In this episode of the Growing a Successful Orthopedic Practice podcast, we discuss what the orthopedic practice of the future looks like and find out from fellow practice administrators and orthopedic surgeons how you can begin preparing for long-term success right now.
Tune in to discover:
- How other practices are recovering from COVID-19 closures
- Ways to allocate resources to attract and retain employees
- What can be done to reduce patient leakage
- When and how clinical roles will continue to evolve
- What technology has done, and will do, to impact the patient experience
- James Coyle | Business Development Consultant, OrthoLive / SpringHealthLive
- Stephen Colaeizzi | Business Development Consultant, OrthoLive / SpringHealthLive
- Adam V. Metzler, M.D. | Orthopedic Surgeon, OrthoCincy
- Gil Tepper, M.D., F.A.C.S. | Orthopedic Surgeon & Director, Valley Spine Center
- Jeffrey Cave, MPH, CHFP | Chief Operating Officer, Orthopaedic Associates of Muskegon
Dr. Adam Metzler.: So for my schedule now, I have plenty of built-in virtual visits. There are patients surprisingly who still don’t want to come in. So this still gives an opportunity for those patients, whether they’re brand-new patients or whether they’re post-op patients or MRI reviews, which I found to be my favorite is imaging reviews for telemedicine.
Announcer: Welcome to the Growing A Successful Orthopedic Practice Podcast. Join us every episode to hear from fellow medical practice administrators, staff, and physicians as we break down current issues affecting the industry and share real stories from guests on their way to growing a successful orthopedic practice. Let’s get started.
Jennifer: Hey there. Welcome to our new podcast, Growing A Successful Orthopedic Practice. I’m Jennifer and I’m going to be your host. Join me biweekly for can’t-miss interviews, insights, tips, and tactics from orthopedic leaders around the US. On every new episode, you’re going to hear directly from physicians, medical practice administrators, and industry partners as we break down current issues affecting our industry and share real stories from guests on their way to growing a successful orthopedic practice.Now, topics are geared specifically for ortho practice administrators, and surgeons, and include strategies for reimbursement, marketing, employee engagement, technology, HR, budgeting and just about everything in between.
Jennifer: A little about me and the team that’s putting this show on. My name is Jennifer, as I said, and I own and operate Insight Marketing Group, and have done so since 2006. So what the heck am I doing hosting this show? Well, our offices are inside of a very large orthopedic practice. In fact, our marketing suite is literally attached to their ambulatory surgery center, which is right next door. We work with a ton of orthopedic practices and surgeons. The idea for this show came from one of our clients, but they didn’t have time or resources to put it together, so I volunteered us.
Jennifer: Now, we’re not new to podcasting. In fact, we produce a weekly show, the Dr. Marketing Tips Podcast, and that show just celebrated its 240th episode. So I certainly urge you to go check it out. That’s the Dr. Marketing Tips podcast. In this very first episode of the Growing A Successful Orthopedic Practice Podcast, we’re going to join into a discussion between two surgeons and a practice administrator about the orthopedic practice of the future. There’s a lot of really good talk about telemedicine and how surgeons are using it.
Jennifer: Today’s discussion is led by James Coyle and Stephen Colaiezzi of OrthoLive. OrthoLive is the sponsors of this show, and they’re going to be joined by Jeffrey Cave, the chief operating officer of Orthopaedic Associates of Muskegon, Dr. Adam Metzler, an orthopedic surgeon from OrthoCincy, and Dr. Gil Tepper, an orthopedic spine surgeon from Valley Spine Center in Los Angeles. Be sure to stay tuned, because in this episode you’re going to learn how practices are recovering from COVID-19 closures, ways to allocate resources to attract and retain your employees, what can be done to reduce patient leakage, when and how clinical roles will continue to evolve, and what technology has done and continues to do to impact the patient experience.
Jennifer: I really hope you enjoy the show. Be sure to hit the subscribe button on your podcast player so you don’t miss a future episode. Let’s go ahead and get started.
Stephen Colaiez…: What has the initial impact of COVID been to the practices that you’ve helped with?
Dr. Gil Tepper: It’s a really good review for the mindset that we’re all in, both as practitioners, as patients, administrators. I personally have started exploring telemedicine late last year, early this year because I was preparing for semi-retirement and I wanted to shift into a different method of delivering care. Obviously, as soon as COVID hit, the biggest thing is a novel virus. We’re all stung by something on a global scale that we’ve not seen before. It basically stunned a lot of systems, certainly, most importantly, self-protection and emergency care.
Dr. Gil Tepper: The trickiest thing about it is that there’s more unknown than known about it and the data is shifting a lot. But the practice has had a profound impact immediately. Elective surgery was stopped. It was recently resumed, but it’s slower and there’s some places, including California, where it may be stopped again. I think a lot of us either before or during this transition luckily we’ve had some time off to expand, to think, and to try to procure a system to continue interaction with our patients and to carry on with the care. A lot of us have jumped on whatever was available in the very, very beginning.
Dr. Gil Tepper: Many systems that were not necessarily HIPAA-compliant had challenges with security, had challenges with delivery, and had very limited integration and functionality beyond the videoconferencing. So it was just a fancy phone call. But if you had to get some stuff done, it became time-consuming and cumbersome. Right now, things are loosening up a little bit. I think the people that have jumped on systems with poor fit or poor functionality are in the market looking for better systems, better integration, and more specialty integration and functionality.
Dr. Gil Tepper: I think personally that these are all good things because for many, many years … I’m probably guilty of it also. I mean I thought the whole world and my practice and my patients all revolve around me. But I had to remind myself that my practice has to be a patient advocacy practice. It has to be patient-centric. It has to integrate the family and complex decision-making, lifestyle changes, et cetera. I think that telemedicine as a platform on a going-forward basis really lends itself, for me as a clinician, to deliver a much, much better, much more customized, much more efficient patient-centric care.
Stephen Colaiez…: Thanks, Dr. Tepper. Dr. Metzler, are you with us?
Dr. Adam Metzler…: Yeah. Thanks for your patience. I had some updating issues with Zoom.
Stephen Colaiez…: No worries.
Dr. Adam Metzler…: Sorry I’m coming a little late here.
Stephen Colaiez…: No problem. I already introduced you because I knew you were on your way.
