All right, we can get started. How's everyone doing? Great. I know this is the final panel standing between you guys and some cocktails outside and enjoying the weather and the nice evening. So we'll try our best to be succinct and get you guys out to enjoy the nice weather outside and enjoy those cocktails. So I'm Himanth Kalia. I'm one of the physiatrists in upstate New York. I like to say that I'm from the Napa Valley of the East. I know some of you who are in this region might disagree with that statement, and we can debate on that after this talk. We do have a gorgeous upstate New York Finger Lakes region, and we are known for our whites. I do like to put that plug in there. So I was part of a health system practice for almost 11 years, and then I recently went private. And that's where the idea of this talk and some of the concepts and the constructs which we'll be focusing on, we'll go through that. So as the topic suggests, and it's self-explanatory, are we witnessing the death of outpatient private practice in physiatry? And are there any pragmatic solutions which we can talk about or explore to keep this part of physiatry practice viable? These are my disclosures, nothing pertaining to the talk we are giving today. So in about next 40 minutes with my esteemed faculty, what we will try to do is we'll try to explore the scope of the problem, and then we'll explore two or three different pragmatic solutions on how to maintain the viability of private practice in physiatry. We'll also look at some of the contracts which can be really helpful to explore, especially when you're coming out of your training as a resident or a fellow. And then we'll delve into different models ranging from solo practice to a private practice model with multiple options to negotiate your contracts with your peers. We do have our esteemed faculty with us, Dr. Desai. I've known him for, gosh, too long, Dr. Desai. He's a medical director of the International Spine Pain and Performance Center in Washington, D.C. And we have Dr. Rispoli, who is a solo practitioner in Los Angeles. And they will share their experiences and go over some of the nuances and some of the aspects of their specific practice patterns in the later part of the presentation. So with that, let's quickly look at the current landscape. This is not... Okay, it just started working. Thank you. Let's look at the current landscape. There was a survey done by AMA, and this survey looked at the percentage of private practices over the course of a decade. So between 2012 and 2022, overall in the United States, the physician-owned practices decreased from 60.1% to 46.7%. And in that same timeframe, the hospital-owned practices increased from 23.4% to 31.3%. So these are startling numbers. It's giving us a trend where physician practices are moving in our country. When it comes to our specialty, physiatry, this was a survey done by the Academy. And this clearly kind of gave us some really startling numbers. You know, private practitioners are, although small in number, but we have a really strong voice when it comes to advocacy through our subspecialty societies. And with the Academy, we have an opportunity to work together and reinvigorate this aspect of practice through the support of Academy. So 11% of physiatrists are in private practice setting. And as you can see, a majority of them, 45% are inpatient, outpatient, 28%, and academic, 16%. So how did we actually get here? It's important to understand the landscape and then what prompted and what led to the decline of private practice, not only in physiatry, but all across the board in the United States. I promise you, our story is not as exciting as the election story of 2024, of 47th election in our country. We have just basically four factors which led to the decline, or which is leading to the decline of private practice in our country. Mostly the economic factors. We have administrative and regulatory burdens, which we have to deal with when we are in private practice. And then finally, we have to deal with the mergers and acquisitions of not only non-profit organizations, but also the impetus of private equity coming into organized medicine and practice of medicine and business of medicine. So all these four factors are leading to slow decline of sustainable private practice in our country. If we delve a little bit more deeper into economics of how private practice works, you know, going back to our high school and our undergraduate years, Econ 101, you know, you provide a service, you charge a fee, and you get paid. As simple as that. I wish healthcare industry would follow the same rules. Unfortunately, they don't. We have a huge behemoth known as insurance, which comes in between that transaction. So we are providing service to our patients, but we are getting paid through the insurances. And if you get into the private practice, the revenue cycle management and the practice management piece, the steps which are required to get that claim paid are too cumbersome, and there are so many variables which leads to not just delayed payments, but also the viability of private practice becomes more challenging, primarily because of all these convoluted aspects of revenue generation which comes here. So one main factor, inadequate reimbursement rates from public and private insurers, the cost of doing business. We all know where the inflation has reached over the last, you know, five years. The operating costs keep increasing. On top of that, we have regulations around EMRs, our regulatory burdens on reporting certain very specific metrics. Our payments are associated and linked to these metrics. So all these factors affect the reimbursement which we get for our services. Not to mention, the services which we are offering, if you look at the overall operating cost of that specific service, let's take an example I did. Let's say I did an epidural injection this morning in my clinic, and then doctor decided exactly the same procedure in his clinic in Washington, D.C. Barring the geographical distribution and changes, operating cost would kind of remain almost the same with a certain delta. And then on top of that, you have a physician fee which comes on it. But the difference in the reimbursement for exactly the same service in two different geographical regions will be startling. And that will be dependent on not only the geographical region, but also the contract which individual practices have done with the insurances. Now, there are specific rules and laws which will not allow me and Dr. Desai to do a collective bargaining with the insurers. In order to do that, we have to explore certain protected legal entities which Dr. Desai will cover in his talk, how physicians can come together and do collective bargaining under legal structures. Because as private practitioners, myself and Dr. Desai, with our individual private practices, we can't go to do the insurer and do a collective bargaining on our services. So, there are a lot of challenges, economic challenges which have led to the decline of private practice over the last decade, decade and a half. Administrative and regulatory changes, I briefly talked about the burden of the insurer policies. How many of you have done a prior authorization in the last week? Every single one, yeah. So, we all know the burden of prior authorization has decimated the practice of medicine, there are certain legislative solutions which are coming out but they're not fast enough and they're not holistic enough. All these administrative and regulatory challenges have further increased the operating costs of private practices and thereby making it even more challenging to stay in private practice. Some of the claim management and claim processing systems with the insurance companies are so complex and the delays which are there in the claim management is so significant that your AR, which is your account receivable, becomes really hard to manage and which further affects the bottom line of the business. I briefly talked about the federal and state specific regulations around your EMR, your electronic health record, your HIPAA compliant portals which we use to reach out to our patients which further increase the overall cost for the private practice. And finally, I think we have lacked in educating our residents and fellows during their residency and fellowships on the business side of medicine. If you look at the ACGME curriculum, there is no specific curriculum in place which teaches residents or fellows on the business side of medicine. So most of the residents and fellows, and according to a survey which was done recently, 90% of them are unprepared to handle the business side of the medical care which is a really startling number. And that's another reason why most of the residents and fellows don't feel comfortable in starting