Thanks, Chuck. So I'm going to talk about the top eight most critical factors with respect to reimbursements in ASCs. Number one, ownership is everything. 100% orthopedic surgeon ownership is definitely king. Other sub-specialty owners that can add value are podiatrists with residency surgical training, ENT docs, pain management hand surgeons. Let's stay away from gynecologists who take forever to do a case because they don't know what they're encountering. Some general surgeons and ophthalmologists who have primarily Medicare patients. ASC management companies vary between 20% to 51% ownership, arguing that they have superior management skills and can get you better contracts. I honestly believe this is BS. I've worked with nine or 10 different orthopedic groups, including my own, where we had just hired our own manager and did a great job getting contracting. It's really not that hard, but they'll try to pitch that it is. Hospital-employed physicians can have ownership in ASCs, and yes, you can do gain sharing. We can talk about that potentially later, for shared savings with your hospital or healthcare system lasting up to five years. Number two, group size may help. Clearly for the office codes, it's not significantly different, but if there's a significant market share that the insurer needs for its employer customers, you can get up to 20% greater reimbursement depending upon what area of the country that you're in. Number three, pair mix is absolutely critical. If you have 60% to 70% Medicare, you're going to need massive case volumes and extremely efficient surgeons to overcome ridiculously low reimbursements. Dealing with insurers is almost impossible, and slowing payment reimbursement is their methodology and they're very good at doing it, as you're all aware. Number four, optimizing patients for total joint arthroplasty. You're going to hear some more about this later. I happen to be involved in an article that was published four years ago with two claims managers where we looked at 2,500 cases with four-year follow-ups for outpatient total knees. And we broke this down into phase one, phase two, including optimization, management using case managers, follow-up, and payment. And it's really a very good article which I didn't have much input into, to be honest with you, but the case managers did a great job of putting this together. For those of you who want to see a large series of outpatient total joints with very good results, this was mentioned by Eric who, by the way, does a phenomenal job for advocacy for both ANA and AOSSM, and has for several years. This is the HOPD rate, which you just heard from Michael, for total knee arthroplasty, 11,899. So Medicare's not stupid. When they decided to take total knees out of inpatient only, they dropped the rate down for 27,447 to 8,600 bucks. If you're paying $2,800 to $3,000 for your implants, this is a hard number, and it's a very small margin to make money on. Look at what you get for a ligamentous reconstruction, 10,700. In a state in the southwest, the outpatient total knees are about 7,800, and total hip reimbursement is 8,000. So this concept of a race to the bottom is definitely real. Number five, you gotta reduce implant expenses. There's something called stable implant technology, and what that means is the same total knee that John Insall developed in the late 70s and early 80s really hasn't changed that much. And so the implant technology is basically the same, and the same is true for anchor technology with very low manufacturing costs, yet a very high purchase price. The actual cost for making a total knee is about 500 bucks, anchors are about 49. So you guys go figure that out when you go back and look at how much you're paying for these. Secondly, I want you to just kind of remember this website, cafepharma.com. This is when all your reps get online and they talk about how to get Dr. Beach and Dr. McIntyre to use more anchors when they're doing a shoulder procedure. You'll get a kick out of reading some of the commentary. Next, allograft should be done in the outpatient ASC only when pre-approval with a real-time reimbursement is known. So I've had some issues with this. You have to get it in writing ahead of time, or they'll deny they ever had the conversation. So I urge you to do that. Number five, cost containment, I just mentioned it briefly. But there's a very good article in Becker's health care report from last month, and it's called Economic Ignorance for the ASC. And there's a lot of truth to this, that we really don't understand why we're paying so much for what we're paying, and using the examples that I just gave you. But they talk about reducing overhead, the fixed variable direct expenses, surgeon cost effectiveness and efficiency. And speak with the surgeon who takes 90 minutes to do a simple meniscectomy, or three hours to do a totaling arthroplasty, or has to have multiple anchors and use every disposable instrument possible. These are very, very difficult conversations, obviously, to have with your partners. Number six, physician and staff engagement. Physicians must be motivated to bring all cases to the ASC. There's a group in Oklahoma, for example. They give whoever does their total joint, for example, at their surgery center, even if it's not an owner, double their professional fees. So they actually have surgeons from outside the ownership circle come and do their cases there. But they do this if they have bundled or packaged pricing for direct employer contracting, or cash-based cases. The staff must be engaged to give outstanding patient satisfaction, and provide efficient case turnover. Number seven, position the ASC for packaged pricing or bundled payments. What is very disconcerting is the fact that this is how much employers are paying for a family. And of course, there's a high deductible with these, but think about that for a second. GM actually spent more money on healthcare in 2018 than they did on aluminum or steel to make cars. So you can see how horrendous this is for a lot of employers. And you can also see this trend that's occurred in greater – 91% of employers nationally now are self-funded. If they have a thousand employees, 75% are. And 100% of Fortune 500 companies that have 5,000 employees are self-funded. This was interesting. This was just published in the last month. A two ASC orthopedic group, many of you may know, just inked a bundled payment contract with Florida Blue. It's estimated, from talking to the president's group, it's gonna quadruple their referral rate and their group of patients are gonna be sent to them. So what's the future? And I'm gonna end with this. I believe it's direct contracting with employers. More employers are demanding cost reduction strategies. Brokers, third-party administrators, cost management companies are seeking partners that can provide savings. The brokers are the ones that have the relationship with the employers. These are the folks you have to go to to try to develop these relationships with your group. And musculoskeletal care, believe it or not, is the largest single healthcare expense for employers. It even dwarfs cancer care in many, many cases. So I'm gonna leave you with this final thought. Orthopedic surgeons are positioned perfectly to provide efficient, cost-effective, bundle case or package pricing care and improve ASC reimbursements, if they are willing to take on risk, which can easily be managed with stop-loss policies and aggregate umbrella insurance. Thank you very much. Thank you.

reimbursements

ASCs

cost containment

physician engagement

bundled payments