Why Business Skills Matter In Medicine

Dr Andrew Greenland 0:00

Welcome back to Voices in Health and Wellness, the podcast where we speak with practitioners and healthcare leaders about both sides of model medicine, the work we do with patients, but also the realities of building and running the organizations behind that care. I'm your host, Dr. Anthony Greenland, and today's conversation is really about the business of being a doctor. Because clinicians receive years of training in how to look after patients, but we're not necessarily taught is how to employ and lead teams, manage cash flow, deal with insurance, use technology, open additional locations, create systems, and ultimately build an organization that can grow beyond us as individual practitioners. My guest today has experienced that journey firsthand. Dr. Mike Daniels is a prodigist with an MBA who serves as president, CMO, and managing member of WeTweet Producty, sorry, WeTweetFeet Producty and WeTweetFeet MSO. With that, Mike, I'd love to welcome you to the show. Thank you very much for joining me today.

Dr Mike Daniels 0:53

Thank you. I appreciate the invitation.

Dr Andrew Greenland 0:55

So if we go right back to the beginning, what drew you first into healthcare in the first place?

Dr Mike Daniels 1:04

My whole life, my mother told me I was going to be a doctor, and when I got to college, I couldn't figure out what anybody else did. So I just, you know, kept going in that direction. My wife argues I should have been a lawyer, primarily because she doesn't like to argue with me. But it really honestly, it it was just the way I was brought up. And I to this day wonder what people do all day. People sit in offices. My wife's a school teacher, so at least I have a reference for her. But she talks about the administrators, and I'm like, what do they do? They're always busy doing something. And I can't figure it out because you know, in my day, every 10 minutes I have a new meeting all day long. So I'm constantly moving. And in between those, when there is time, which there never is, you know, I have to document those meetings. So, you know, it's just one of those things to this day, I don't know what else I could do because this is pretty much all I know.

Dr Andrew Greenland 1:58

Thank you. Really helpful context. So, of all the directions you could have gone and taken within healthcare, what was it about podiatry that caught your interest?

Dr Mike Daniels 2:06

So, when I was very early

Choosing Podiatry And Early Expectations

Dr Mike Daniels 2:08

in my college career, my grandmother was a diabetic who had a foot wound. And I went with her to her podiatrist appointment and met her podiatrist, who was a wonderful guy, um, and just was really interested. And he was very enthusiastic about the profession. So I then spent some time in the office, and then uh during my college time, I spent some time working in a podiatrist's office in Allentown, Pennsylvania, where I was in college, and it just I just moved in that direction, was all I ever really wanted to do. Um, I find it interesting when you look at the different medical specialties, especially ones that require different schooling. So, even between MDDO, dentists, chiropractors, optometrists, you name it, um, a lot of them applied to different versions. Uh, I'm the only one I know who and only applied to podiatry school. That was it. So I I I've been kind of on this path since I was about 19 years old.

Dr Andrew Greenland 3:00

Thank you. So, from this point you were making about not really knowing what anybody else did in their professional work all the time, when you were training, what did you imagine your career was going to look like when you kind of started out?

Dr Mike Daniels 3:11

That's an excellent question. I definitely thought my days would be shorter and my anxiety level would be lower. Uh, that has not worked out so well for me. Uh, I always tease that you know, my goal in life was to have a job where I didn't have to work weekends and I didn't have to have my name on my shirt. Um, that didn't go so well for me because I do that too now. But uh as I just kind of progressed through this whole thing, uh it just developed into what it is. I I don't really know what I expected. I mean, you know, we did clinical work as residents, you know, we had clinic days, and it was funny because those were the days we as residents despised. We didn't want to go to clinic, we wanted to be in the operating room. That was, you know, that was where we wanted to learn. Um, but you kind of get into the flow. So when I went into practice, it was actually a step backwards for me because I was much busier in my resident clinic than I was in my private practice when I started for you know the good six months or so.

Dr Andrew Greenland 4:05

And what surprised you most about the reality of being a podiatrist?

What Changed In Patients And Payment

Dr Mike Daniels 4:10

I think the reality has changed over time. I remember being surprised at what how much we were paid for different things when I was early in my career. And nowadays I'm surprised at how much people uh will do two things. Number one, trust Google over you. Um, and you know, number two is scoff at paying medical bills. You know, people will go and spend a thousand dollars for tires, but if they have a $50 copay, I mean that's I always say them's fighting words sometimes. Um, I don't make those decisions, I don't set their copays. Uh, but it it amazes me, you know, at how people, and I don't want to besmirch or anything for anybody else because you know everybody's money is their own, but sometimes I think priorities are just kind of out of line.