Dr. Adam Metzler: Yeah. No worries.
Stephen Colaiez…: Same question to you. How has COVID-19 affected your practice?
Dr. Adam Metzler: Well, I was just catching probably the last half of what Dr. Tepper said, but a lot of what he said is definitely what I agree with. I mean Dr. Tepper, where are you practicing?
Dr. Gil Tepper: I’m practicing in Los Angeles as I have been since I finished fellowship.
Dr. Adam Metzler: Yeah. I’ve been in Cincinnati at OrthoCincy now eight years now. I’m a sports medicine specialist, knee and shoulder, arthroscopist. Mark Twain said, “If you want to live 10 years longer, come to Cincinnati when the world ends.” So I would say things are probably drastically different in Cincinnati than they are in Los Angeles. However, I think the region was pretty strict very early on and that sort of set the tone for a lot of what we did within medicine.
Dr. Adam Metzle…: Ohio and Kentucky makes pretty strict guidelines pretty quick with COVID. I think it definitely helped spur some of the early cases. I think we’re all under fire now with this resurge, if you will. Right away we stopped elective surgeries mid-March. As a sports guy, that was pretty devastating to my practice. Thankfully, I still have a large call pool that I’m a part of and still did a lot of call trauma. So there was enough to keep food on the table for the family, but it was a drastically different scenario from going from 150 ACL surgeries last year in 2019 to I’ll be lucky if I hit 50 this year with no sports.
Dr. Adam Metzle…: I think the thing that immediately came to mind for us was we already had somebody who was working on something good, which was Dr. Greiwe with OrthoLive. I think, to be honest, we were very hesitant to utilize telemedicine in our markets. Cincinnati’s a very conservative market that’s not progressive. Having grown up in this town as well, the concept of telemedicine, particularly in orthopedics, is really a progressive idea. The pandemic certainly pushed that to the forefront, so progressing everything and every way we think. I can be honest. I mean Dr. Greiwe has pushed this agenda to me many times and I have not been accepting as I should have been, primarily because my practice was so well-oiled without having to deal with telemedicine.
Dr. Adam Metzle…: We would see, my physician assistant and I, 70, 80 patients a typical day. So why do I need to integrate telemedicine in when it’s already a well-oiled machine? Well, that’s what COVID-19 did. It messed it all up for everybody. So we all have to figure out ways to adapt and adapt and survive like anything else. We’ve done that. No matter what platform you’re on with telemedicine, I think you’ve had to survive and adapt. I personally was able to accomplish close to, I think, 250 telemedicine visits during about a 10-week period. Those are 250 patients that needed some type of patient contact. I didn’t have one single complaint, which I was very surprised with.
Dr. Adam Metzle…: I figured patients would be very apprehensive in our market to do that at all. They weren’t. They were very happy to be at home. Is it different? Was it an adjustment? Absolutely. Your templated exams, all these things we’ve been doing for years, that has to change. You can’t template a physical exam that’s normal when you’ve never touched a knee before. So those things had to adapt. You had to be very adaptive for that as well. But I still find now that we have adjusted our schedules. We are on our pandemic schedule number four. Pandemic schedule five would be a normal template for us.
Dr. Adam Metzle…: In order for us to stay socially distance, we have adjusted our template so that the physicians can see a set number of patients for each half-day of clinic, in addition to our extenders, a set number of patients, as well as the regular PP adjustments that every practice has made. I don’t know if we’ll be back to full schedule, essentially unrestricted schedules, probably until … I can’t imagine until 2021 within our large practice of 32 physicians. There’s just too much chaos within the waiting room to create normal, unrestricted schedule.
Dr. Adam Metzle…: So for my schedule now, I have plenty of built-in virtual visits. There are patients, surprisingly, who still don’t want to come in. Or not surprisingly, I should say. So this still gives an opportunity for those patients, whether they’re brand-new patients or whether they’re post-op patients or MRI reviews, which I found to be my favorite is imaging reviews for telemedicine. But now that it’s forced to be adaptable myself and adjust my schedules and schedule to adjust for what the patient’s needs are, just like you said. There are more patients asking, requesting for telemedicine than I ever would have expected.
Dr. Adam Metzle…: So I think that’s the biggest adjustments for us. Obviously, the practice management things that are different, we see less patients. We’re more cautious. We’re more careful. We clean more. We don’t let people sit in the waiting room. We have patients wait in cars. If the waiting room gets too full, we have waiting room monitors to make sure that that’s not happening. I feel blessed to be part of a big practice with good rules and good regulations and affiliated with hospitals that helped us to get those set up. But I think, to echo you, that’s where we’re at.
Stephen Colaiez…: Perfect. Jeff, so from the business since of things, how has the practice changed through COVID-19?
Jeffrey Cave: Sure. So thanks for that introduction, Stephen. Orthopaedic Associates of Muskegon, we’ve got 19 physicians. As of next month, we will. We have 11 mid-levels and they are spread out across three different physical practice locations. We also have an urgent care that is staffed by primary care sports medicine physicians at one of our locations. So COVID in Michigan came pretty fast and furious. We were actually one of the later states to get our first case. But after that first case happened in Michigan, we just ballooned off.
Jeffrey Cave: We were under executive orders to only see urgent and emergent patients for about eight weeks. So starting late March through late May we had a total practice shock, if you will. We closed two of our locations just to consolidate staff. We actually relocated our urgent care from one location to our main larger location. On the business side, unfortunately, we had to lay off a great number of our staff. The positive though, which is crazy to think that we’re already beyond this, is that they’ve all returned to work as of late May when we were able to see more than just urgent and emergent patients.
Jeffrey Cave: So while that was very difficult in the moment, now that we’re on the other side of it, we’re glad that everyone was able to return. Through that, we implemented OrthoLive was our telemedicine platform we decided to go with. COVID-19 really was that push. So I haven’t been with OAM for too long yet, but I knew that implementing telemedicine was on the roadmap, but where on the roadmap is undefined. Had we not had COVID-19, we likely would not have even touched telemedicine yet. So knowing that we needed to spread out the patients, knowing that patients didn’t want to come into the practice either for a while there, and some still don’t, we needed to provide some type of solution for them.