their own practice these days soon out of their training. Dr. Desai and Dr. Espoli is going to go over some of the very specific aspects of private practice in their talks. Dr. Desai is going to talk about the contractual ways of doing collective bargaining and Dr. Espoli is going to share her experience on her journey to start a solo practice and share some of the challenges she faced and how to sustain a solo practice in this environment. And before I hand over the presentation to them, I'm going to quickly touch based on a very small segment of private practice which is really important. It's not only important private practice, but any resident or fellow who's coming out and even going into an academic or a hospital-based system, they have to review or go through their employment contract. So obviously the talk today is not geared towards getting into the details of physician contracts. So it's almost like a 36,000 view of what physician contract looks like and what different types of contracts are there. Details are definitely out of the scope of today's presentation, but I'm going to just give a quick succinct overview of physician contracts in the next five minutes. So these are some of the types of physician contracts which are out there. Your employment contracts, your independent contract, your partnership agreements, and affiliation agreements. Each one of them have specific sections and specific rules which you should look into if you're exploring any one of those in your practice. Some things to consider before negotiating, whether you want to make more money or you want to spend more time with your family so you have a nice work-life balance or you want to focus on your career or you want to have a nice schedule where you can spend a little more time with the patients. It's important to understand what is your priority and top two priorities. There is actually a nice segue story around it when I was a program director at one of the fellows and I always used to go through these four or five things and I used to say, well, what do you guys want in your contract so that I can help them come up with some questions to negotiate their contract? And one fellow said, I want everything, which is out there. Well, that's really hard to attain. You will have to focus your priorities, what exactly you're looking for, so that when you go on a negotiation table, then you can have a rationale argument to present and do a meaningful negotiation on your contracts. There are about seven key elements of a contract which you should review. Some contracts will definitely have more stuff into it, but these are seven things which you should definitely focus on. One is obviously your employment status, whether you are salaried or you are independent contractor. The difference is if you're an independent contractor, you will have to cover your own benefits, your taxes, your malpractice insurance, as opposed to when you're salaried, some of those perks will come under the benefits. Your compensation and productivity, I'll go into a little bit more detail in the next slide, but benefits are something which, depending upon what your personal situation is and where you are seeking employment, the benefit package can vary a lot. And that would give you opportunity for negotiation on transforming those benefit intangible numbers into tangible numbers and increasing your base salary if needed. Duties and responsibilities should be clearly delineated. Non-compete clause, malpractice insurance, keep an eye on the tail insurance. That's something which is really critical and important and having a conversation with your employer up front on who will cover the tail insurance is going to be really, really helpful and critical. So when it comes to compensation structure, I think there are two broad compensation structures to keep in mind. One is obviously based on the production. One is the number of patients you are seeing, which is either collections-based or billing-based. So percentage of your collections will be given to you as your production salary. Or you can be in a situation where your production is measured in work done. And work done is your work RVU. So these are specific numbers which are assigned to every CPT code by the federal agencies. You can go on CMS website and you can actually look at specific work RVUs which have been assigned to each and every CPT code, which will give you an idea of how much work units which will be used to remunerate you for your work done on these patients. So a quick hypothetical example. This is a hypothetical, completely hypothetical example. These are not like real numbers. So if you have a collections-based model and your base salary is 200,000, your productivity bonus let's say is 50% of collections, which starts above 500K of collections. So basically what this contract is telling you is that this practice assumes that their overhead is about 50%. So you have to generate twice your base salary before your bonus is going to kick in. And your bonus is going to be 50% of your collections. So that gives you an idea of what different parts and pieces you can go back and negotiate. Similarly, a work RVU-based model, let's say your base is 200K and your productivity bonus is $50 per work RVU, which starts above 4,000 work RVUs generated. So basically what this is saying is that you have to meet your salary by generating 4,000 RVUs and your bonus is only going to kick in after you have generated that 4,000 RVUs, right. So most of the fellows or most of the residents come back and say, well, I want a higher base. Sure. You can have 400K as your base, but they will increase your work RVU generation to 8,000 units. And it's a, there is no negotiation in that argument because the cap or the guaranteed salary is going to be there for one year or two years. And after that, if you don't generate that number of RVUs, your base salary is going to drop down. So instead of negotiating on a base salary, it would be helpful to negotiate on the dollar amount of the RVU. That is what will be helpful for you to have a more meaningful and more effective negotiation on your salary if your work RVU-based. So again, there are multiple facets to this. We can't go into the details, but I just wanted to give you a 36,000 view of how physician contracts are laid out. And there are so many nuances at each and every step. And every contract is negotiable. So where do we go from there? I think we have our excellent faculty. I'm going to hand it over to Dr. Espoli. And she's going to share her journey on the solo practice. Great. Thanks. Thank you. Hi, everyone. I'm Leah Espoli. Thank you, AAP MNR. Thank you, my esteemed colleagues, for joining me today. So my section today, I'm going to be more personal and just describe a little bit of my experience. I'm only three years into my own private practice. So I'm still a newbie and still learning so much. But at least these three years have been very enriching and very exciting. And the point of today is to really share that with all of you if you have any interest in ever proceeding with a private practice of your own. So, yeah, just disclosures. I am a NALA consultant, but it doesn't have to do with today's talk. I'll talk a little bit just background of my biography here. I went to Rutgers Medical School. I did residency, obviously, in PMNR at New York Presbyterian. And then I went on to do an Interventional Pain Medicine Fellowship at New York Presbyterian as well. To be honest, I never, ever thought I would go into private solo practice. I wanted to start a family. I had never thought business was a good background of knowledge that I had any education in. I didn't know the first thing about starting a practice. And I'll get into the details of how it kind of all unfolded in my life and why it presented as a great opportunity for me and why it's become pretty successful. But first, I just kind of want to go over a couple key points and objectives that I found looking back at the last three years were really key points to think about if you're considering joining a private practice or starting your own. So geography is huge. And for me, the one thing I wanted was to live in Southern California. So now, you know, a little background more, I should have said this before, but my practice is now in Marina Del Rey, which is part of Los Angeles and in Newport Beach. And I commute between the two. And I'll explain that clinic design and why. But for me, after graduating, I spent many years in New York City and I was ready for a change, weather change, and obviously seeing why the weather's so beautiful here, why I wanted to be here. So knowing and understanding the geography and why you want to be somewhere and where you may want to start your first job as a graduating fellow is really important because you would