Ownership Reality And Reimbursement Pressure

Dr Andrew Greenland 4:57

And at what point did owning your own practice become something you wanted to pursue? Was there like a turning point where you thought, actually, this is this is this is the direction I want to go in here?

Dr Mike Daniels 5:06

Um, so when I was finishing school, you know, uh finishing residency, you know, 25 years ago at this point, um, there were really two different ways you went. You either started a practice or you went to work for a practice. And the idea being if you worked for a practice, you would either eventually buy in as a partner or you would leave and buy somebody else's practice and continue to go on. Um, and that was the vast majority of practitioners at that time. Um, the concept of employed physicians with health systems and multi-specialty groups and even with orthopedic groups uh really didn't exist in any significant manner. You know, hospitals were not hiring podiatrists, those sort of things back in the day. Nowadays, as somebody who hires podiatrists on a fairly regular basis, um, people no longer are looking for anything other than a job. And they will literally tell you that. Um, you know, they have zero interest in anything business-wise, they have zero interest in ownership. Uh, when I started hiring doctors 20 years ago, I would get asked all the time, are there partnership opportunities? I never get asked that anymore. Um, and quite frankly, it when I was a resident, all of my attendings were private practice guys, so I saw how they all worked. Nowadays, people are being trained by employed physicians for groups, so they're still not getting that whole practice management experience. Um, and due to the way some of our you know contracts get structured and the way health systems do, and due to the Stark Law regulations, um, I think the way they get compensated is very, very poorly understood. Um, and it really hurts them because they have a lack of understanding.

Dr Andrew Greenland 6:38

Thank you. And so for you, was it um the wanting the clinical independence or seeing a business opportunity or wanting to do things differently, or all of the above?

Dr Mike Daniels 6:47

Uh I think probably a little bit all of the above. Um, you know, I I just never imagined doing anything other than you know going into practice and taking care of patients. Um, I remember, you know, early in my schooling, so my first year at Temple University, um, looking at my clinical doctors, the podiatrists who work at the school, most of the clinical first year is spent not with actual podiatrists, it's spent with PhDs who you know have experience in physiology or anatomy or whatnot. So you don't get that quite that much, but you do get a little bit. They have, you know, you have a couple of classes where podiatrists come in and teach, you know, basic biomechanics and those sort of things. Um, and some of these guys were full-time employed by the college, and some of them were, you know, they came in, they taught a class, they had a private practice. Um, and I decided pretty quickly that I didn't think I wanted to be a teacher. Um, I didn't think uh, you know, stay sitting in the audience thinking about what I was thinking about the people talking to me, I'm like, I don't want people thinking that about me. So I said, this isn't for me. Um, so I, you know, I just went off. And I would ask a lot of questions to our part-time uh faculty, you know, who had practices about what they're doing and why they do it. And, you know, most of them it was very consistent for them, and some of them had a love for teaching, um, you know, and some of them had some other ulterior motives that that you know would come out every once in a while. Um, but I felt very differently about you know being in a employed clinical space where I was responsible for just you know one thing and didn't have, I guess, creative freedom or the ability to practice within my in my true scope of practice. Um, you know, there was we had biomechanic attendings, we had infection attendings, we had surgery attendings, you know, everybody wanted to work with the surgery attendings, nobody wanted to work with anybody else. And I figured, well, that's not good either. So I kind of just pursued this whole thing. And as I went on, I was fortunate. My residency director was a private practice doc. So, you know, and he would try to teach us all kinds of things. Uh, you know, I I talked to him a couple weeks ago. I'm still very grateful for the opportunity he gave me. And uh, you know, I just moved in that direction. And then after I started working, uh, when I started to see what I was generating, and I started to see, well, what percentage of what I was generating was I actually getting in benefit, I started scratching my head and going, well, it makes more sense to have a lot of people working for you so you can take you know pieces of everything than to just try to do it all yourself. Um, I I think every day I think that might have been a mistake. Uh, because sometimes I think my life would be a lot easier if it was just me. Um, but the ability to be a single solo practitioner doctor in this in this day and age is so challenging because you're just getting eaten alive with fixed costs. Our reimbursement is not increasing, it is declining both in actual and inflation adjusted dollars. And it just gets harder and harder to keep the lights on every day. So I don't know how the single practice guys are doing it. And if you look at our demographic as podiatrists, most of the podiatrists still in single or just dual practice are my age and older. The younger guys aren't doing that. Very, very few. And if they are, they're finding a niche. Um, you know, there's a whole concept of concierge pediatry, which is trying to go, and that's doctors who take no insurance. Some of them travel and go to people's homes, some of them have an office. And, you know, everybody's kind of looking to find their place. Uh, I'm too old to look anymore, so I'm kind of stuck where I am, and I think this one's gonna ride this wave until I grow until I retire. But um it's it gets to be to the point where you know you have to kind of figure out, you know, where does the money you you make come from? Because if you don't know where it comes from, you don't know how you get it, in which case maybe you don't even appreciate it. And I think sometimes doctors have lost the ability to appreciate their patients because of that. I mean, listen, the system beats the daylights out of you, it really beats the humanity out of you. So sometimes it's hard to remember that, you know, it really has nothing to do with me. It's all about the patient.