Jeffrey Cave: So implementing OrthoLive was definitely a huge help and a big nugget of hope that came through with the pandemic. But there were also some other positives too that we were able to send more staff to work from home that we may have not explored before. When we kind of started under these Stay Home Stay Safe orders by our governor, I think there was a little bit of panic and fear across the state and the community. People really just wanted to be home. So it did get some of our administrative staff kind of scratching their head and going, “I think I can do my job from home.”
Jeffrey Cave: Through that, we now have more ways to track productivity for some of the staff we deployed to their home because we said, “Well, you can’t just go home. We have to have a way to track you.” And then that kind of geared up some of the staff that didn’t necessarily have a metric or measurement for their role to say, “Well, this is what I think,” and then we can come to an agreement. And then we let those staff go work from home now. Since then, some have returned. Some have flourished at home, preferred to stay at home, and we can now track them. That’s another, along with telemedicine, nugget of, “Hey, this actually worked out well.”
Jeffrey Cave: Chances are, it would have taken us six months to a year to figure it out if we weren’t in the middle of a pandemic. Physicians’ schedules were all over the place. If we’re only seeing urgent/emergent, each surgeon really went down to about a day a week, some a half-day a week in the practice actually seeing patients. As everyone in the country or the world, we really started utilizing Zoom and other technologies for even our administrative meetings with, and of course, I’m sure everyone’s done this, the removing a great number of chairs from the waiting room, social distancing stickers on the floors. We have plastic shield dividers at a lot of desks, so when patients have a surgery scheduled they need to have or a workup when they are meeting with staff at a desk area, they have a shield there between them.
Jeffrey Cave: Every day was a totally different day. At the beginning when we saw this happening and we, unfortunately, laid off a lot of staff we thought, “Well, we have some time to get a lot of stuff done that we haven’t gotten done, like policies and procedures and really roll our sleeves up.” But that wasn’t the case. They just came every day with new executive orders and new PP loans you could potentially apply for and how we’re getting back to normal. Every day was just a little crazy, but in a good way.
Stephen Colaiez…: Perfect. Thank you.
James Coyle: It’s interesting, Jeff. It almost seems as though it gave you a pause to … I think Becker’s quoted something like 65% reduction in patient visits during that March through April period. It almost gave many of the practices a pause to think about, all right, how are we going to adjust to this?
Jeffrey Cave: Yeah. Yeah, we definitely saw that, if not more. We did see a slight uptick in our urgent care, which I think was a little expected because a lot of our local urgent cares closed and a lot of our local primary care offices closed as well. So with our urgent care remaining open, we actually had a little relief there, I mean nothing compared to elective surgeries. But it was interesting to see that take place.
James Coyle: Right. Well, with that, you guys have actually moved us right into our second question partially. So we’ll go to the next question. It’s how is it currently today? You’ve been through, you’ve talked about how COVID impacted you and how you’ve adjusted. Where do you see yourselves now as things are kind of … Are they getting back to normal or are they never going to be quite normal? What’s the picture look like today?
Jeffrey Cave: I’ll jump in. I think there’s a new normal. I don’t know that we’ll ever be back to a normal normal. Similar to the physicians on here, we are limiting the amount of patients that can come through our door a day. So we are not on total unrestricted schedules. Physicians are still not seeing as many patients as they would prior to COVID, but we are up there in a way. We are extending hours for physicians that have somewhat of a backlog. So prior, if we would maybe see patients at 8:00 and the last patient at 4:30, we now are starting at 7:00 and we can go to see patients at 5:00 or 6:00.
Jeffrey Cave: We’ve been open every Saturday in June. We’re open this Saturday, just exploring different ways that we can get the patients in the door. Telemedicine is a huge part of that because we’re doing this for really social distancing. So if physicians have the capacity and want to see more patients, we’re not going to hold them to a number. We’ll hold them to a rounded number of physical patients, but they can add on as many telemedicine patients as they want, which is great. We have some that are really embracing that. Like I mentioned, that we were fortunate everyone returned to work.
Jeffrey Cave: There is this interesting almost phenomenon of staff. We aren’t even up to our full capacity yet, but when staff are not working for two months and they come back, it kind of takes a while to get back into that groove. We’re kind of going through that of how did we ever see 90 patients for some physicians months ago and now it feels like we’re burning out, going around 50 to 60. So that’s been interesting to go through. Honestly, from an administrator standpoint, one real struggle we have right now that we deal with almost on a daily basis is when staff have exposure to COVID in their personal lives or they have someone in the household that has symptoms. Who can come to work and who can’t come to work?
Jeffrey Cave: If there was a COVID-positive patient in that we found out after the fact and who interacted with those patients? So really, when I say we’re now back to a new normal or we’re going to a new normal, it’s because we’re managing COVID still every day with a fully busy practice. That’s just been the greatest headache is coming in and getting five text messages of, “Hey, I was with my friend last night and now they have symptoms or my spouse is getting tested.” It’s just going, “Okay.” We look at the CDC guidelines. We try to follow those as much as we can on who can and can’t come to work safely and still manage staffing has been challenging.
Stephen Colaiez…: You don’t even think of the human resource aspect but, now that you mention it, the idea of staff. What can you do? If they get COVID, they certainly can’t come to work.
Jeffrey Cave: Right.
Stephen Colaiez…: And then all of a sudden, you’re really stuck. Just curious, when you go back to at the beginning, what percentage of patients were virtual versus inpatient and where do you think your percentage is today?
Jeffrey Cave: Prior to COVID or during our two months there?
Stephen Colaiez…: During the heat of COVID and then where you think you are now.
Jeffrey Cave: So during the heat of COVID, our telemedicine population was probably somewhere maybe 25% of our patients. It definitely could have been higher, but it was brand-new to our practice. So we had some physicians that embraced it fully and we had some that are still … Everyone does them now, but we still have some that would prefer to have their patients come in. Overall as a group, I’d say we were probably around 25%. Now we are actually still a little bit lower than that as we’re learning how to get telemedicine plugged into our new normal.
Jeffrey Cave: We know that it’s something we have now. We want to utilize it and we need to utilize it going forward. But now that we’re finally in this, okay, how many patients makes sense to come into the building? So it’s still a day-to-day discussion of what makes the most sense. I have some physicians who do see a great deal of telemedicine patients and I have some that don’t see near as many. So it’s kind of all over the board. We leave it to our providers to pick.