need to investigate your local competition. What other doctors that do the same thing you do are out there already? Are they successful? Are they needing to hire someone here? Are they heading towards retirement? These conferences are great opportunities to explore that if you have an area of interest and want to get to know anyone that knows that area. Because that also will be an important factor in deciding what kind of patients you're going to be seeing. Southern California offers a different patient population than the middle of the country in a very rural area. That's a big key because if you're going to be a similar doctor to 10 other doctors within a five mile radius, what's going to separate you? How are you going to be successful? It's going to be very hard to generate any patient volume if you're doing the same thing that 10 other doctors within a five mile radius are doing. So it's an important thing to think about what niche you offer. Do you offer something different? Are you open to seeing a different patient population? For me, it was a little easier being female and interventionally trained and I was open to seeing some pelvic pain, which nobody wants to see. So keeping that open mind and being open and adaptable and being willing to learn through seeing patients and revisiting some colleagues and mentors is an important thing to keep in mind. And moving on, knowing your referral base. And some of this you'll understand as you get experience in private practice because like Dr. Hammond said, you don't learn this stuff in fellowship or residency. You kind of learn it as you go. But there's a whole way you can go about running a private practice. So you could be in network, you could be out of network, you could take HMOs and Dr. Desai's gonna talk a little bit about some of these insurance models that practices could be in or out of network with. Medicare or in some states like Texas, Florida, I know Jersey and California, you need to be really heavily involved in med legal and that's like a whole nother world, but it could be another vessel of income. There's a lot of people that have interest in regenerative medicine, which we know is not really insurance covered. So do you have interest in starting a cash practice? And then there's always workers comp too. So these things are important factors to know early on, kind of what your idea of a private practice future may look like for you. I'll go into this further, but if you're starting out in an area and not really sure, it's always better to be more open to seeing everything and taking what you can get in the beginning and then narrowing down later. So once you decide what kind of patients you wanna see and what niches you may wanna specialize in or market yourself as, the marketing game is massive because people don't know who you are. You're just a graduate. You're just a new doctor to town. You have to make a name for yourself and find a way to market who you are and what you offer and why you're different and why you're special. So this is all kind of just obviously a lot of information to just kind of just develop if you're thinking you wanna start a private practice, but these are definitely huge bullet points that looking back on my three years, sort of evolved into being a huge reason how to be successful and how to actually generate a private practice that sees a lot of patients. And practice model's a really interesting thing too. I'm still understanding it and it's still such an evolving topic because you can be solo, sure, and you can be the only doctor in your practice, which is essentially my model, but we were just talking about this, me and Dr. Desai, if you have a plan to become busy, do you have a plan to ever hire somebody else? Do you wanna ever partner? Work isn't everything in life. Do you wanna have a family and have personal time? How do you do that if you don't have a partner? So it's interesting topic to have now, especially for me three years in when I'm busy, but I wanna be a little less busy. And I wanna be able to hire somebody without necessarily just duplicating me. So those are things that you think about a few years in more, but it's good to kind of brainstorm those ideas early on. If you're an interventionist like me, you have to also think about where do you do your procedures? Do you do them in the office? Do you do them in surgery center? And what does that look like for payment and partnership with different ownership of surgery centers? And then there's the small elements of running a practice, which include who are you hiring as your biller? Who are you hiring as your staff? Who are you hiring to run your practice? You need office managers and you need people to answer your phones. And one of the big things that I've had success with is virtual assistants. So I actually have five employees that are in the Philippines and they answer all my phones, they do all my scheduling and they're excellent. And they're a lot less expensive than people and more reliable than anyone I've hired in person in LA. So those are small intricacies to the practice that also save a little bit of overhead costs. And then, we were just talking about this, but once you're established in a practice and you're up and running and you're busy, it's like the next step is how do I become efficient and not work endless hours while still having a successful practice? Do you hire a mid-level PA or an MP? Do you hire an associate MD? And then, the whole factor about being partnered with as an interventionist, do you do your procedures in a surgery center and are you buying in? Are you buying shares? Are you invested in there? Are you building your own ASC? And ASC means surgery center, ambulatory surgery center for those that don't know, by the way. So I know it's a little bit all over the place, but that's kind of how it is from the beginning. If you have the intention to really start on your own and you don't really have background like me in business and no one really tells you how to start a practice, you sort of just collect all the information you can, make a list of priorities of what things you need to decide on early and take risk on and basically go from there. And it's just, for me, it's been this ongoing learning process three years in and we are a busy practice, so I think we're very proud of what we've grown. And I say we as in just me and my staff, but I'll kind of delve into exactly my personal attempt and timeline of how that happened. So as I said, I graduated, I knew I wanted to probably be in private practice and I knew I wanted to be in Southern California, so that was the start. And then I got hired as an employee and worked for a small private practice and sort of learned through working as an employee in a small private practice some of the intricacies of Southern California and private practice in general. And then like anything in life, an opportunity just happened to be arising at the same time that I was realizing it was time to move on from that practice. And the partnership, that's an interesting model that's something more Dr. Desai will probably talk about, different type of models to work in. But private equity firm was taking over or buying half of a big spine surgeon group and needed pain management and needed physiatry and wanted to market that. And me being one of the few females in the area, they thought that was a great idea to kind of bring me on board. But their model was great because everyone here is private equity and you think, wow, you lose your autonomy, you reduce salary, you work like a dog. But their model's great and I think this is something that might happen more throughout the country. They partner with you, so I just basically pay them rent and have opportunity to buy into the surgery center but stay my own solo entity. So I have my own billing, my own staff, basically everything independent as if I didn't have a partnership but have the opportunity to market myself to the larger group of surgeons who basically feed me patients. And it seemed to be a very successful feat so far. And that opportunity arose at the same time of me wanting to leave my other practice and personal side note, I was also four months pregnant with my second kid and wasn't the ideal time but opportunity arises and you decide whether or not to take risk if it feels right in your gut. And I'll end with basically just giving some tips to anyone that wants to explore more of this opportunity if you feel like it might be something you just have questions about or not sure if it's the right fit for you. But I think it's really important to be flexible and adaptable, like meaning if you really only wanna see cash regenerative patients, it's hard to start that way. Maybe start just by seeing everyone and then developing a name and a reputation and then kind