Dr Andrew Greenland 10:39

Thank you. So thinking about that time when you were you know wanting to open your own practice, one thing I'd realized in medicine or any clinical training is that we don't get any business training at all. And I guess we're either working it out from other people around you who understand the business side of medicine, or you're kind of figuring it out on your own. Which which camp were you in?

Dr Mike Daniels 10:58

So I joined uh a gentleman in practice uh when I first got out of residency. Um he had been there for 25 or so years by himself, uh sitting in a you know at the same office basically. And you know, I came in and I was, you know, all full of spit and vinegar and wanting to save the world one foot, one toe at a time, or cure the world one soul at a time, maybe. Um and you know, I very, very quickly realized that um he didn't really do that much uh as far as what patients' needs were, what the services we could offer or could provide patients were. So, you know, two years into this thing, I was making, I was generating more revenue than he was, and I was making more money than he was. So, you know, I foolishly took a pay cut and became a partner. And you know, that kind of started my journey at that point. Um, and I really didn't see any other way. I explored the possibility of buying a practice, but I I had you know somebody there who was teaching me, you know, how to practice. It turns out a lot of it was incorrect, which you hear a lot of. Um, people are just not told the right thing because a lot of doctors, you know, after the ages really, you know, flew by the seat of their pants. Um, if you go to lectures and you you talk to older doctors who are on the lecture circuit talking about practice management aspects, they'll tell you crazy stories about how when they first got there and started in practice, there were four codes, and they paid some you know person $10 an hour just to select the code. And they figured, well, I could do that myself and save the money, and you know, and all just these crazy, crazy stories about what it is. And you know, as time has gone on and reimbursement has not kept up with inflation and has actually been cut, the regulation and and uh and specificity of medical records for the purposes of billing has just gone crazy. Um, here, for example, uh CMS's uh audit criteria is perfection. If you send a medical record and it is not perfect, they will do a clawback. You know, it's no good try, it's no, okay, we understand the patient needed the service, it's oh you did it. It's no no no. There are 27 things here, and you only have 26 of them, so we are clawing back the money, which is an impossible standard. And they know it, and doctors know it, and that's why everybody expects to have money clawed back, but they're already paying us less for these services, and now they're taking more back, and it's just an unsustainable model in that regard. So, going back to where the discussion started is none of that existed when I was starting out trying to figure this out. Um, I don't know, I might have given up and gone to work at McDonald's at that point because it's it's absolutely crazy. I generally worry about the doctors coming out of residency and coming out of training now, what they're gonna do. Because I mean, I never imagined it could get to this. So I can't even imagine what the next 20 years is gonna look like. Uh, it is a little bit scary. So, you know, I think looking at back at it, uh, I didn't really know anything, and it was probably a good thing because I think sometimes you can, you know, know enough to be dangerous. Um, and I've just developed this and I try to explain to our younger doctors how these things are working, but sometimes it's you know it's like a deer in headlights, and you know, every time I hear it, it's like, well, I don't have an MBA. I'm like, okay, well, I didn't have an MBA when I started either. I couldn't answer any of these questions, that's why I got one. And guess what? An MBA taught me I really didn't know what I was doing. That's all it really taught me. So, you know, you just and and the last thing I tell people is I have probably made every single expensive mistake you can make in podiatry along the way. If there's a mistake that costs money, I've made it. So you learn a lot from the lived experience as well. So, you know, I have just matured into this position. I don't think this was ever an actual goal. I don't think I'm ever going to arrive at, you know, the end at the end of the road saying, I got there. I think my road's just gonna end one day, and I'm gonna say, okay, and you know, do what all people do and retire and move to Florida.

The MBA As A Business Translation Tool

Dr Andrew Greenland 14:52

Thank you. Really great insight. So you just mentioned the MBA in talking. I'm just curious to know what did it do for you and how has it helped you over the years?