Stephen Colaiez…: Interesting. Gil, Dr. Metzler, anything on that?
Dr. Gil Tepper: I think that we’re still in a transition period and I think that some of the practices are optimizing the system they procured. I think Jeff did well and got into a good system early on, so there’s minor adjustments. But there are people that jumped into systems that have presented significant challenges that required pivoting. So we are in transition period where each specialty, orthopedic being one, other specialties, is going to settle into a mixture of visits again in, I think, in a patient-centric way for the visits that don’t absolutely require an in-person visit.
Dr. Gil Tepper: And then there’s going to be the clinician way when a more complex exam or situation comes up where the person should be seen face-to-face and examined more thoroughly or decisions are more complex and should be done face-to-face. But it’s going to take a little bit of time to figure out where this whole thing is settled. What I like about this transition period is that we get to examine efficiencies, flexibility of schedule. I could tell you, when I got started … This is for Adam. When I got started practicing, one of the guys in the group had late-night hours, I mean late, like 10:00, 11:00, 12:00 at night.
Dr. Gil Tepper: His patients kind of liked it. He had a group of patients that either liked it because that’s what he wanted to do, but he would see them in the clinic late and so on. It always seemed odd to me, but today it’s all about customer service, patient efficiencies. Patients love doing the important things they need to do on their own schedules, their own terms. Let’s not forget. We’re challenged as an industry. We’re challenged as individuals and all of our patients also have incredible family challenges, kids, schools, virtual schools, entertaining these kids.
Dr. Gil Tepper: They need flexibility also, but we don’t want them to neglect their health and not deal with what needs to be dealt with. So telemedicine, flexible scheduling, asynchronous messaging, like uploading all this stuff on Felix already and then having that meeting. I think that helps the patients and I think adoption will increase. I think it helps the clinicians as we get more and more proficient with it. I mean I’m 60. For me, the challenges are also technological adoptions. I’m not at the cutting-edge of anything. I’m trying to learn and adopt. I represent those of us that have not been growing up with tremendous degree of technology.
Dr. Gil Tepper: It’s a challenge, but it’s fun. It’s a period of a lot of creativity and generativity. If we’re open to adoption, then I think we’re going to wind up in a great place through telemedicine.
Dr. Adam Metzle…: My take on this too is obviously similar as well, but I’m in a unique position to being on our board as well right now. I’m a little bit younger than you, Doc, I’m 40. So you got 20 years on me there. But being on the board during this process has been unique. We met every three days for 10 weeks. So we made huge adjustments in very short periods of time, although we panned to just being able to see 15 total patients per half-day per physician, including the extenders. That was it. That was what we could. That’s all we knew how to do and that’s I think what a lot of practices did, urgent and emergent only, made those decisions, and then slowly that was sort of our pandemic schedule one.
Dr. Adam Metzle…: And then we evolved over to the current template, which allows us to see up to about 20 to 25 patients in a half-day with unlimited telemedicine. So I’m pushing the telemedicine for my own practice because it allows me to add additional patients, particularly my MRIs, my favorite way to do that. That’s just a great resource. It doesn’t always work out well if they needed an injection. But anything I think potentially could be surgical, it’s a great way to do it. You can share your screen. The patients love seeing that when you can share everything that you would show. You’re going to show them all the things, all the resources that I developed during my down times sitting on my front porch not operating.
Dr. Adam Metzle…: I created a whole subset of pictures and PowerPoints and I could, boom, pop it right up. There’s rotator cuff tears. What does it look like? What’s an ACL look like? Little videos and clips and things that I can show them while we’re on the conversation. I think I adapted and my patients love that component of it. They have no questions going into surgery. I’m still challenged with the fact that we don’t limit or let family members come into the office and for obviously everyone’s safety. But I get a lot of questions there today of, “Well, you never discussed this with my wife.”
Dr. Adam Metzle…: Well now, put them on speakerphone. We used to never do that. They need to be a part of this conversation. As I talk, they need to hear a part of it. We used to limit video and audio recordings, all that stuff in the room. We still don’t want them to record. Obviously, those things could be dubbed and changed to whatever patients want to change it to and that’s very easy to do. But at least with FaceTime and with just speakerphone, the families are there with them. Obviously, if the patient has dementia or something like that or they’re a young child, they’re going to have a secondary family member. But those are certainly some adjustments that patients have made.
Dr. Adam Metzle…: In general, patients understand it’s a trying time and we’re all working through it together. Very few patient complaints during the pandemic and after the pandemic. I think patients actually get it, that we’re all working hard. We’re all trying to make adjustments. We’re all learning on the fly. I think if you don’t, then patients have every right to be nervous and afraid and upset. But I think most practices that are going to be successful are going to adopt significant rule changes, adopt telemedicine, and listen to their patients. Those are the things that we have done, amongst the many other things, adjusting hours.
Dr. Adam Metzle…: We cut back our urgent care clinic pretty quickly, but we do have an urgent care. It’s been very successful for over 10 years. We have Saturday hours, which patients love. We still don’t have close to the volume for our urgent care that we typically have had, but we’re getting back to those numbers. From a future standpoint, I think it’s here, even in Kentucky and Ohio, we don’t really see high school sports happening. We don’t think it’s going to happen even though everyone keeps talking about it. Some of the kids are practicing in Ohio, but in Kentucky, they barely are conditioning right now.
Dr. Adam Metzle…: With the surge obviously everywhere going on, I just don’t see it happening. So for me, I mean it’s a change in practice. I’m seeing more arthritic patients and rotator cuff issues than I am young ACL and patellofemoral issues and that’s just an adjustment. I still can’t believe that I’m fairly busy. I’m still filling 45 to 50 slots a day, in-person visits, which is crazy to me and crazy in the fact that I didn’t think that would happen. I probably fit in another five to seven virtuals in during the day. That typically would have been a 60-person day template with another 20+ for my physician assistant easily.
Dr. Adam Metzle…: So I mean we’re all probably taking a 20% hit, but it’s the new norm for now. I do think through 2021, we’re probably going to feel the same pain. I think it’s going to be 2022 for those numbers, if not 2023, before my 2019 numbers return to what they were financially. So I expect two years before “herd immunity” and then effective vaccines are out there for patients and politicians and attorneys to feel comfortable to allow us all to open up and do what we did before.