of dialing down what more of your interests and specialties are. Diversity, so varying your vessels of income is really important too. I do a little bit of med legal, a little bit of my private practice. I try to, for a while I was doing some subacute work on the side during pandemic too because I wasn't sure where anything was going. But we have a lot to offer as physiatrists and if you have a fellowship too, you can look for different sources of income and it just creates stability. Probably my biggest takeaway and one of them is sitting right here, Dr. Desai. Mentorship is huge. I wouldn't have had any direction without leaning on people that have done it before me and the right people. So the people that you align with ethically, the people that you see as being successful not only in their practice but personally. So I think finding those mentors now and hanging on to them is huge. Knowing your own limits and boundaries is really important too because private practice, it's easy to get really hungry and want more and more and it becomes this little bit of rat race because you're around people that are also working hard and trying to make a lot of money and live in Southern California and afford living here. But burnout, like any specialty, is a real thing. And knowing your boundaries, because in private practice I do feel like it's easy to just keep getting ahead of yourself and wanting more. So that's it. Enjoy your career and avoid that burnout. But I offered here my email for anyone that's a fellow and graduating, wants to chat through it because I'm going through it still. So it's a little bit of a youth relationship here versus someone that's been established for quite some time. And then I'll pass the torch now to Dr. Desai. Thank you. Six weeks. Six weeks? Yeah. So I'm not a big believer in you can have it all, right? But Leah just has a, how old, six week year old at home? And is the youngest of three kids, has three children under the age of four at home. So she's trying to prove that you can have it all. And she's doing a pretty good job at it. So this is, I feel sort of uniquely qualified to give this talk. I started my career in academic medicine at George Washington University in Washington, D.C. Spent six years in academics. Towards the end, I was not particularly happy with the world that was created there. I had a non-compete when I left GW and I worked in an orthopedic group for a year and also at the time, the largest pain group in the country for a year. So really sort of took all that experience when I started my own practice. I started my own practice in D.C. in 2016 and we started by rent subletting space from a primary care friend of mine. So she let us use two rooms in an office at a pretty nominal rent. It was me and two staff. And now we have, I think, 25 employees with three docs, two mid-levels. We have an entire research arm. We have two nurses and a whole, we built an administrative team from the ground up so we have all our pyros, all our billing, coding, everything happens in-house. So we sort of, I've sort of felt like I've had the experience of that entire journey that we've sort of talked about. I'm here from Washington, D.C. so I'm clinically depressed currently like everyone else in D.C. And I like to give talks that also depress everyone. So if you're not depressed, I feel like this talk should really have like a happy hour associated with it where like someone comes around with drinks. The bookend talk I'm giving, which is the last talk on Saturday, will really, it's a doozy if you really like being depressed is because the billing and coding update, Dr. Kaliana on that talk as well. So that's, I feel like there should be like buckets of Xanax at the doors when you walk into that talk. So with that in mind, quick question for the group. How many folks here would describe themselves as being in private practice? Can we just get a show of hands? Okay. So sort of preaching to the choir here a little bit so it's good to know. How many folks are in training, like residents, fellows? Okay, great, that's awesome. Let's see, any other groups you wanna ask about? Any folks thinking about making a change like starting their own practice? Okay, oh, great. Any people started their own practice recently or ever? So I think there's not one singular resource that you can use to tell you every single thing there is to know about starting your own practice. It is, to some extent, a labor of love. It's a lot of setbacks with some really great victories. And at the end of the day, it's one of the few things that you can do that allow you to have some control in a world that often doesn't feel all that controlled. While there's lots of pain points, if you've had to review anyone's resume over the last couple years, it is really a mind-numbingly horrible process. In general, when we hire for a patient, like a MA or a patient care coordinator, we review 200 resumes for every one person we interview. And of every two people we hire, one person gets fired within three months. And you'll get these resumes now that are for people who are 20 years old, and they're seven pages long. And they've been at each job for three months, and they're leaving for a higher salary or they get fired. And it's completely predictable. And so that's just one example of some of the tasks that you have to sort of decide upon if you decide to be in private practice. The other thing I would recommend to everybody in this room, whether you're already in private practice, whether you've been, you're thinking about it, whether you're seasoned or brand new, try to learn a little bit about your leadership style before you really get deep into private practice. Try to figure out what sort of leader are you, what sort of appeals to you. I was one of the leadership fellows for the academy here, I think in 2016 and 17, perhaps. And one of the outputs from that was we took this test called the DISC leadership style test. Has anyone heard of that? A handful of people. So it kind of helps you understand what your strengths are as a leader. And as we know, you could either lean into your strengths or try to shore up your weaknesses. But most adults don't really change. We tend to be sort of like, I'm who I am and I'm gonna do what I do. So whatever it is you decide, whatever you figure out, supplement it. Shockingly, if you know anything about the DISC training, I came out as a strong D. Most people would agree with that no matter what you add at the end of that D. But what I did to supplement that is I hired people that were really good at the other parts. I tend to be good at high level ideas. So I hired people that were good at operations. I made sure to supplement my weaknesses. I'm not gonna be the person who's gonna sort of make sure every little piece of paper is printed the correct way, but I'm gonna be the person that's gonna notice when it's not printed the right way. So getting into this a little bit, this is my, I think, my disclosures, none of which are relevant to today's talk. Okay, so objectives. Really, I'm gonna repeat some of the things that Dr. Kalia said, because I think they're worth repeating and perhaps giving some context around. And then talking a little bit about private practice models. What are the things you should think about whether you're thinking about starting your own practice, whether you've started your own practice, or whether you're looking to make a change within the practice that you're in? So we talked a little bit, if my slides go, about employment patterns. So physicians are less likely to work in private practice than, obviously, 100, but I think that's meant to say 10, sorry, 10 years ago, due to economic, administrative, and regulatory burdens. I mean, we talk about it all the time, but the number of prior authorizations we have to do, the number of sort of administrative challenges we have, regulatory burdens. But I will say, in my practice, as much as when Dr. Kalia asked about prior auths, I haven't done a prior auth in three months. And that is primarily because I paid to have an administrative team that takes care of that. Now, that's a trade-off, right? You can decide to have someone who really understands the sort of coding billing, and you can send them to courses, and you can pay the money it takes to get them really good at it, and figure out a way to retain them, because the second they get good, they're gonna get offers. Or you can do it yourself. Either way, there's a trade-off there. You may see a little bit more money, but you may also see a lot less stress, depending on how you decide to tackle that thing. There have been questionable business practices from large institutions forever. I mean, that's sort of part of the Constitution, I think. But if you think about it, some good examples. The average resident