Dr Mike Daniels 15:01

Um, the best way I can explain it is my MBA program was more like a foreign language degree. Um, the the language of business and the language of finance is very, very different than the language of medicine. And you you get into a group of doctors who are generally the smartest people in the room, and they start talking to people who now run hospitals. Now, when I was training and when I was early in my career, most of the hospitals were run by doctors. Most of the C-suite were doctors. Now you have one doctor in the C-suite, and nobody else there has any medical degrees. It's all business guys. Um, and when I was, I don't know, about five or six years old or so, I started serving on the perioperative governance committee for the hospital. And that would be a committee, there would be admins there, there would be representatives from the different specialties there. And I remember sitting in that class and sitting in that meeting, and people who really had no animosity towards each other were screaming at each other because they weren't even talking about the same thing. And and when I got the language skills from my MBA to realize what the business people were saying and why the I knew why the doctor people didn't understand, it was like an epiphany for me. So now, whenever I'm in those things and I I sit there and I laugh because I love how you know the they'll come, the the admins will come in and say, Well, the hospital did better. We only lost four million dollars last year. And then you look on the and then you look on the PL and there's you know $17 million worth of depreciation. Like, well, you don't lose four million dollars because you didn't spend that money. And like everybody's like, oh, well, the hospital's losing money, we're gonna go bankrupt. No, it's paper loss, and they don't understand. And the business people either don't understand that the doctors don't understand or are happy with them being uninformed. I don't I never know which one it is. But it's just it's learning those language skills to be able to actually sit there and understand what's going on when people tell you stuff, and basically to understand when you're being lied to.

Dr Andrew Greenland 17:00

So is the MBA something you pursued because of problems you're encountering in the practice, or had you always wanted a formal business as education to kind of cement what you were doing?

Dr Mike Daniels 17:10

Um so I was an economics minor in college, which taught me absolutely nothing about business. Um, but you know, if you want to talk about you know supply and demand or laugh at her curves, I'm your guy. Um, so but I I the funny thing is, I was talking about this the other day with with a colleague, is um I loved my economics classes. Everything just made complete sense to me. I really didn't have to study for them. All I had to do was learn the vocabulary, and it was easy because you know, I mean, listen, everything actually comes from supply and demand, and then you just break off. Uh, it's kind of it's kind of like physics uh with Einstein's theory of relativity. Everything starts with that and then breaks off, and you start breaking the components down into their other components. You can do exactly the same thing in these circumstances. So when I started running the practice myself, when I bought out my original partner, um, and I told people when I got to my first you know million dollars of revenue year, and I was thinking I was the greatest thing since sliced bread, um, I began to realize in talking, especially my accountants, that I had no idea what that meant. And I had no idea where our dollars were going, and I had no idea how much taxes I was going to owe. I didn't understand any of it. And I would go to meetings with my accountant, and the accountants would just start talking, and I was they might have been, I always say they were like the teachers from the comics, uh, the comic peanuts. Charlie Brown and Peanuts are very familiar with that. Well, every time they had a cartoon of that, and they had the teacher, the teacher was just a trombone going, wah, wah, wah, wah, wah. And that's what the accountant sounded like to me at that point. So, you know, I was able to do this, and then, you know, last year, the year before, I'm sitting in a meeting with our accountants, and I said, you know, oh, we need to put this on the balance sheet because this is a single-time use and it's an abnormal thing, and it's not really an expense. And the junior accountant's like, no, no, no, you paid it as an expense. And then the senior accountant said, No, no, we can do that, we can move that over. And part of it was because I was trying to, you know, increase valuation uh by you know increasing profits by moving costs off the PL. Um, but again, I knew to do that, and the the younger accountant didn't quite get it. So it's kind of one of these things where uh I'm glad I did it. I actually did enjoy business school. Uh I was I did a cohort, so I was basically it was all done at home. Um, I would just sit there and write, and I would come home every day from work, and from like seven to nine, I would sit there and I would write, and then I'd spend you know four or five hours on each day during the weekend, and I would just sit there and write. And you know, I got through it. Um, and I actually didn't struggle at all. I really enjoyed it. And I'm still kind of toying someday with the idea of maybe going back in uh my health, my MBA's in healthcare administration, maybe getting a concentration with finance, um, because I'm a glutton for punishment, I guess. I don't know, but um, I still don't think I completely understand corporate finance, at least understand it enough to really and I would like to learn more. But I'm also from the generation where if you didn't understand something, you went to the library and got a book. You know, you didn't whip your phone out and have you know Google tell you in 12 seconds. So um that's why I went back to school because that was me getting a book. It was me getting the education that I would have had to Google and try to figure out and wouldn't be able to comprehend.

Dr Andrew Greenland 20:14

Okay.

Building Service Lines Beyond Clinic Visits

Dr Andrew Greenland 20:15

So in your evolution then, when did your thinking start moving from I own a practice to I could actually build an organization here?