Stephen Colaiez…: Let me ask you a question about … You talked about telemedicine. Are there other technological advantages that you’ve looked into? And if you have, how do you make the decision which ones to go with in your practice?
Dr. Adam Metzle…: It’s forced us to look at just our EMR and our practice management system at the board and we are going to be making some pretty drastic changes to those to allow us to be more efficient, particularly allowing people to work from home with the system. The current platform we have, it requires a lot of in-house intranet versus Internet type of work. It’s a little bit old school. It’s really easy to use from a physician standpoint, unlike Epic, which is painful for every single physician to touch, but yet it does a lot more for research and P4P and all the other things that we’re going to be looking at in the future.
Dr. Adam Metzle…: Unfortunately, that’s probably the model that our group’s going to be going to but, for better or for worse, allows us to make some adjustments for more people at home and looking at research and our performance. So yeah, it definitely forced us to be much more diligent. I think my standpoint, our website, I’m on the marketing committee as well. I’m the chair of the marketing committee. So we said, “Look, this website needs to be clean. We’ve got time now. Let’s make sure that everything is up-to-date.” We’ve done a lot of good work with that. Obviously, most websites are changing as COVID has. That’s just the standard stuff, but just looking at ways to enhance your websites.
Dr. Adam Metzle…: Your marketing strategies should have changed during this timeframe as well. Certainly, then telemedicine became a huge component of that and then online bookings. People are home. They’re sitting around. They want to read good information, so your website needs to be really good. And then number two, you need to have an online booking platform that needs to be good. That’s always been a challenge because there’s online booking platforms that just flat-out stink, and we’ve probably all been there. So we’re making those adjustments with our practice.
Stephen Colaiez…: Dr. Tepper, when you decide on a new technology, what’s the decision-making process within the group?
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Dr. Gil Tepper: In our group, I get to explore and bring ideas and bring options in front. We look at it and we do side-by-side testing. I think the biggest rate-limiting reagent for these changes is the EMR, EHR, and the system. It’s super hard and very costly to change that, so you need to look at the best, most functional, most integrative platforms out there that work well with your specific EMR. I think that with time, of course, as Adam says, focusing on marketing, on better positioning in general. I mean I was going to say integrating trainers and other physical therapists in the community and making them a part of the platform can help.
Dr. Gil Tepper: But obviously, if there’s no high school and other sports going on around you, I feel your pain, man. It’s going to take a little bit of time to come out of it. We need to integrate features and systems that also expand our offerings, expand our revenue bases. Personally, I think that it’s time that physicians in general integrate in a big way preventive care, nutritional care, et cetera, to not just operate and treat the broken parts, but to control the obesity that we’re challenged with and to do more to prehab people, to get them in better shape.
Dr. Gil Tepper: I think through remote interactions and remote monitoring, I think we stand a chance. There’s enormous amount of innovation in that right now that is worth integrating.
Stephen Colaiez…: Thank you. So Jeff, kind of as the referee and running the practice, I’m sure you must get great ideas from all of your physicians. How do you, as a practice, go about making those decisions?
Jeffrey Cave: We have a fairly decent search here. We have an executive committee, which is a couple of the physicians who make those decisions and then actually physicians do a turn on there and they rotate around. So everyone knows who’s on the executive committee and that’s who’s usually clued in on our decision making. But to the point, the one thing that we always look for now is reporting, reporting, reporting. We have a couple systems that we can’t get very many good reports out of and it makes tracking staff, tracking productivity challenging. So anytime we’re looking at something that has to have good reports, that can come out of it.
James Coyle: Got it.
Stephen Colaiez…: But if you can’t measure it, you can’t manage it very well, right?
Jeffrey Cave: Yeah.
James Coyle: That’s a good transition. I’m thinking about switching gears for a moment. Let’s talk about how this is affecting the patient. What’s been the feedback? What have you guys noticed through this last eight, 10-week journey on how this move and shift has impacted the patients?
Jeffrey Cave: I think one thing it’s doing, and everyone understands this about telemedicine, but at my practice we have a history. It’s not quite the reality anymore, but we have a long history on really long wait times in the waiting room and then in the exam room. So that’s kind of a community-known thing that we’re trying to turn around. But telemedicine has flipped that on its head immediately. Prior to, we may have a patient that got an injection and they may have their recheck appointment. They’d have to take a half day off work to come in and check in for their appointment, waiting in the waiting room for maybe 30, 45 minutes, go back to the exam room, wait back there for a while, see the provider for five minutes, and then out the door.
Jeffrey Cave: Now, they can do that 10, 15-minute appointment on their break at work in their car or wherever they would like to be. That has just been the biggest thing of we’ve kind of had this reputation of we have to wait a long time and now it’s the exact opposite with, well … And not only that, but providers are more on time when they have their half-day telemedicine blocks because they know that patient’s sitting in that virtual waiting room. For some reason, that just gives the staff and providers a little bit more angst behind them of they were sitting in a physical exam room before, but now they’re just with their iPhone but we feel like we need to get them in sooner. So that’s been good.
Stephen Colaiez…: Interesting.
Jeffrey Cave: Yeah. Patients, well, in Michigan I feel like at least here we’ve had most of our patients who are over it and they want to be seen. We still do have patients that are uncomfortable coming to the practice where, as mentioned earlier, they want their family members on or they want their nurse care managers on there. So telemedicine has been a way that’s made that a lot more seamless. And then the third part that I think is great is the continuity of the staff. They have the same medical assistant or nurse every time they come into the practice. And then when they’re waiting for their telemedicine appointment, up pops that same medical assistant or same nurse that they’re familiar with.
Jeffrey Cave: So having that embedded within the practice and that familiarity and continuity of the staff, I think, is also key. We heard comments from patients that they really appreciate that too because you can get a primary care visit from health systems or other companies, but you don’t know who you’re talking to. You’ve never seen those providers before. So the fact that they can have these visits with their known providers has also been a big win.
Stephen Colaiez…: Interesting. Have you seen any trend in terms of online reviews or an improvement of your reputation scores as a result of any of this?