will get a contract from Entity X. We won't name any names. The contract will look really favorable. In the fine lines of the contract will be the non-compete, which is like not only five years, 15 miles, but from any adjacent county to any county you've been practicing in. So if you live in LA, if you live in DC, you have to move. So if you decide to fight that, you're gonna move. You're never gonna win a non-compete fight in DC or any state other than California, because it doesn't even matter if they're wrong. They have bigger pockets, and they can throw legal teams at you until you give up. But interestingly, other things that large institutions have done is they buy up practices at low cost, they drop the cost of their services, and then once they own all the practices, they triple the cost, right? This happened in Western Pennsylvania, where they basically got into legal battles with the insurers because they owned all the practices so they could charge whatever they wanted, right? But we know one thing, no matter how much that entity makes, it's not like they're sharing that money with the docs. It's not like everyone gets a bigger paycheck because 100% of the practices in Western PA are owned by one practice. So these are all things you should look at. When I talk to my residents, my fellows, if the contract's too good to be true, it's too good to be true. It's not real, right? I've had fellows sign contracts with private practices where the number at the end is the only thing they see because it's lots of zeros. They get there, they're gone within three to six months. If the practice has not been able to keep anyone for year on year on year, there's a reason for it, right? So some of the other challenges, and we've talked about payers. Payers are sort of the bane of our existence, obviously, in this country. If you look at just a few of the payers, the CEO of United made approximately $12 million in frontline compensation last year. That's not including stock options or any of the other deferred reimbursement they made. The CEO of CareFirst made like a paltry $8 million, I think, give or take. Aetna's CEO, I think they just got fired though, but they made a whole bunch of money as well. That doesn't come from saying yes, right? That comes from saying no. It comes from a whole army of people that say no to all of us. And if you've ever read an EOB, has anyone ever read an EOB? You need like a PhD to make out what it's saying because the whole system is based on you giving up, right? Like that's the whole process that's there. So there's been a dramatic shift in practice ownership over the past 10 years. So between 2012 and 2022, the share of physicians working in private practice fell by 13% from 60 to 46.7. And that continues a trend that started in the 80s where in 1988 to 1994, ownership fell from 72% to 57%. So that was a 14% drop. So if you look at sort of the last 40, gosh, 40 some years now, there's been a tremendous demographic shift in terms of physician employment patterns. A different survey than the one Dr. Akalia talked about suggested that there are still physiatrists working in private practice, like 47% or so. But when you look at sort of the academy demographics, approximately 50% of us practice some form of spine, pain, or musculoskeletal medicine. And when you look at the folks who are holdouts from employment, it's private practice people who practice spine, pain, musculoskeletal, and orthopedic surgeons. And the only reason the orthopedic surgeon demographic has shifted in an enormous Herculean way recently is because of private equity. But if it wasn't for private equity and giant upfront payments, they would still stay private because they know the value of the work they do. And they're also the strongest lobby that is in the country from a healthcare perspective. Employment patterns have also shifted. Working in hospitals or as direct employees have increased from 5.6 to 9.6%. And then working in practices that are at least partially owned by hospitals or healthcare systems have increased from 23% to 31%. And while I think this number probably underestimates the reality, 4.6% of folks worked in practices owned by private equity. And that's likely to, probably has grown over the last couple of years, although there's likely a bit of a plateau there, primarily because there isn't as much free money floating around to buy practices. And secondarily, a lot of the private equity money that has gone into pain or spine practices has not turned into more money for the private equity firms. Because those firms, those private practices have already optimized reimbursement as much of it as possible. So you can't squeeze much more blood from a stone, even though private equity will try to. But private equity, if you get into a private equity relationship, will typically take 30% of all the profit up front. So if you run a practice that's running at, let's say, 65% overhead, hypothetically, and someone's already taking 30% out, that leaves 5% to be shared amongst owners. The finances stop making sense pretty quickly in those scenarios. So employment also grew from 41.8% to 49.7%. And in physicians under the age of 45, self-employment fell pretty precipitously, from 44% to 31.7%. So work-life balance, there's a lot. I'm going to sort of make a sort of joking comment, but my residents are constantly telling me about their self-care days, and they go to the museum, or they went to some sort of cider place recently. I'm like, oh, okay. I'm like, you can do that, but maybe don't post it online with your neurosurgery friends, right? Because they're dying over there in the hospital. And you're like, oh, this cider is really delicious. So large practices continue to grow because of economies of scale. Small practices shrink because of the lack of economies of scale. Practices over 50 physicians grew from 12.2% to 18.3%. Probably also because of venture capital investment and hospital investment, right? So if you're partially owned by a hospital, they pump some money into it, you hire more physicians. Practices less than 10 physicians fell from 61.4% to 51.8%. So all of this sort of sets up sort of a landscape. Like, this is where we are. And I think this next slide, which is intentionally intended to be compelling, it's been used sort of probably in all sorts of worlds, especially the national security space. But Ben Franklin said this many, many, you know, he may have been blinded by syphilis by then, but still, those who have given up essential liberty to purchase a little temporary safety deserve neither liberty nor safety, right? So we're just trading for one other, for a different group. When we en masse abandon private practice, we're not necessarily getting what we think we're getting. We may be getting perception of safety, but I don't know very many people at the C-suite who are that, who really care about my input or my success. I worked at, I was talking about, I worked at GW, and their perception was, we're the brand, you're the doc. And when we all left, the brand somehow stopped making money, right? Because essentially, we are our own brand. And if we don't, if we remember that, we have a lot more agency in our discussions with people. But if we forget that, it becomes easy to be manipulated by the entities. So what are your options? If you're gonna go at it alone, you're gonna go at it with some friends, what are the ways you can, you know, sort of move forward? I think one thing Dr. Rispoli talked about, which I think is incredibly important, is that sort of network or mentorship, if you can find it. You know, historically, the spine pain world has been an eat your young kind of space, right? Like, we love to cannibalize each other, and everyone, you know, like, the second someone makes a mistake, there's 20 people whispering about how they knew that was gonna happen. Or we, their hiring practices of large pain groups often is very sort of predatory in some ways. But if you can find the folks that you do trust, you can find the folks that are sort of gonna be honest with you and give you good advice, I think it's worth hanging on to those people. And even if it's not so much of a mentor relationship, but a peer relationship where you can go to someone and be like, hey, what do you think of this idea? You know, like, how do you think I should navigate this process? Because if you go at it alone, probably the biggest thing you're gonna have to deal with is payers and contracts, right? So when I started my practice in 2016, I knew I was sort of, didn't want to work for anyone anymore. I wanted to start my own practice. But I was pretty risk averse at that point in my life. I had just candidly gone through a divorce, had left my job of many years, and I was sort of trying to figure out, like, how I was gonna enter this next