Dr Mike Daniels 20:23

Uh that just mature by itself, too. Um, when I was first in practice, um the idea of in-office surgical suites was really kind of coming into its own. Um, and back then the surgical suites were really well compensated. And I said to myself, well, why am I giving all this money to the hospital surgery center when we can just have our own? So that evolved. There was already durable medical equipment when I got there. We were already doing diabetic shoes and cam boots and some braces and those sort of things. Um, so that aspect was there, but you know, we've now expanded that to wound supplies and compression garments and things along those lines. Um, and then you know, we've started a clinical trials arm. Um that's a revenue generator and a patient generator as well. Um, part of it is because we take projects that we're interested in, and secondarily is you know, it helps to you know put our brand out there for that. Um, and then along the way, and again, this is around 2010, um, we were really unhappy with where our billing companies were. So uh a friend of mine and I started our own billing company, and we started with two clients, his practice and my practice. And we grew it and we had about a dozen clients at one point. Um, but it actually started to wind down. And when we moved out of the our our private market, where we just basically practice into a medical services organization, we folded the medical billing company and rolled it into the medical service organization and got rid of the last of our clients. So now the only billing client we have is us, um, which has made life a little bit easier for us. But it's that whole kind of progression of just adding services that I talk about now, I consider them service line. Where back then I didn't know what a service line was from a you know from a bus stop. Um so as we got these service lines added and we started to look at added value for these things, that's kind of the progression that we go. So to fight insurance decline in reimbursement, we look to figure out is what are our patients getting that we're not providing and what can we provide them? So we get the dollars. I mean, they're spending it anyway. We're not looking to have people spend more money than necessary. But if you're already getting it and you're going to XYZ distributor, and I can do it in my office and you know have some profitability with it, well, that's what I want to do. And that's where this whole thing blew out of is it's okay, what can we add now that generates revenue to displace the decline that we're seeing and to provide better service for patients because it's a win-win for us. And you know, to this day, there are lots of practices that don't do a whole bunch of those things. I think they're really missing out. One is they're missing out on revenue sources, but number two is when you give somebody a prescription and send them out the door, they are far more likely to lose it and not do it than you are when you give them the product in the office. So compliance goes up, so satisfaction goes up, and all of that is super important these days because people go on Google and rank you now. Uh, you know, and you know, if everybody's, you know, if if if you know somebody says, Oh, you know, my doctor got me my diabetic shoes, and I was like, Well, well, I had to go to this pharmacy and they didn't fit right, and you can see the difference. So, aside from being revenue generation now, it's also practice promoting. And, you know, anything that we can do that promotes the practice for free or promotes the practice where we get paid to do it, like clinical trials, we're all for that and we take advantage of that.

Expansion Choices And Leading Change

Dr Andrew Greenland 23:45

Thank you. And is it um which is the biggest leap? Is it from one practice to the second office, or is there somewhere else further down the line where it becomes the biggest challenge for you for doing this?

Dr Mike Daniels 23:55

The biggest challenge is just the concept of expansion and whether or not you're going to do it through acquisition or de novo development. Um, I personally am a big believer in acquisition. Um, you know, it's nice to buy a revenue source, it's nice to buy an office where everything's already equipped and you just have to update, as opposed to you know, going into a blank space and imagining what it could be and building something. Um, again, you can tell what somebody did, and you know, statistically we always talk about it. You buy a practice, 10% of the population walks out the day you walk in because they're only coming to see the other doctor, and it's not convenient for them, so they're going to go somewhere that's convenient if they can't see the same doctor they're soon. Um, so I but again, and I account for that whenever we do an acquisition, but I think that's better because you have a revenue source and you can actually put together a budget for that and figure out whether or not you can improve that. And again, a lot of that is going back to adding ancillaries to improve revenue. But um, when you start cold, uh, unless it's an area with a huge demand, you know, it's like any business that you're starting. And you know, if you want to compete against the neighbor, I mean there's nothing wrong with that, but is that always the best medicine? Um, and and I personally don't think so in most circumstances. So, you know, I think the the concept of just I think everybody wants to be bigger until they figure out what that really means. But when you decide to get bigger, do you do it by acquisition? Uh, do you do it by de novo, or can you expand your current practice beyond what's currently being done? Uh, because if you talk to anybody, most people will tell you that they're maxed anyway. Nobody ever seems to have you know extra room. Uh, you know, nobody has some extra time there to throw in and do it. And everybody's just you know crazed. And we had this exact thing happen in our office this week. We have added a balance and fall prevention program to our practice. Um, and you know, to make sure it takes the medical assistant about a minute to just run the patients get an iPad basically and they fill out, you know, I think half a dozen questions, not a big deal. The medical assistants spend you know about a minute doing you know, balance testing, and then we come in and we review all the results and we discuss them with the patient and you know put together treatment plans to prevent falls. Um it's actually a CDC and CMS promoted program. Um, our admins in our practice were freaking out because nobody has time to do anything, and this is gonna add so much time. I asked the medical assistant that works with me regularly, I'm like, what's going on here? Is this hard? He goes, No, it takes me less than a minute. So if you're a minute and we're adding revenue, we're gonna prevent falls, which is gonna help our patients, and our admins are freaking out about it and saying, Well, it's not enough. I'm like, Well, I'm sorry, it's hard to find enough. And if you ever do, please let me know because I haven't. What we're trying to do is keep the doors open, and this is one more way that we can help people and keep the doors open at the same time. So it's those decisions because inevitably nobody likes change, and it doesn't matter how good the change is, the first reaction is usually negative. Oh, we don't want change, change is bad. Change means more work, change change means more complaints, more issues. Yes, but again, change is also how you grow. You can't grow without change. And yeah, and I know getting the expansion bug, those are the sort of things you need to look at. Which one of those three? And if you do that and you can make a decision and you can be happy with your decision, then sometimes you're a better man than me.