Jeffrey Cave: Those are pretty, unfortunately, delayed as we get those. So we’ve definitely been looking for them. We’re still kind of getting the comments that, “I’ve been rescheduled five times and I’m sick of this.” So hopefully, next month in some of our satisfaction surveys we do hope to see that shine through. There’s been a couple but, throughout our practice, it’s still so fresh and new when we implemented this that it hasn’t been directly through there yet.
Stephen Colaiez…: Dr. Metzler, you mentioned that you haven’t had any patients complain. What’s been the feedback directly from the patients?
Dr. Adam Metzle…: Well, especially at the height of the pandemic, I mean I think it was pretty interesting. The patients loved it. I mean they could be at any level, new patient, patients from the ER. They would just call. We’d set up a new visit form. Actually, they had to be sent over from the hospital, some platforms, different platforms we have to integrate the systems, to integrate the imaging, that is. So that was pretty straightforward. There’s certainly a little bit more uncomfortable feeling as a physician when you’re evaluating a new patient visit over telemedicine. I think it takes some getting used to and some adjustments on how to actually accomplish that goal.
Dr. Adam Metzle…: Who’s going to hold the camera? Are they going to flip the camera in reverse? All those kind of things that we haven’t even talked about here. How do you get a good exam telemedicine, I think is really important from a medical/legal standpoint and your comfort as physician, particularly getting through those tons of all the new scopes and all the arthroscopy cases that needed to be seen in their post-op setting, their global period. I mean there was a lot of patients that just it was easy to examine those patients at two or three months, four months. Even six months out from a rotator cuff, you could have them do their exam. They had no problems with it whatsoever.
Dr. Adam Metzle…: As you got more comfortable as a physician utilizing that tool, then the patients seemed to be more comfortable with utilizing it too and your documentation obviously reflects that. I think the easiest thing I’ve found to integrate now in a practice is in Cincinnati, I mean patients are certainly more comfortable now in this region that they want to get out. They want to go to the grocery store. They want to try to shop. They want to go to their physician. It’s an opportunity just to get out of the house, honestly. So these patients are willing to come in.
Dr. Adam Metzle…: Very few people are reluctant to truly come in, but it’s enough to fill, even in my practice, five to 10 virtual visits Mondays, Wednesdays, and Fridays. So I think one of the challenges, as you just mentioned, Jeff, is that you got your physicians half-days. We set it up however you want to run it, but we integrate ours within our practice. So I may see two or three patients and have a virtual setup mixed in between there. What I found is interesting is now that I’m running my schedule, if I’m running a little behind on my telemedicine visits, patients actually complain.
Dr. Adam Metzle…: They said, “Well, why aren’t you on time?” But even though I may have made them wait 30 minutes two months ago in my office, they’re actually expecting me to be on time for that virtual visit. I’ve had a little bit of struggle with that. Thanks to the Apple Watch works really well because it dings 15 minutes before their visit and then right at the time of their visit, which is certainly helpful to keep me focused on that. But it’s something else dinging that we don’t need dinging, like an old pager. But at the height of the pandemic, I couldn’t even have it on because I would be doing 30+ telemedicine visits in a day.
Dr. Adam Metzle…: My nurse practitioner/PA would be seeing my live patients in-person and I would kind of wave at them. We had a good relationship to be able to do that. But that was kind of at the peak where we were still seeing 45 patients in a regular office day, with 30 of those being virtual and 15 in-person. It was pretty crazy. Now we’re back to close to 45 to 50 in-office and, again, five to 10 patients virtually a day. Yeah, go ahead.
Stephen Colaiez…: Interesting when you point out the difference in time and the expectations. What’s really, to me, striking is that your partner, Dr. Greiwe, who’s had a lot of experience having started OrthoLive, when he compared one year to the next, he was able to do 213 more virtual patient appointments, which generated … Not only did it save him on average a lot of time because the patient, when you looked at the patient, the patient’s average visit virtually was 17 minutes. The average visit from door-to-door when the patient would leave to get to the office, find the office, get seen, come back from the office, was a little over two hours.
Stephen Colaiez…: So you start comparing for the patient, 17 minutes versus two hours, pretty striking difference.
Dr. Adam Metzle…: I think that’s where it becomes challenging too. As a physician, we’re used to for a standard meniscus debridement post-op, I mean we’re probably in the room three to four minutes as a physician, if you look at the actual numbers, maybe five, if you’re lucky. But then you can get stuck on telemedicine and you can be on the virtual visits for over 10 minutes. I think productivity comes into play too. How productive is a postoperative visit? Even though it’s convenient for the patient, is it really convenient for the physician? Or do you set aside time to do post-op checks at your lunchtime while you kind of munch away a little bit?
Dr. Adam Metzle…: That’s the hard part, I think, of telemedicine. I think that we’re all trying to figure out the most efficient way to see our patients via telemedicine that provides the best patient experience and the most revenue for our practice. I would love to see that written down somewhere because I’ve yet to see that anywhere. Because if we can figure that one out, then we’ll be much better off because maybe Jeff’s facts is right. Maybe I should set aside and not do any telemedicine Monday, Wednesdays, and Fridays, except for my Wednesday afternoon. I should have 20 virtual visits only. I don’t know if that’s the right way. I have yet to see a practice show me which way is better, but I’d love to know.
Stephen Colaiez…: Interesting.
James Coyle: Dr. Metzler, you do a great job of teeing these questions. It’s like you knew what was coming.
Dr. Adam Metzle…: This is last minute. I got the email 3 a.m. last night.
Stephen Colaiez…: Dr. Tepper, I think we’ve answered the question that we see telehealth becoming a longer term strategy. But the bigger question is, how do we leverage it for greater revenue?
Dr. Gil Tepper: Well, first of all, for spine surgery, I just want to sort of chime in that in spine surgery, the biggest challenge is really patient selection and really exhausting conservative care and using a lot of options before we go to the knife. I think, like Adam says, in sports, et cetera, a lot of times it’s the MRI and the mechanical symptoms and a fix and a happy patient at the end. Logistics right now of transitioning the practice to this method or that method is painful, period. We’re going to work through.
Dr. Gil Tepper: But for spinal surgery, there’s been a study done out of Jefferson, the Vaccaro Group, specifically that looked at small group for surgical outcomes for comparing patients that had virtual physical exams and those that had in-person physical exams. There was no difference. In spine surgery, short of the emergency involvement which we’re still doing, for elective spine surgery, a lot can be done virtually. There’s a lot of patients with emotional issues and other issues that you really need to work through to get a good result. I think that integrating some of these things into the practice, some other allied health professionals within the practice that can offload the physician when things get too time-consuming or additional handholding is necessary.
