087 What is a GPO and Why is it Important to Pediatric Private Practices, Andy Johnson

Andrew manages operations for PracticeWell, applying his over fifteen years of experience working in healthcare and technology. He understands that healthcare is a unique type of business which requires creative solutions. His years of experience have merged medical care, business, and technology. He believes this intersection will ultimately transform healthcare. Having worked with start-ups, and larger companies such as Google and Apple, Andrew gained insight into how technology can improve the medical care experience from the provider to the patient level. Andrew sees the momentum for change in healthcare and how PracticeWell will support this change through benefits to its members. The ultimate goal is to produce healthier patients. Andrew holds a bachelor’s degree in mechanical engineering from Cal Poly and an MBA from the University of San Francisco. Andrew has also spent five years as a firefighter paramedic in California. He still volunteers regularly as a first responder in the Bay Area, where he resides with his creative two-year-old daughter and active five-year-old son.

Transcript

GPOs 

[00:00:00] Dr. Bravo: Good morning, George. It's Tuesday morning again. How are you today?

[00:00:03] Dr. Rogu: How are you doing, herb? Yes, it is Tuesday and today we have another great person that oh, he's like me. He is an mba. Cool. I am, yes. Excellent. You know, today we're gonna talk about his name's Andy Johnson mba, and we're gonna talk today about what is a G P O and why is it important for pediatric private practices to succeed.

[00:00:23] Dr. Bravo: Andy's a seasons executive in operations, finance and healthcare. He's joining us today to talk about the importance, saving money in acquiring supplies and lean processes for successes of pediatric practice. Welcome, Andy. 

[00:00:37] Andy: Hey, thank you guys. Hey, first of all, congratulations, big milestone on your last podcast. So glad to be here. Yeah, thank you. 

[00:00:45] Dr. Bravo: I Andy we always started with. Asking our guest, how has been your journey through pediatrics and pediatric management, where did you start and why are you in 

[00:00:54] Andy: this field keeps sucking me back in. So I actually got my my degree in engineering as a mechanical engineer.

Worked at Apple and Google and a couple other places back in the early two thousands. I've been doing stuff with pediatrics and primary care probably now for about 20 years. And I really got into it because both of my parents are pediatricians and so I kind of grew up with it around the dinnertime conversation.

Everything from the interesting conversations to the challenges that were being faced every day, probably from the late seventies through the eighties, the transition to managed care and it just seemed like there was a lot of a a lot of stuff that needed to happen and a lot of work that needed to do.

And, you know, healthcare has been traditionally very slow to act when it comes to adopting technologies. So that's kind of how I got sucked backed in I really was chasing my childhood dream to become a firefighter and a paramedic out there. But at the end I actually found myself working in pediatrics.

[00:02:04] Dr. Bravo: It's in your blood? It's in my blood. And it's hard to get away from I I think you guys even talked about it on previous podcasts. It's kind of a, becomes kind of a family business. Yeah. Those conversations that you guys have talked about before about. Should you know, you encourage your, your child or ever to go to medical.

[00:02:24] Andy: My parents were of the type of like, no, you're gonna get so much debt. You're gonna go, go do something with engineering or something like that. But I think at the end it worked out Great. So 

[00:02:34] Dr. Bravo: are you, are your parents still practicing 

[00:02:36] Andy: \ . So my mother retired. She was working with Kaiser for, oh my gosh almost 35 years.

And then my father has been practicing now for 46 years, I wanna say, and is going to finally retire at the end of next month. Wow. So he is still seeing patients full-time. It's actually been a very interesting journey watching him go from, I believe, doing spinal taps and having his own lab. All the way to now having to deal with EHRs and the technology curve and all the other stuff, especially since running a pediatric practice has gotten exponentially more complicated over those years with all of the administration dealing with insurance companies the back and forth with all that, plus, you know, their main desire just to deliver the best care they could, so. Right. Wow. It's yeah. Well, that's a little bit of my story. 

[00:03:38] Dr. Bravo: Interesting story. Is your dad in a physician owned 

[00:03:43] Andy: practice or, yes. Yeah. Yeah. So he is in he works and now I work for SF Bay Pediatrics, which has got 10, providers, 10 doctors and they're in San Francisco. They have an office in San Francisco, and then another office across the bridge, the Golden Gate Bridge in Mill Valley.

And when he started it was just two of them, and now it is up to 10. 

[00:04:09] Dr. Bravo: Wow. I I never understand how you can run a practice in San Francisco or New York City or, , the middle of la I mean, where rent is, you're competing with, you know, Ferragamo and Gucci and, you know, no. Where the margins are a hundred percent.

You know, a pair of shoes is 1500. They make $700 off the sale. They only have to sell, you know, three shoes, three pair of shoes a 

[00:04:33] Andy: day. Yeah. Real estate is definitely at a premium and it posed challenge, you know, like when you have employees, like how do you get break rooms? How do you fit everything in there?