The MSO Model And Economies Of Scale

Dr Andrew Greenland 27:22

So bring us up to date with where you are now. What does um we treat feet look like today compared to that first practice?

Dr Mike Daniels 27:29

Uh so we are now uh, you know, as we say, we're now a platform, that's why we turned into a medical services organization. So we actually now have an ownership structure where we have a non-physician owner. Um, and there's corporate practice and medicine laws and things like that that are well beyond my understanding or my pay grade uh to make it legal. But that's the way it has to be. So, you know, we have the ability to compensate our you know really good employees and turn them into owners, um, which is a big change from where it is. And you know, I came in and I paid, you know, I wanted half the practice, so I paid you know half a year's gross, um, which nowadays is insane to think about given what cost runs are for practices. Um, so you know, we can do that. Um, it allows us to give equity pieces to physician in our uh area um without having them go out and borrow a million dollars to buy 20% or whatever. So uh we can do it to them without with adding significant structured debt through a couple of different ways that we go about doing that. So, you know, breaking it down and then breaking it down into different service lines, and you know, you can't do every service line in every office, but what are the crucial or the essential ones that have to be located there? Um, and then there's just the shifting demographic of medicine in general, with you know, higher deductibles and higher copays and those sort of things, which start to limit treatment options for patients, um, you know, which is hard. I mean, if you think something's better for patient and they can't afford it, um, what are you gonna do? And we we had those decisions before, but not like we do today. So those things all combined together have now allowed us to do that, have allowed us to get to our current state. And the idea being um, you know, two offices cost as much, cost more than one office, but two offices don't cost as much as two one offices. And then three offices cost more, but they don't cost as much as two two offices, and it just grows from there. So by doing economies of scale and reducing your overhead burden, um, that's the way to continue to grow. And and again, you know, um as physicians, we're not exactly a sympathetic group when it comes to you know earnings. Uh, people are not really worried about their doctor not being able to eat dinner tomorrow night because their the reimbursement declined. So if you're gonna figure out how to be able to run the place and you're gonna figure out how to be able to maintain everything where every year the rent goes up and every year the employees need raises, and every year health insurance goes up, and you know, malpractice goes up every year, um, you have to figure out how you're going to do that. Because the previous answer was just see more patients. Well, I'll tell you, there aren't enough hours in the day for me to see more patients anymore. So I got to figure it out somewhere else. And that's kind of you know where we've moved it into, and that's the biggest difference now. Because again, I got out, I figured I could see everybody in the world, I can see 100 patients a day, and I'd be fine. Well, no, I can't. I'm too old for that now. I don't move that quickly. Um, but even so, I you know, when you see too many patients, the care you provide starts to suffer, and that's unacceptable to me too. So we try to make sure that we're doing everything we can to keep the lights on while still providing the highest level of care that we can. Because if you start to compromise care, then you you might as well go out of business because you've done.

Dr Andrew Greenland 30:42

And there's

Why US Insurance Overhead Is So High

Dr Andrew Greenland 30:43

a follow-up to that, and you may have partially already answered this, so forgive me. But why is the overhead of running an insurance-based medical practice in the US so high? Obviously, I'm in the UK, so I don't have this understanding of the model quite so much. And also, what are people doing wrong that are not making it work?