Dr. Gil Tepper: At least we have the option to set up another appointment with the pain guy in the clinic or with the RN, et cetera, to keep the patient feeling well-managed, to keep conservative methods done, and to interact with the patient to their satisfaction. I mean in general, I think that remote patient monitoring and wearables are going to increase over time. I think it’s worth looking into now to try to find strategies and methods, especially now that we’re in a transitional period where I believe that payment pairing is still in effect and some of the restrictions are still somewhat relaxed.
Dr. Gil Tepper: I think a lot of it is going to change. Honestly, I don’t know which direction it’s going to change. But I know that in LA with the way the traffic is and the way that long waits are, et cetera, patients really prefer and take on the telemedicine visits. They’re appreciative. Obviously, there’s lots and lots of visits that can be done well without face-to-face value. Some of it, Adam, has to be what do you see yourself doing? How do you want to condition your followers, your group of patients to believe that you will give them the best care possible, the most efficient and the best outcome? Part of it is going to have to be you carving your way and say, “This is the way I do things.”
Dr. Gil Tepper: I believe, like in LA and other places, we’re going to get into now it’s the surge and next it’s the flu season. This is going to go on for a while. The more we increase our productivity, efficiencies, integration, editing methods for easier prescription and integration with the physical therapist and renewing prescriptions and so on and so forth, the more we can do that online, the more efficient we can be. I think that ultimately we can grow the revenue as well.
James Coyle: Dr. Tepper, I think in that same article you quoted Dr. Vaccaro, he mentioned that he felt effectively see about 80% of his patient population via telehealth.
Dr. Gil Tepper: As I said earlier, I think it really is very subspecialty-dependent. It’s pretty much specialty-dependent. I think that some of our colleagues, neurologists that are doing headache, they can really do a lot by reviewing diagnostic studies in telemedicine visits. I think some of these primary care and specialty care clinicians are going to do 80+% of their work tele-medically and 20% or so in-person. For the surgical-intensive specialties, like sports, et cetera, ultimately I think it’s going to be whatever the clinician wants based on the community that he’s in, based on the type of patients that he gets, whether they’re …
Dr. Gil Tepper: I mean the elderly is struggling with adoption new technologies. Like Adam said, just the logistics of getting it done is difficult. So if the demographics shifted, you’re going to experience some secondary effects from that. It’s going to be more frustrating.
James Coyle: Guys-
Dr. Gil Tepper: We’re also working on systems that are much more octogenarian-friendly right now. So ultimately, that’s going to change as well. But it’s going to settle down at a very specialty clinician and environment-specific rate which, I believe, is going to be substantially higher than it is today.
James Coyle: So Jeff, for you, as you look at the practice as a whole and incorporating all of your surgeons, one of the people watching had a question that said, “Do you plan to integrate or have any desire to integrate a system to offer, track, and monitor patients’ joint health, activities, and controlled exercises? This would be an opportunity to increase revenue.”
Jeffrey Cave: I can’t say that we’ve looked into that specific example, but we are looking at every time a new enhancement comes out through OrthoLive or whatever, any of our systems, how we can help implement that. So even having where the, and we haven’t done it yet, but the medical systems being able to have their time with the patients as well as with OrthoLive. I think this is a new growing business, I think as we all know. Anytime something changes, we want to act on it and jump on it. Again, because we’re only two or three months in post-pandemic, we haven’t had time to really go and enhance our system.
Jeffrey Cave: We’ve got it installed quickly. We’ve been able to use it, which has been great, and now we’re getting back to normal, the newest normal. So a lot of our energy has been focused on that. I think once we get past that a little bit, then we’ll be able to look, “Okay, we installed this two or three months again and we were in the middle of a pandemic. Are we using it correctly? Are we using it to its full potential? It met the need at the time, but what else can we do with it?” So that’s something we’re absolutely going to look at. It’s time and band width.
Stephen Colaiez…: So Jeff, let me ask you a follow-up to that. When you’re looking at your practice as a whole and you look at all of your surgeons, how do you encourage … When you find a surgeon that’s utilizing telehealth and they’re doing a great job with it and they’re increasing the revenue to the practice, how do you encourage the other surgeons to adopt that same technology and use it to a greater degree so that the entire practice is benefiting from the increase in revenue?
Jeffrey Cave: Yeah. There are some, I would call it. maybe low-hanging fruit tactics, such as that. We have had this, where it’s some of our overachieving physicians have spoke at the board meeting on why they do it, what they hear from their patients and whatnot. I think the balance is to try to get some of their partners to come around. The balance is some of those partners who may not embrace it as much are saying, “My patient satisfaction scores are so high. My patients are still coming in and seeing me. I don’t necessarily see a need.” But kind of on the horizon, what we’re currently looking at is, well, how does it impact overhead?
Jeffrey Cave: While we still need staff to verify the insurance and whatnot, current state today, when the physician’s in the practice, they usually have a little team around them of usually two medical students and a nurse. At telehealth though, if they have that afternoon, which they each have a little bit different schedule, but a handful of providers just do a half-day of telehealth a week. They only have one medical assistant with them. So right there, and that’s kind of tugging on some different heartstrings. So it’s not necessarily we want you to use telehealth, but if you do use telehealth, the overhead for the practice will be less because you do need less staff for telehealth appointments. So we’re just trying unique tactics like that to come at it from different angles.
Stephen Colaiez…: Okay.
James Coyle: Jeff, just touching base real quick on earlier you mentioned you have less furniture in the front because you can’t have the seats so close. I mean how is this going to affect your commercial real estate? Do you still need such a big office? Do you need as many clinical rooms? Is that going to change? Is the equation changing as we starting thinking how this practice is going to look?
Jeffrey Cave: So I think it’s all about a balance. Obviously, obtaining more real estate is an idea, but in the long-term an also expensive idea when we can use things such as telehealth. We are doing okay now with, even though we limit the patients, but having more unique process flows of we know on Tuesdays and Thursdays we’re really busy. We have a lot more physicians in the practice. We do have patients wait in their cars from time to time, really taking a strategic look at provider schedule. Prior to COVID, Fridays around all of our practices was a little bit lighter.