phase of my life. So what did I do? I hedged my bets. You know, I did, like, I got, I took, added as many pieces of positive material to one side of the scale to set myself up for success as much as I could. So I rented space on the cheap, right? I didn't have this glorious palace of an office. My, I practiced, again, in downtown D.C. and in Arlington, Virginia, and we have an office in McLean, Virginia. Our average rent is probably around $50 to $55 a square foot, just as an example, right? So my just rent on one month is about $40,000, right? So that doesn't need to be the case, right? You could practice 20 miles away, and suddenly your rent is $30 a square foot. So we minimize that by renting space from someone who had extra space. Two, and we're gonna talk about some of this, we joined an organization. The organization did our contracts for us. They helped us with all the payers. We didn't have to do any negotiating, right? If you're, if you're a solo person and you go to a specific geography, it is actually possible to get rejected by Blue Cross, as an example. They can say to you, nah, we don't need you. Our panel's full. We have enough pain docs in this area, right? Cuz as individual pain docs, we have very little negotiating power. They see us as a loss leader for them, not as a value add. So that can be another thing you can do, because it's not, you know, we, we all know about malpractice insurance. You, someone talked about tail insurance as an example. But now you have to have insurance on your IT. Your computers have to have an insurance policy, because if you have a, if you have a, a, like a, a leak, you're actually liable for that financially if you don't have insurance. You have to have insurance in case one of your employees slips and falls at work, right? Like, these are all things that no one talks about, but each of these things cost money, right? And when you're talking about this, you know, when you just look at aggregate numbers, if you look at your charges, you're like, oh, we're doing all right. Then you look at collections and you're like, oh, we're the only business that exists where we charge $100 and we get paid like 35% six weeks later, right? Like, has anyone else had, like, has a credit card ever said to you, like, yeah, it's cool. Just pay us when you want. Like, no interest charges. We're going to, we're going to give you the next year free. Yeah, they do that, but they do that so they can suck you into more interest rates, right? Hiring staff, like how can you, how can you augment that, right? So we, when we started, we had medical assistance. We found that the medical, the error with medical assistance is they were not invested. They wanted the next job. They weren't really there. So we switched our hiring model to hire patient care coordinators who are all college grads. They're all wanting to go to PA school, medical school, nursing school. I've sent, I've written recommendation letters now for like nearly 10 people who are in medical school, PA school, nursing school who worked for us for about two years. Yeah, you have to train them every two years, but at least they are partially invested because at the very least they want a letter of recommendation, right? Or they want some positive output from that experience. Most of these, these organizations will help you with your EMR. You could have a whole session up here on EMRs and how much we all hate EMRs, right? Like, but the reality is we all have to use them. It's all tied into our reimbursement, our compliance, but that's another thing. If you're on your own, you still have to do compliance. And then as Dr. Rispoli talked about, the key to all of this in our practices is relationships. If you're not willing to go out and make yourself a little bit uncomfortable to develop relationships, you will very quickly close your practice because it's 100% about relationships. I've been in practice 18 years. I still go knock on doors, kiss babies, shake hands, right? I don't bite them like President Biden did at Halloween recently, but at least, you know. But the point of it is, is that if you want a successful private practice and you're not willing to market, don't do it. You'll be unhappy or your employer will be unhappy because it is a lot of that. That is an enormous part of the practice that's germane to private practice. And the number of new grads we talk to who are like, ooh, I don't want to do that. I'm like, okay, that's not a problem, but then probably shouldn't be looking for a private practice job. So what are some of these organizations? There's a whole host of organizations. And all of these organizations have slightly different, they're nuanced. And they do different things for you. So for example, hopefully by now, everyone in the room familiar with MACRA? Can you show of hands for people who know what MACRA is? Okay. MIPS, APS. Okay. So these are all, thanks, Hammond. It's like raising his hand for everything up here. You're not my target audience, sir. So all of these are things that were mandated through Medicare these days. So these are all ways that people get paid or penalized, right? So they're part of the Accountable Care Act. And the Accountable Care Act had a whole set of consequences and things that came about as a result. So we're going to talk really briefly about Accountable Care Organizations, Clinically Integrated Networks, Independent Physician Associations, and Managed Services Organizations. These are all practice models. Some of these are practice models that allow you to retain nearly 100% independence while still getting the benefits of a large group. Some of them, you give up your independence. Others, they're just a loose sort of confederacy of groups that allows you to sort of bundle some of the things you need to bundle in order to get some advantages of scale. So Accountable Care Organizations are groups of healthcare providers that work together to give coordinated care to Medicare patients. ACOs are typically made up of hospitals, doctors, and other healthcare providers who voluntarily participate in the program. And they aim to improve quality of care, reduce cost, right? And they do this by coordinating care. So you're sort of sharing test results, treatments, prescriptions, trying to reduce medical errors and drug interactions, trying to reduce unnecessary services, like unnecessary radiology services, duplication of services by, you know, repeating things that the patient has already had done, and having some level of internal communication that also allows you to sort of talk to people within the ACO, which can help with coordination of care, but also with waste and fraud. These are different than HMOs because providers have a lot more freedom to develop their infrastructure. They're typically paid with like alternative payment models, such as capitation, and when you... So basically the way this works is it's sort of a shared risk sort of model. So you have a number. If you save money from that number, you get to keep some of that money. If you use too much money, you pay the payer extra, right? So it inherently sets up a system where you're trying to reduce cost, improve efficiencies, and increase things like primary care, getting patients in often and early, and getting lots of touch points. It turns out that a primary care appointment, even if you went 10 times a year, is relatively inexpensive compared to going to the ICU at any hospital for even a night, right? So those kinds of things are part of this. These typically are called Medicare Shared Savings Programs, MSSP, right? And we're going to talk a little bit about that. MSSPs are not... I mean, they're exclusive to Medicare, but there are other value-based share programs that can be done with Aetna or Blue Cross. I mean, a lot of the big payers are experimenting with these things as well. Clinically integrated networks look similar to ACOs on the surface, but are intended to unify or unite groups of providers and support clinical and financial improvements. These folks may share health IT tools like EMRs, clinical quality goals, or financial targets. They may collectively negotiate. So these are basically a scenario where you're under one TIN or IRS ID number. Does everyone know what a TIN is? So basically, you get... Anytime you register a corporation, you get a tax ID number or TIN. And in this scenario, you have a TIN that's the clinically integrated networks TIN and they negotiate all the contracts through that. So it gets paid through sort of a filter mechanism through that entity. However, in these situations, CINs cannot directly participate in Medicare Shared Savings Programs, but they can form a subgroup or an ACO within a clinically integrated network that can enter into an MSSP. Independent physician associations. These are very popular for people