Dr Mike Daniels 31:00

Uh, quite frankly, I'll tell you, I don't think there are people who aren't making it work because they're doing it wrong. I think the people who are doing it wrong are just getting in trouble down the road. Uh, because people don't tend to be under, they tend to be over. Um, it I joke about this all the time. It's like sometimes I think, well, maybe if I just charged every patient 50 bucks whenever they walked in the door and took no insurance, I would be better off because first we have forms that have to be filled out and insurance forms that have to be copied and have to be scanned. Then I have to see the patient, do a note, and then figure out what I did and how that relates to the billing codes that I choose. Those then go from you know, from our section in the electronic health record to the billing section, and they then have to review it, make sure that everything from their address, phone number, date of birth, and all the coding is correct. Uh, they're looking for modifiers and other things, I see different ICD tens, because you can have two ICD tens that say the same thing, but one is paid and one isn't. If you don't have the right diagnosis, it won't get paid, so they have to scrub those. So we then send those to a clearinghouse. A clearing house, I don't know, even know, other than being a middleman and exchanging money, I'm not really sure what they do. But they then process it and send it to the third party payers, and the third party payers, you know, then decide to pay us or decide not to pay us, and that's where it gets to be expensive. So every single step you have costs you money. So, and there is zero way to eliminate any of that because I've done everything I can to try to. Um, at the end of the day, can I streamline some of them? Yes. Is technology and AI helping? Yes, but every single step costs money. So think of it this way the the care you provide the patient is only one part of a very long chain, and that's why everything in the US costs so much, because everybody has their hand in the line and everybody gets paid along the way. Um, and then you know, talking about billing and that with a lot of doctors is you know committing blasphemy. So, you know, dirty money is a dirty word in medicine. So, you know, nobody really wants to take the time to figure that out, and that's really where the problem is.

Dr Andrew Greenland 33:06

Yeah, when we first connected, I think you said one of the biggest operational challenges was phones. Tell us what's happening there.

Dr Mike Daniels 33:13

I'm sorry.

Dr Andrew Greenland 33:14

I think when we first connected, you said one of the biggest operational challenges was phones. So can you sort of tell us a little bit more about where what's what's the problem there?

Dr Mike Daniels 33:23

Well, I think I think it's way too easy to get bogged down in um in the patient care aspect and realize that at the end of the day, if you can't keep the lights on, you can't help patients. So, you know, the focus is always on the patient. We're all taught to do that, we all do that. I mean, it's almost just uh gut reactions at this point, and we know nothing else to do. But again, sometimes you're missing the bigger picture, and that's that's really what's going on. So uh you really need to stay, you know, focused on the medical part, and then either you better have somebody like me who can focus on the business part to make sure everything drives, or you're gonna end up in trouble. And I think that's primarily what I mean by focus.

Cash Flow Stress Staffing And Lawsuits

Dr Andrew Greenland 34:09

So, with all your business experience and where you are in your um professional journey, what are the things that still keep you up at night in running this show?

Dr Mike Daniels 34:18

So I, you know, again, there there are a handful of things that do. Uh, you know, obviously, is there enough money this week to make payroll is always on my mind. Um, you know, I I I tend to work now in you know short, maybe you know, three to five day blocks of revenue generation because we have to make sure that we can pay all our bills so that keeps me up at night. Uh patients who aren't doing well still keep me up at night. Um, it doesn't matter if I had anything to do with it or not. You know, I will lie there and think about what else we can do differently, do differently for people. Um, you know, and then again in the US, you know it's a very litigious society. So, you know, I sit at dinner with the TV on and there's 17 doctor, 17 lawyer commercials screaming, did your doctor make a medical mistake? Call me, I'll get you justice. I don't know how justice became a synonym for money, uh, but somewhere along the line it did here. So those are the sort of things that keep me up. That and then staffing issues, and it doesn't matter, physician staffing issues are always an issue, and support staff issues are always an issue. Um, it seems like we never have enough of either. Um, and doctors hanging a shingle and sitting in an office for 30 years is is over. There's a ton of mobility in people's careers now in medicine. And uh I've had people tell us that you know, our initial contract offer, so somebody coming out of residency, we're gonna offer them a three-year contract. Well, three years is too long because I'm not sure I want to stay there for three years. What you have a hundred, you know, you're $500,000 in debt and you don't want a guaranteed job for three years? That doesn't make any sense to me. So, you know, the grass is greener somewhere else, I guess. Um, but it shocks me that people are now just blatant about the fact that they don't intend to spend their career there. And you know, you're you you're a doctor, you've gone to the doctor. People like to go to the same doctor, they they like to get that comfort level, especially in a profession like ours, where we do have patients that receive four to five times a year, every year for years. Um, you know, I I assume it's similar in primary care where you know you're seeing the patients whatever the protocol is for whatever their conditions are. Um, but again, I hear from my patients when their intern is move on and they can't find you primary care doctors or they don't like the new one and had the old one for so long, and those sort of things. So I I worry about how to make sure that we're maintaining the same kind of um practice integrity, I guess, that people grew up relying on because it's really not there anymore.

Dr Andrew Greenland 36:45

So if I gave you a magic wand, then you could fix anything in the business overnight.

Shocks Regrets And Exit Strategy

Dr Andrew Greenland 36:49

What would that be?