Jeffrey Cave: Now we need to kind of look at, okay, we’re putting some more providers on Fridays and Saturdays just so we can have less patients in the practice at any given time. All of our other ancillary departments really appreciate that too because, it was mentioned earlier, cleaning, which is great and we all need to be doing this anyway. But when we started cleaning the X-ray equipment between every patient, my X-ray tech’s looking at me just sweating bullets going, “Oh my gosh. This is putting us behind. There’s so much more to do.” And then spreading the physicians out throughout the week and having some on Saturday, it helps the X-ray staff, helps our [inaudible] medical equipment staff.
Jeffrey Cave: That’s a piece, kind of another lever we’re trying to pull. Yeah. It’s just different every day, to be honest. It’s surprising that we can still fit patients in the waiting room. I think back to the days prior to COVID and it looked like a packed waiting room. We took out the majority of the chairs and somehow all the patients are still fitting. We do still have visitor restrictions which is good and bad. We get some pushback. We got a lot of pushback when we allowed no visitors, but we actually had an executive order from the governor to allow no visitors for a period of time.
Jeffrey Cave: So now, I think that’s helped us by saying only one person allowed for the appointment. And then we have had days where we have patients coming in. The waiting room is looking full or unsafe for social distancing and we ask the visitor just to wait in the car and we’ll call them in when it’s time for the appointment. So honestly, every week still is a little bit different of what can we add to the equation as we get a little bit busier and busier. I don’t think there’s a great playbook or platform of how we’re supposed to navigate through this, unless someone had a huge practice they’re not currently using. But we’re taking it day by day.
Stephen Colaiez…: Interesting. Thank you. One last point or question, Dr. Tepper and Dr. Metzler, we were talking about the roles changing. Things are changing in the future. I think Vaccaro was quoted in Becker’s recently saying that he envisions more of his PAs and MAs doing some of the triage work, so he’ll only see the patients that really are probably going to be primary surgical candidates. That way instead of him seeing 45, 50, 60 patients in a day, he may be able to focus in on the subset that are actually going to need the more complicated discussions. Are those roles clinically changing in your mind?
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Dr. Gil Tepper: Now, for me, I’ve always had kind of a practice that had elaborate use of allied health, chiropractors in my office that were functioning as physician’s assistants doing the nonoperative care and physician assistants, nurse assistants, and so on. I think that, again, in my specialty, a lot of it is complex decision making, referrals for injections, and so on and so forth for conservative care, patient selection. I think that the PA and the physician extenders that we train carefully as our extenders can really carry that message well and can really make it much more efficient and enable us to be more efficient with our time, our surgical time, and our family time, time off.
Dr. Gil Tepper: I’m optimistic that working through this and integrating some more allied helpers can free us up and we can find a way to have a better lifestyle ultimately and maintain the income.
Dr. Adam Metzle…: I think the region sort of dictates that pretty significantly. I mean I think some regions are accepting of extenders and other regions aren’t. I mean our region is fairly accepting of extenders and there’s other regions that don’t accept that very well. I think my personal opinion, particularly with telemedicine being new to our practice, I took the onus of saying, “Telemedicine is my baby and not my extender’s baby.” I want to know what’s going on. I’m very OCD. I don’t want the responsibility or liability to be on an extender, not being able to visualize a patient appropriately or adequately over telemedicine.
Dr. Adam Metzle…: I want the responsibility and the medical and legal liability for that if something happens. But I don’t necessarily want to “babysit” somebody over a telemedicine visit when I trust what he’s clinically doing in the office already. So I took the onus and said, “This is mine. You don’t have to worry about telemedicine. Unless I tell you you’re doing telemedicine, don’t expect to do telemedicine ever.” That’s not what other people in my practice have done either. A lot of them have said, “I want nothing to do,” particularly the older physicians, “I want nothing to do with this technology. This is crazy. Who would ever force me to do this bogus stuff?”
Dr. Adam Metzle…: But my 30-year-old extender is going to be wonderful at it, AKA forced to do it, and they probably never will integrate that. Now, I don’t think us as a 30-person group, we’re ever going to force someone to do telemedicine. That’s just like forcing somebody to be on your board. That’s not probably the best decision because they don’t really want to participate. If somebody wants to be a part of something, they should be. If they don’t, they don’t need to be. But if the time comes where it’s not producing and it’s not effective for the group’s overhead, which would probably be unlikely if they’re already producing well before, then that might have a conversation be brought up.
Dr. Adam Metzle…: But I think the use of extenders, I don’t think that role changes too much right now except for how much you’re willing and want them to be involved with telemedicine. Again, I’ve given you my approach on taking it. It’s been successful for me. Besides Dr. Greiwe, I perform the second-highest telemedicine group visits within our group. I’ll continue to do that. I would not have done that, to be honest with you, if it wasn’t for this pandemic. I did not see a value within it. I thought it would be a waste of time. Frankly, pre-COVID, it would have been hard to do. It would have been hard for me to integrate it in without taking time away from my family.
Stephen Colaiez…: Right, right.
Dr. Adam Metzle…: To me, that’s the hard part with three children is everything I view as family first, patients second, and in the operating room, patient first, family second. But I want to be home with my family like anybody else does. I want to be efficient and effective. I think generating more surgeries, like any other surgeon, we want to be busy surgically. We want to be operating more, performing. But if you look at your numbers, it’s absolutely amazing when you have a full office, how much revenue you generate from being an effective office provider.
Dr. Adam Metzle…: So I think if you’re very effective and efficient in the office and learn to see patients efficiently with your extender, then you start looking at surgeons like, “Well, I’m not here just to soak up all the surgeries from the group. I’m here to see a lot of patients for our practice and help triage to get the patient to the right place.” If I’m the right person, great. If I’m not the right person, I’ve got plenty of other great physicians within my group. For being on the sidelines 14 total years now, a lot of what we do as sports sidelines physicians is triage to the hand guy to the foot guy to my joint guy. That’s the way that your practice should continue to evolve.
Dr. Adam Metzle…: We really shouldn’t lose side of that. Telemedicine shouldn’t change that for us. COVID shouldn’t change that for us.
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