You know, you kind of reach a capacity. And so the Mill Valley office has a little bit more space, but Not really any way for us during covid to say, like, pitch a tent and see people in the, in the parking lot or anything like that. Or, you know, really being able to divide up our office like we wanted to, to have sick patients into, and well patients into in another place.

So we did a lot of telehealth and still doing a lot of telehealth, which I think is great. And also getting all gowned up, walking out, doing our, our tests and turn around, come back, say, okay, you're negative, you can come in and stuff like that. 

[00:05:27] Dr. Rogu: So do you manage your, your dad's practice or.

[00:05:30] Andy: I do half. There's actually another full-time practice administrator who was recently hired, is doing a great job. And because of the HR and all, we actually just transitioned our EHR too. So yeah, there's two of us out there. There's actually two, and then we actually have a couple other remote employees, which is another thing we started doing is actually hiring people remotely to provide advice.

So like our advice nurses don't have to be in the office anymore, give 'em a computer and and the zoom and they can answer the phone. It works out really well, so. Well that helps with real estate. It helps with real estate, so you don't need Yeah, yeah. Space. And, and, and also, you know, employment's pretty high.

Yeah. You know, we can Sure. Later we can talk about all the expenses and the practices out there, and. Vaccines obviously are a huge expense, but you know, for us, we also have to deal with rents and, and you know, salaries. So 

[00:06:29] Dr. Bravo: why do you, why do you think you said pediatricians, but I would imagine it's all primary care doctors are slow to adopt technology?

[00:06:37] Andy: Geez. You know, I you did talk about this a little bit on on previous podcasts. It's just the way that doctors who are trained to be very certain. And so there's not really that desire to adopt very fast. You wanna make sure that it's correct and so , that causes a little bit of a delay.

So you can go to another industry and look at it and say like, oh yeah, they're gonna go what, what was my example? I was, oh 7-Eleven and Frito Lays Doritos. Like, you buy some Doritos at 7-Eleven, they know when and where that was manufactured. They have barcodes down to when it was delivered, whether it was on an end cap or anything like that.

So the technology to know all these things really exists, but healthcare is not gonna pick 'em up until they have certainty that it's going to make a positive outcome. There's just a lot of money involved, there's a lot of risk involved. And so it's, since it's so heavily regulated, just takes a long time for those operational and technology items to matriculate down to the practice. Especially in private practice where there's, you know, the primary. Earners are also the administration, so the people who are doing all the work to earn the money or majority of the work to earn the money mm-hmm. Have to sit in an administration role. And so that's, causes some delay in an adoption as well.

[00:08:05] Dr. Bravo: Yeah. I also think it, if it doesn't improve care, it doesn't improve margins and it creates more work for me. I don't see it as anything but a pain in my right. I mean, 

[00:08:18] Andy: but also when you have those doctors on the administrative table, they can also push things forward faster.

[00:08:25] Dr. Bravo: Sure. But, some things don't need to, some things don't need to be pushed. And I get in trouble by saying this all the time, 

[00:08:31] Dr. Rogu: but I, I know the paper charts are yesterday's news. They need to be pushed. You need the No, no, 

[00:08:37] Dr. Bravo: no. But no, no one put a gun to anyone's head to go buy an iPhone. I mean, people put, people stood in lines still standing in lines to fork over $1,400 for an iPhone.

And the only way they could get American doctors to adopt the HR cuz it wasn't ready, was to put a gun to their head and say, we'll pay you less. Oh, by the way, we'll we'll pay you less, but by the way, we'll throw, I think it was 20 billion to California's it industry to build the r to be a cash register for you and it won't cost you a dime.

Which wasn't true. That was kind of like, you can keep your doctor if you want to. But anyhow we're going off target here, why don't we do this? Oh, that's 

right. 

[00:09:24] Andy: I mean they're all, they're all problems we've been dealing with for, 

[00:09:28] Dr. Bravo: but really, right. So they didn't have to force anyone to buy an iPhone. So I think that's part of the problem with the solution is not something you want, it's forced upon you.

It's harder to adopt. 

[00:09:41] Andy: There was, there was definitely a carrot and a stick. There were you know, depending on how much public care you gave you know, you could get some incentives to adopt an ehr. But on the other side, you know, we were all stick with the high tech DAC and everything because at our practice we don't have much, you know, Medicaid in our case.

And so we got no incentives. We just got the stick, like they had to do it. So, yeah. That's tough. You know, I think that's what happens a lot with primary care especially pediatrics is it's overlooked. And you know, I, I actually like a lot of the ideas that you guys are coming up with because I think it needs a better spot at the table.