because they're... You maintain a fairly significant element of independence. They're organized and owned by a network of independent physician practices. They provide the benefits of a larger group while allowing each of the independent physicians to retain their independence and their own ownership structures. It does not provide or control the compensation to any of the providers. It's typically done on a sort of a local level at the practice level. You can also have an IPA and still join a clinically integrated network so that you can make it easier to refer to specialists, coordinate strategies with other providers, and keep your costs low as well. Beyond that, independent physician associations... Sorry, this is a busy slide. ...can help you with better contract negotiations obviously. So for example, our group, it's called Privia Health, we're in I think about 20 states now. On average, we have about 130 to 150% of Medicare as our contracts, right? So way higher than almost everybody else. And it's because we have few specialists. We have like 4,000 primary care doctors and so we get bundled in with them. So all of our quality reporting is through them. All of our sort of contracts are through them and it allows us to sort of be like we're allowed to sort of tag along with them for this process. IPAs can also help you reduce administrative burdens. Some IPAs will have payroll, HR. Certainly compliance is a big part of this. We have compliance training that happens every year. If you don't do your compliance training, you don't get your shared savings checks. So it is very closely tied in. Some of these entities can do other things like own labs together, own radiology services together. And they almost all have access to a secure EMR which allows you to sort of have a micro environment within EMR. So I use Athena Health. We have... Privia has its own Athena Health sort of micro environment which looks like any other Athena other than the fact that I have access to all the other Privia docs notes. So if you're a patient that has a Privia doctor, like a primary care doctor, when you come see me, your lab results, your radiology results, all of those things are readily accessible to me. Members of the IP can also join an ACO. Typically, these entities are pretty savvy. They figure out who their best docs are to join an ACO. They don't want, you know, candidly like a pain doctor to join the ACO to bring their numbers down. They're going to try to make that a very small subset of people that join that ACO. And that gives you sort of beneficial financial arrangements. And you don't... Being a member of an IPA doesn't make you... doesn't make it so that you have to be a member of the ACO. You can separate those things out. And again, so many of the payers now, whether it's Medicare or others have these value-based arrangements that can be really beneficial. And in the right setting, you're talking millions and millions of dollars of money that comes back, that gets divvied up amongst independent physician groups within the IPAs. And then finally, we're just going to end with talking about... Managed service organizations. This is just another organizational structure. Sometimes when a practice gets very large and wants to... And there's a time that comes when there's going to be a multiple, like a number of partners within that entity. Instead of being a straight percentage, like you own 50 shares, 50% of the shares and you own 10% of the shares, it turns into an MSO. Another time where you'll see an MSO is where a venture capital company comes in and buys your practice. They'll set up an MSO and all the physicians and the MSO own. I'm sorry, the venture capital group own the MSO. So in that situation, the venture capital group would own 50% of the MSO and the docs will own the rest and they'll put money back into it. So part of the money to get for being bought, they put back in to own the MSO. And when you have an MSO, you can you can dole out levels of shares. So it's like any other corporate entities. You can give out tier one shares, tier two shares and so on and so forth. And these are companies that provide administrative and non-clinical services to health care providers. So anything from financial management, human resources assistance, although that's not I haven't seen that as commonly. Risk management, for sure. So you can bundle your malpractice insurance as a group. So you get like we work with doctor's company and we get that. We get a preferential deal for doctor's company because of our group and they sort of mitigate our risk as an entity, as opposed to just as an individual pain provider. Staff education, equipment and supplies, IT services. We used to have an integrated IT arm where we could buy all our computers and they would come in and help set them up. And they can even go as far as to help you with renting space and equipment. I know that was sort of a whirlwind through, you know, starting your own practice. I, as well, am happy to share my contact information if anyone has any questions or wants to talk further. And I think we can take some questions, right? Is that because I'm doing a switchback or... Yeah. Any questions? Do we scare everyone into not going to practice? Or did I? These guys are nicer. I had two... Can you hear me? Yeah. Two questions. The first one, is there any major downside to joining an IPA? Do you want to answer that? Or I can go. Yeah. I mean, I think the devil's always in the details. You should read the fine print. If you don't have any experience with this, you should definitely talk to an employment lawyer or a corporate lawyer to make sure they've read it for you. Because there can be some language in there about competition. There can be some language in there about, sort of, if you want to recruit people. There can be language in there if you're, sort of, unhappy and try to break off. There's all sorts of things like that that can be a part of that. But generally speaking, it gives you buying power because almost all of them have a deal with a GPO, a group purchasing organization. They almost all have some sort of discounts on, whether it's your EMR or other things. I think it's a very reasonable way in which you can mitigate your risk if you start your own practice. Yeah. I've been rejected a lot by a lot of payers as a small practice. The other question I had, I mean, you guys are obviously more in the pain space. But how much have you guys thought about telemedicine? Because, I mean, you don't need a lot of the office space. Is it something that you've thought of? Or is it just not, like, the ROI on it is just not that high for you guys? I mean, so I'll speak for myself first. So we have five providers in my practice and everybody does telehealth except for me. I don't do any telehealth. Mostly because I joke that I... Like, you know, in medical school we get trained, like, if you hear hoof beats, it's horses. Well, in my case it's zebras and it's always the zebra with, like, the stripes backwards or some upside down thing. So I see a lot of unusual patients. So it's really hard to do telehealth in that situation. Right now, based on the federal government, telehealth is continued through 2026, I think. But the one question mark that still exists is whether it will perpetually be renewed. And the challenge is if Medicare gets rid of it, then everyone else will follow. But certainly I think that if you have the ability to leverage telehealth at a very, like you said, a very low cost, I think it's very well worth doing. Especially if you're not, like, in our space where you're doing a lot of hands-on procedures and you're... From a marketing standpoint do you your guys's practice find that you're leveraging certain aspects more than others for instance like marketing to potential referral sources versus like building you know a website or You know like search engine optimization like buying ads like social media like that yeah those types of options I Can go quick and then give it to these guys I think it just depends on what you're trying to get so I My big priority is I don't want to have all my ducks and like all my eggs in one basket Right so so many of us are like my ortho buddy right like or my neurosurgery buddy But the problem is all those relationships can be fickle at times like the second your ortho buddy decides He doesn't like you or something happens. You suddenly that dries up so we did a I would say 50% of our referrals are self-referred and We don't do a ton of opioids. This isn't I mean because that's the worry with self-referred patients we Have we we spend a nominal, but meaningful amount of money on our search engine optimization our website. It's all bundled There's all these companies out there now that you can just go to and they can build you something from scratch But