I'll start off by saying Rothman has not sold out or sold off a portion of the practice to private equity today, so I don't stand in front of you as an expert who's gone through a transaction, but I stand in front of you as an individual who is part of the development of a platform that has attracted a lot of attention, and as such we've learned a lot about this process, and I'll tell you where we ended up anyway. Rothman Orthopedics was founded in 1970, but the modern day Rothman Orthopedics, as I would describe it, started in the mid to late 1990s when Mike West pulled Rothman Orthopedics out of, I think it was about $12 million in debt, and started to rebuild with a handful of young surgeons, including Todd Albert and Pete Charkey and Bill Hosek and Mike Ciccotti, and that was probably around 1997, 98 when they started building. At that time I was at Penn, and over the course of the next 10 years I watched Rothman grow into arguably one of the largest private practice orthopedic groups in the Northeast, certainly in the Delaware Valley. When I was recruited to Rothman, I sat down with Dick Rothman and Todd Albert, who was the president at the time, and I said, you know, I'm a little confused. You know, you've got this incredible CEO in Mike West, you guys are the largest group in the area, you're doing incredibly well, you're academically prolific, you know, if I'm successful, how would you know? And Todd's answer was interesting. He said, we'll go from 55 surgeons or physicians to 155 physicians without compromising quality, without compromising our academic mission, without compromising our service standards. And really what Todd was talking about was, we want to build infrastructure and we want to be able to scale. I got excited by that. I left a 15-year career at Penn with that energy. And today, when we look at Rothman's growth, it has been significant. So from 1998, when there were actually eight physicians in the group, to the last full pre-COVID year, we have seen remarkable growth, not only in the number of physicians and not only in the number of surgeries, but we also continue to pay attention to the number of peer-reviewed publications. In fact, that has always been a standard for shareholders to become a shareholder. They have to generate a certain number of academic points. But it was interesting, when you peel those numbers back just a little bit more, and you look at the revenue base, I came in right around 2009, it was late 2009, early 2010. It was Mike West and a layer of directors underneath him. We had no analytics. We did not have patient-reported outcomes. So that's really where I jumped in and we started developing a lot of the platform and the infrastructure that I referenced earlier. That infrastructure, over the 7 to 10 years that I've been involved in building it, probably cost our shareholders close to $100 million. And it all came out of shareholder-retained earnings. So if you're a full shareholder at Rothman Orthopedics, we retain about $175,000 a year of your earnings. Lower-level shareholders, it's down near $60,000. But really what our focus was on from 2009 to 2014 was really, how do we grow? How do we create analytics so we can manage the practice more efficiently? How do we look at staffing ratios and controlling overhead? And it wasn't until 2014 that the big surge in the investment in other components to our platform took place, and it was a much more difficult climb. I would describe going from $135,000 to $350,000, sort of like reducing your handicap when you're a 22 to an 18. But if you think about going from a 14 to a 10, it's much, much, much more difficult. And that's really what happened to us between 2014. And so what drove that really was, beyond the analytics platform, we knew we needed a system that helped us measure outcomes. And we didn't want patient-reported outcomes to be a sideline deal that was done by the research department. It had to be baked into operations. We needed to risk-stratify patients as part of their intake process. We needed systems that could really manage online physician reputation. We needed a system to navigate patients. We were entering into risk bundles, but we didn't have a system for air traffic control. So what we ended up with, well, I'll share with you first some of the benefits of the systems that we created. We entered into the bundled payment environment, and from 2016 till 2020, we realized somewhere around $92 million in gross savings. $35 or $36 million of that came back to Rothman in gain share format, and that dropped straight to the bottom line of the investors. And to put it in perspective, $36 million over five years is about $7 million a year. For a group that's doing $250 million in patient service revenue, it's really a drop in the bucket. It really wasn't giving our shareholders the ROI on their investment that they were looking for. So really, we started to talk about how do we monetize this platform in a different way so as to bring greater value back. And so what we ended up with is, and today have a system that is a blend of proprietary software and off-the-shelf systems that we've been able to integrate. We created an analytics platform. This is just a snapshot of the dashboard, but what's unique about it is it sits on top of nine disparate database. A lot of times when you're an EMR, you can report on the data that are in that EMR, but you can't report on the data that are outside of that EMR. So what we did is we have a system that's feeding from our EMR, our billing system, our patient satisfaction, our patient outcomes, our time and attendance system, all feeding up into one analytics system. And that allows us to do true multivariate analysis. So for instance, how many patient visits per front desk FTE before patient satisfaction starts going down or before they start making mistakes with credit card swipes and getting pre-certs? We know the number because we're taking information from our time and attendance system and we're coupling it with visits in that specific office, just as an example. So pretty cool stuff, but what we really needed to do was to create a system that was fully integrated, and that's where we are today. So how does this translate into private equity? Well, what we're finding today is that more and more groups are coming to us because of Rothman's expansion. We just opened a division down in Central Florida with Advent Health System. And so certainly you're going to see a lot of these private equity groups come out. And in a very simple format, the way it works is they look at a group like Rothman, or I'm sure a lot of the groups that you all are in, and what they want to do is they're going to make an initial investment in your practice. And then what they're going to do is they're going to really put your system on steroids so that you can go out and capitalize on the acquisition of other smaller practices. And with that expansion, you create value, and when you create value, you also create second and potentially third bites of the apple. Sounds exciting. We looked at it time and time again. But what I'll tell you, you know, it's just some of my thoughts and some of the soul searching that we've gone through at Rothman, is we really needed to sit down and understand, you know, what were our practices, goals, and objectives? And what did an event of dilution with a strategic partner or a private equity firm, what would the impact be on our ability to accomplish that mission and vision? I'll tell you that the investment that we were looking at into our infrastructure was exciting because we felt like we're going to be able to reduce overhead costs even more. And the tax advantage liquidity for the shareholders at the time was exciting, not to mention some of the rollover equity that they would realize. But the flip side to it is really, you know, and this is the soul searching that we had to do, you know, how much autonomy are we willing to lose? How much control are we willing to give up? The mechanics of that initial liquidity event, and then it prompts a scrape because they're creating debt. And with that debt comes a debt liability. So it's really a race to the next tranche and a race to the next liquidity event so that you get that second and third bite of the apple. So many details about buyout clauses. What about those shareholders that aren't going to make it to the next event of liquidity? What happens to your senior management team? I know it sounds a little self-serving, but for a lot, a lot of, we had to think about what was that going to look like moving forward? The advisory fees are astronomical. Between the bankers and the lawyers, it's unbelievable what it costs. And I think most importantly, and this is where we kept getting stuck, is, you know, we were 70 shareholders in a 200 physician group, and a lot of those shareholders were 48 years and younger. And what did it mean for them over the long haul in terms of what did they own and what was the mission of Rothman Orthopedics going to be moving forward? So I would say to you and leave you with this. We think it can be exciting and the benefits can be significant, but seller beware. So we've decided to stay on the sidelines. We have found a way to monetize a lot of what we've created in our platform through relationships with health systems, through licensing and branding agreements, center of excellence agreements and the like. The sales cycle on that is slow, so it's slow growth, but allows us to really retain the mission that we set out from the very beginning. Thank you very much.

Rothman Orthopedics

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orthopedic groups

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