You know, pediatrics, it affects lives much longer than the specialists who are, you know, generally running those conversations. So, yeah. So 

[00:10:31] Dr. Bravo: what's the biggest practice expands for, for a pediatric office today? 

[00:10:35] Andy: Depending on location vaccines could definitely be one of the largest expenses out there.

For us it's rents and salaries and then vaccines in that real and just, just on the expense side of it. And 

[00:10:52] Dr. Bravo: so how can any pediatric practice manage , the cost of their vaccines on the commercial side?

[00:11:00] Andy: Well you know, I think the whole topic of this podcast is really around GPOs and what they do.

They go by a lot of different names out there. So some people call 'em GPOs, some people call them physician buying groups, or maybe physician organizations. And you know, they come in a lot of different flavors but they are. Honestly, the most cost effective way to procure your vaccines. Y you know it's one of those things that just kind of happens in the background.

It's not something that people are really aware of. You know, I've been understanding and working in this this particular marketplace for 20 years, and it's just not something that people think about. However, it is crucial in order to deliver the highest quality care. And as we talked about earlier, some, some margins, which, you know, there was a long period in the, , late eighties and early nineties where, you know, people were giving.

Vaccines because the benefit to population health is overwhelming, but they're doing it at a loss and, you know, going outta business. So how, how do you get those costs down? And that's what A G P O does. So they, they can aggregate a large consumer base in this care. It's mostly primary doctors and get discount tiers from the manufacturer of those vaccines.

So, so a 

[00:12:28] Dr. Bravo: DPO is a group purchasing organization? 

[00:12:31] Andy: Yes. Yeah. That's what it's what, what do you mean by 

[00:12:32] Dr. Bravo: that? And, and it basically functions like a cooperative where a group of consumers get together to have the buying power that they can't have alone. 

[00:12:44] Andy: Yeah, that's, a nice, simple answer.

However, I think like most things, it's in the details and how they do that is how different GPOs form. So some of them are more hospital based, so they'll go get, you know, two or three hospitals together to get certain volumes on stuff. Whereas other GPOs out there are, I think the best term is a committed term where they're saying like, okay, we're gonna buy this product from you and not buy something else from somebody else in terms of a competitor.

And then the cost gets reduced. So you're committing to a certain percentages of your purchases being purchased for those products. GPOs group, purchasable organizations are not just in healthcare. They span hospitality, manufacturing, engineering and they do have a specific designation within the I r s and in the United States as well as from, from a federal level.

So they are regulated, but in healthcare particularly, they had to carve out and make a, a safe harbor section for GPOs in, in that realm to make sure and try to reduce healthcare costs. By doing that, so everybody gets together, you can kind of choose one. If it's a volume based contract, negotiate that directly with a manufacturer and then turn around and say like, Hey, I've got a couple hundred thousand people here that are gonna be buying your product.

And using those economies of scales, get the cost down to those. And so GPOs Yes, go ahead. Go ahead, go ahead. I was gonna say, GPOs are not like a distributor. They do not take and own the particular products that they're dealing with. So vaccines, they don't claim ownership of them, they just negotiate those contracts to lower the prices and hopefully pass on those prices to the to the people that are actually buying it.

So, 

[00:14:43] Dr. Bravo: just to better understand, I would assume that may maybe your practice in San Francisco does anywhere between a hundred and $200,000 in vaccines per provider, cuz you take No, no Medicaid. 

[00:14:57] Andy: Mm-hmm. Yeah. And that's a 

[00:14:59] Dr. Bravo: good, good estimate. A a, a single practitioner who takes 60% commercial will probably be around a hundred thousand dollars a year in vaccine inventory.

You know, yeah. Depends, depends whether you have a young practice, an old practice. Some vaccines are more expensive than others. And the margins on what the industry calls the serum are very tight. Six to 10%, that's, that's the most you're gonna squeeze out of that. And that is not only dependent on what you pay for the product, but also if someone makes 10 times an error in billing for your H P V vaccine and you've not now lost about $3,000 that you paid and never, you know, it came, it really came outta your pocket.

You paid for that serum, you gave it, you can't on give it, you can't 

[00:15:55] Andy: call, you can't take it back. No. 

[00:15:57] Dr. Bravo: Bring the kid back. I'm gonna take the vaccine out because I never got paid for it. And that's a real loss. I mean, that's not just a loss of my time. That's my pocket bit picket that by three grand.

That's correct. If we do a math, if you're make, you know, buying a hundred thousand dollars, you're gonna make 6,000. Somebody made a mistake 10 times times 300, that's 3000. Now your margin's down to $3,000 and a hundred thousand dollars investment. That doesn't include the carrying cost of, yeah.

Storage. Storage. The loss of opportunity disposal, or that capital had, that impacts your cash flow. So it's a real, it's a real tight margin operation when it comes to the vaccine. Zero. Yeah. Now, one thing I always get kind of stuck on in the GPOs is there's a price list that the CDC d puts out, right?