honestly like we've tried Facebook Instagram none of that stuff works. It's it's really like handshakes and like you know talking to people like you got it you've got to be willing to go door-to-door or have You've to leverage your if you have reps in your line of work like companies you've got to get them to help you it is a lot of Boots on the ground is my philosophy. I mean if you're not willing to boots on the ground. It's not gonna work. Yeah, I think It's really important to develop a marketing plan and a marketing budget for your practice and before you do that you have to understand in your specific Area of practice, what's your? CLV what's your customer lifetime value if you know your customer lifetime value? Then you can backtrack and figure out what's your customer acquisition cost? Once you know your customer acquisition cost That will allow you to allocate dollar amounts Which can be really helpful to develop a marketing budget? I personally think in In in medicine unless you are a really big scale ads are waste of resources But there are other Aspects of marketing be it social media be it you know in person be these are all different channels of marketing So you have to exploit each and every channel of marketing depending upon? What service you're trying to? push So your marketing plan will have two feeding arms obviously decided by the budget your customer acquisition cost and then your different channels, which you will put these Are allocated this dollar amount in to get that patient through the door? I'm sorry just two tips that I learned in the last three years of doing this Find somebody or find the new surgeons or the new referral people that are of your Age you know like it's not Necessarily, I found it a little waste of time to try to chase down referral sources that already had their go-to People that they've had for years they already have a relationship Find the new ones that are also new to town. Maybe you know for us. It's surgeons and maybe primary care doctors And maybe primary care doctors that are just graduated to because they're starting in practice, and you guys can you know? Become each other's referral source the other thing that I found to be Just lost my train of thought oh Geographically cultural so in for whatever reason in LA primary care doctors really feel most comfortable referring first to surgeons so Going after primary care doctors for a while felt like it was gonna have some return, but didn't see much so for us It was more than chasing the surgeons and that varies You know culture Throughout the geography differently because I know in like Jersey friends that have all their resources coming from primary care doctors But anyway those are two tips that I learned Thank you for the talk Brenda Waller Private practice for 22 years Lynchburg, Virginia Want to know if either of you have had any exposure with a cash only practice? That's sort of low maintenance low procedure So any colleagues I know you have it because it sounds like you guys are well. I mean, I think I think there's I Think it just depends on the Magnitude of what you're trying to do right, so I think that at the end of the day I think there that can be done I think there's a enormous Need I think lots of I mean we all see this every day. I joke about this with my staff that I've never Seen as many frustrated angry patients as I'm seeing now right like patients come in and they're abusive From the phone to the first person they see all the way through that experience And it's because they're probably angry at the wrong people right there. It's hard to be angry at your insurance It's hard to be angry at whatever is happening outs externally It's easy to be angry at the person in front of you and part of it is with all this The advantages we see from a technological perspective of things like AI To the patient feel like less time with them I like that you're just trying to cut corners, so you'd have to talk to me less right? So I think that That world of patients who want to be in a place where there's a self-pay option where it's high touch But low technology, I think that's that's Definitely a place that people are we're seeing tons of that kind of activity in our geography at least so I think it's just a matter of Can can the geography support that right so like I live in downtown DC like I joke that there's you can't trip without hitting a Psychologist right because everyone has anxiety that they might get anxiety But you go to a place like a rural place There's no psychologists or psychiatrists right and nobody in DC who's a psychologist takes insurance But could that same practice exist in another place absolutely it just depends on how you structure it and sort of how do you prioritize? Getting those patients and how many patients you're willing to see Yeah, I mean some of that... There are some ways to get that data. It just depends on how much you want to spend. There's all sorts of things. Like you can start... Grassroots, like you could just look and see how many pain doctors are in an area, or if it's pain. You could then look at the demographics of that region, right? Like is it a... What do they make? What's the average education level? What's the population density? All those things play a part, right? Are you trying to go after kind of a Medicare patient population versus a population that's commercially insured? And what are the benefits and disadvantages of that? So for example, the benefit of a Medicare population is consistency, right? They're kind of like... They're going to want... They need your help. The benefit of a commercial payer is they might pay better, right? But they might be more fickle, right? I practice in DC where like everyone thinks they're smarter than everybody else, right? So it's a lot of... The number of people that come to see me now, they're like, I've seen three surgeons. I came to you for a fourth opinion. I'm like, I'm not a surgeon, but you shouldn't have any of that surgery for sure, right? So like it just... It depends on how you want to position yourself and what competition level you're willing to tolerate. I tell any new doc that wants to work for me, every referring doc has my cell phone number. I've been here for whatever, 24 hours. I've probably gotten 10 text messages from referring doctors. I'm on vacation. They're calling me like, hey, I know you're in Europe, but can somebody see this patient? If you don't want that level of accessibility, it's hard, right? Because that's what... Because if you don't pick up, someone else is picking up, right? So yeah, I just want to build up on that and I'm going to give you a term. So some of the methodological terms. So you're addressing a term known as TAM, which is Target Addressable Market, right? So there are a lot of ways, there are a lot of methodologies to calculate your TAM. Dr. Desai just went through one of the grassroots methodology of calculating your TAM, but there are other avenues which you can explore. So if you put in the right terms, it'll give you right methodologies to how to get to that number, which will allow you to come up with strategies to exploit that. I have a... Norberto Vargas, I have a quick question. What is the answer to the question in regards to the title of your lecture? Yes? No? What's the answer? Yeah. TBD. But the caveat is I want you to take pain out of the equation. Sure. Let's forget that you're interventional trained, right? Let's take pain out. I don't want to manage opioids. Sure. Can a physiatrist survive in the outpatient setting? Doing what? If you're going to take pain out of it, that's absolutely fine. Musculoskeletal. Pain is gone. Yes. But take what option? Musculoskeletal medicine. I am not going to do pain. Sure. I am not going to be interventional. I am not going to manage opioids. Yeah. I mean, how much PI can I do to make a living? How much... How many AMVs? However much you want. So it all boils down... At the end of the day, you have to look at it as a business, right? So if you look at it from an entrepreneurial construct, it is possible. You just have to have that entrepreneurial spirit to go through all the challenges which we talked about and explore. The avenues remain the same, right? If you're looking for collective bargaining avenues, the avenues which Dr. Desai talked about, those avenues remain the same, irrespective whether you are a surgical practice, an interventional spine practice, or a physiatry practice who is doing maybe EMGs, maybe some functional assessments. The service changes, but the business model remains the same. Thank you. All right. Thank you, guys.

physiatry

outpatient private practice

physician-owned practices

hospital-owned practices

economic pressures

private equity

business operations

physician contracts

solo practice

practice models

networking