between hospital and ASC or are they consistently at the ASC? Yeah, I can handle that. In this instance, and in all the surgery centers we have, they're dedicated surgery center employees who work for ATLAS. That's not to say a shortage. shared model wouldn't work, but we're really big on culture and mission, vision, value, and we just think that we have a different side of service. We have a different model, we have a different culture, and that's why we have all of our employees work just for us. Mark, let me also just say from experience that collaborate with the hospital and the ASC when you start out in terms of staffing, so it's a very fine line, you don't want to steal all the staff from the hospital because then who's going to do your complex cases, but you can't deny people who want to come work in the ASC, so you really all have to be on the same team. I know we went through, don't take our staff to, let's work this out, and you really have to collaborate because you still are seeing patients in both environments, so it's a very fine line. I do think the point is that it's good to recognize it's going to happen and discuss it beforehand so that between all the partners, they can agree on how best to approach it. I mean, you can't prevent people, nor would you want to from applying for jobs, but I also think, and maybe Lori, you and Mark can comment on this. I do think you'll find that there's a certain type of employee that enjoys one culture, one setting versus the other, and so I think what's happened to us is just naturally, people have kind of taken advantage of opportunities where they feel it's a better fit, and if that is the case, then really the positive way to look at it is you prevented a valuable person, resource, from leaving your organization, and really overall, even on the hospital side, we'd rather have that happen than lose that person completely. Excellent. I was going to make sure you commented on that one, Christina. Thank you. I wasn't going to let you off the hook up there. So we don't have a ton of time left. We've got a great question in, and it is, what was your three greatest challenges that you faced moving forward? So what makes you nervous, and what were the three greatest opportunities that you were able to see? So what's going really well, what keeps you up at night? And although they've asked for three, I think, you know, to close this out and hear from everybody, why don't each of you give us one? So what is the one big success, and what is the big challenge that you foresee, who wants to go first? Go, Lori. Okay, I'll go first. So obviously, I mean, when you're entering into, just to be real, when you're entering into a joint venture with a big hospital system, you always fear your autonomy, right? Are they going to tell us what to do? Do we have any say? So that's probably your first trepidation in wondering. That didn't happen at all. There could not be any greater collaboration, because we're all vested in this, and we all want to achieve the same goals. So that was probably the biggest concern. Probably the greatest satisfaction. Honestly, for us, it's been the patient care. The patients love it, what it's done to convenience for them, and physician convenience in their day-to-day operations. That's been the greatest success. Love it. Christy, I'll go next and leave you for the last bit. I think the biggest concern would be capacity and staffing, right? We're at about 200 cases now. Let's fast forward three or four or five years, we're at 300 cases a month. Can we staff it, and do we have the room? So that's, I guess, a good problem to have. The biggest satisfaction for us is to see Christy and her team and the CV service line and the local Banner Hospital executives support this venture, because we move 200 cases a month or so out of those hospitals she mentioned, and Christy has been extremely supportive of it. She mentioned in her slide deck, seize the future, open up capacity, backfill strategy, recruitment and retention, and that's really fulfilling for us, they're our JV partner, and that we're relying on it, it's for the greater good, and that's what I think gives me the most satisfaction. I'll say, building on that, thank you, Mark, that I think the greatest satisfaction that I've received is observing the incredible satisfier the ASC is for our patients and our physicians, and really, in watching the development and ramp up, seeing the increased engagement from our physicians in really making the ASC successful, but also seeing how impactful and what a satisfier it is for patients from a patient experience perspective. The greatest challenge for us is our continued work on how, as we look down the road, we know that the case volume is only going to increase, and it's going to continue to make inroads in patients we thought of as traditionally only appropriate for acute care settings, so how do we continually deal with the challenge of that and the out-migration growing and growing and growing? We haven't touched on it too much here, but in addition to creating backfill opportunities in our hospitals, it also really brings into play bigger questions around, as we go forward, do we build EP labs in the same way we have, do we build cath labs in the same way we have, how do we really make ourselves more efficient with this new care setting? I love it, and I appreciate it. We've got to close out, and I appreciate the three of you. What's unique about bringing all three of you together is that you don't just speak from a perspective of, oh, we're a hospital that has a JV cath lab, and then we're a practice that has a JV cath lab with the hospital, or, hey, we've helped put these together from the Atlas perspective, it's that you guys are all working closely together on the same one, so when Lori says, hey, we were nervous about the hospital coming in and taking away our autonomy, she really means you, Christy and Banner and all of that, and the fact that the three of you are able to sit here two years ago and two years later today to say, hey, we figured this out, we're getting along, I think that sheds a lot of sunshine, a lot of rays of hope for all of us to say what is making this specific arrangement very productive for the physicians, for patients, for the health system, for your JV partner, it's just come together very, very nicely, so thank you guys for sharing this with us, thanks for being so transparent, thanks for being able to tell your story and answer the tough questions. With that, we are going to end today's webinar, and I appreciate everybody for spending time with us and tuning in.

Joint Venture ASCs

Collaboration

Communication

Physicians

Improved patient access

Reduced cost of care

Physician recruitment

Physician retention

Positive impact