Dr Mike Daniels 36:50

Oh, I I would just double our revenue. I think that would uh solve all of my problems. Uh if I could just double my revenue overnight, um, that that would be nice. Uh, you know, and other than that, it's things that come up as time goes on. Um, we're here in Maryland a couple of years ago, there was uh a big cargo ship that ran and literally knocked one of our major bridges into the water. You may have heard about it. Um and we had three offices within 15 miles of that bridge, and everything just stopped because people couldn't get anywhere because they couldn't get to the other side of you know we call it of the bay. And uh, you know, our revenue within the first three months after that in those three offices dropped like 70%. It was crazy. And of course, now people kind of figure out how to do things and those sort of things. But in the beginning, it was all very much um uh that you know, people couldn't figure it out. So we had doctors just sitting there.

Dr Andrew Greenland 37:47

You've had a pretty long, successful career. Um, if you were to have your time again tomorrow, would you do anything differently?

Dr Mike Daniels 37:54

Yes. When I graduated from college, I would have gone to work in the mailroom at Goldman Sachs and worked my way up. I would have worked less and made more and probably been retired by now. Um, you know, you hear all these Wall Street the crazy hours. And if you talk to private equity guys, the crazy hours they make their junior associates work. And I'm like, well, that's just Thursday. I don't know what you're complaining about. You know, oh well, we get emails at 11 o'clock at night. I'm like, we get calls at 11 o'clock at night. I have to leave and go to the hospital. So I always say, yeah, I probably would, if I had half a brain in my head, I probably wouldn't do this, despite the fact that I'm not sure what they're doing all day that's taking them so long. They're looking at spreadsheets. I don't know what people did before spreadsheets, but uh I don't know. But it seems like uh that probably would be a better way. Maybe I'd be sitting in the Hamptons town instead of uh here in Maryland.

Dr Andrew Greenland 38:40

But on a serious note, if you uh having your time again and you were within you were staying within this career, would you do anything differently um from this career perspective?

Dr Mike Daniels 38:50

Um I I might have looked a little bit um a little bit more at maybe doing going the allopathic career route. Um, you know, I I I have this kind of administration thing, and I in the back of my mind I always think, well, I could run this hospital better than those guys. So, you know, but I I don't have the background to do it. So um I I don't know. That could have been something, but uh at this point, no, not really. Um I'm not I don't have any regrets about choosing to be a podiatrist, uh you know, maybe being a doctor in general, but I honestly don't think it would be any different if I was a dermatologist.

Dr Andrew Greenland 39:26

And what are the future? Where is um WeTreat Feet going to be in the next 12 months or so? Do you have any plans for the business and plans for what you want to do with it?

Dr Mike Daniels 39:34

Well, I mean, again, uh, you know, I'm much closer to the end of my career than the beginning of my career. So, you know, I'm you know shaping out my my exit strategy, and there's no me to come by me. So, you know, one of a couple of things is gonna have to happen. You know, one is I'm gonna have to you know become a part of a larger group, whether that be you know through purchase of equity and you know, being uh uh a tuck-in, or whether that you know being a format, uh platform format for a company, maybe that way. Um, you know, do we start selling off pieces and you know, we buy this piece and you take that piece and that? Um, you know, do I just you know close the door, turn off the lights and say buy one day? So, you know, those are the sort of things they're growing. I think realistically, based on the market, is we'll get acquired by somebody much, much larger than us one. There's a about a half a dozen to a dozen uh companies now acquiring podiatry practices and and you know forming these large groups, two or three and four hundred doctors. And I think at some point we'll get we'll get gobbled up by them. Um, not really sure what that will mean for me. Uh, you know, would I just go back to being a regular plain old doctor coming in at you know 8:30 and leaving it for? I don't know, maybe I would. Would I then start to you know rise in administration and and rise in the corporate structure there? Maybe I would. Maybe it's too late to do that. I I don't know. Um, you know, needs to say, I you know, I'm not 100% sure what I'm gonna do on Monday yet. So I don't know if I can think about 12 months down the road. But uh again, at the end of the day, um I am starting to really seriously think about my exit strategy because they say you got to do that at you know, you know, three to five years ahead of time. So, you know, I'm thinking I'm gonna be around another eight or ten years. I really need to put something in place.

Dr Andrew Greenland 41:18

Mike, with that, I'd love to thank you so much for joining us today. I've really enjoyed the conversation. I really uh um what I would particularly appreciate is your perspective that you're looking at healthcare from both sides. So the responsibility of being a physician, but also delivering good patient care. And it's been so interesting hearing you know how you've built and scaled your business and your perspectives on running it from where you stand. So it's been a great conversation. Thank you very much indeed for talking to me today.

Dr Mike Daniels 41:44

Thank you for having me.