Mm-hmm. For both Medicaid or we don't callem, they don't call 'em Medicaid, they call a vaccines for children. Mm-hmm. And and then there's a price for commercial that they put out and. Then there's two things that I don't understand. One is the insurance companies barely ever pay you what the commercial list price is on the c d C website.

They don't reimburse you at that. They use other price lists, which are significantly below. And how does the G P O get that discount for the practices when there's already a list price that's set by the government? 

[00:17:36] Andy: Most of the industry actually does use the, some people call it wac, which is the full sale acquisition cost.

Mm-hmm. Which is, let's say you're a big distributor and you order train loads of this product, what they would be paying, which is where pricing and reimbursement supposedly gets set. And you know that nothing's as easy as it ever should be, where, you know, you see a price, you have like an M S R P, which is equivalent to that kind of wack pricing.

And what you get paid off of that is, is variable. It could be variable from one payer to the next. It could also be intr that same payer can pay you different amounts. And so we, we really look at the averages over that, that time. The c d C price list is just what the C d C itself negotiates just as if they were their own G P O.

So the government. Should technically be the lowest acquisition cost. There are ways around to get close to that price using a rebate structure, which hopefully, if you are participating in A G P O should be paying you a rebate. Two, lower the acquisition cost of those vaccines. It's a very important thing.

What 

I 

question, what I found very confusing is yeah, when you talk to different GPOs about vaccines, they all say, well, we all have kind of the same price because it's mm-hmm. Regulated. And, but why is there this variability in 

reimbursement? 

Oh 

[00:19:20] Dr. Bravo: so I'm sorry. Not reimbursement and cost and acquisition.

Cost 

[00:19:26] Andy: in acquisition cost or reimbursement. Well, if everybody buys it for a hundred bucks, how can it be that physicians are not making money on vaccines? Some are, some are not. 

[00:19:37] Dr. Bravo: Well there's, so there's two parts of that equation, right? So if you're going through a G P O, I don't think it's possible, but you can get a 10% discount on that a hundred dollars.

You're getting it at 90. Mm-hmm. And you know, so that's one side of the equation. But they all get it at 90. No, everybody doesn't get it at 90. Some people are paying a hundred dollars cuz they don't have any, they don't have any leverage. No, 

[00:19:59] Andy: no. But I think all the GPOs have the same acquisition cost.

[00:20:04] Dr. Bravo: Right. But they have different rebate structures. That's what he's alluding to. Yeah. 

[00:20:08] Andy: If you are on A P B G P O, which is typically a group of physicians, not a hospital based ones, a hospital based ones are, you know, multi-billion mul market cap, publicly traded organizations that make a lot of money.

And, and. I don't like to use the term middleman, but that's what they do, is they sit in between a large consumer population, which would be the hospitals that are buying everything from products that go into their surgical center, to their, you know, more pharmacological products. You know, the, the stuff that's given in the non-acute setting is a little bit different.

And that's where I would say the more physician buying group style G P O comes into play. So our, our office is gonna use stuff that we can use in our a consumable product in our course of doing business during the day. So, you know, we have the, the TB tests, we have the vaccines. Those types of purchasers are different than the type of purchasers that are buying stuff for hospital systems.

So GPOs that are on the hospital systems are volume based. They say we're gonna buy. This particular facility is gonna buy 200 million worth of stuff over the course of the year. Whereas as Irv was saying, like we're gonna probably spend about a million dollars on vaccines in our practice, probably a little bit more.

And there's those two different types of contracts that GPOs are managing to reduce the cost. Everybody who's on the PBG side, the physicians. So the people that we would be working with have or should have the same, I would say, contracted price. So from that contracted price, we can then have a couple discount structures that get you lower.

So your invoice cost is going to be maybe one or 2% lower than that. So if we look at the scale, buying through a distributor is gonna cost you the most amount of money for your product. As we step down, you can go direct to a manufacturer if they offer it, which would give you a little bit better cost savings because they're selling it to you direct.

And then if you take that direct and you apply a GPO or P BG contract to it, you're gonna lower that because you're going to have to, you know, either commit to a volume or you're gonna commit to a market share on it. And by doing that, you have the lowest possible acquisition cost. And, and I know for 20 years of doing this in pediatrics, you kind of choose a, in this case right now, it's a pertussis backbone for your products, which then you kind of build a lot of your vaccine portfolio around.

So once you've kind of dis discovered that, then you find the set of contracts that you like. You know, generally we're talking manufacturer specific. Our practice uses Sanofi and Merck. And you know, that combination of those two manufacturers supplies all the vaccines that we're gonna need. Right.

 I think there's gonna be a lot of changes coming up. Some people like to use a, a Pfizer gsk or you can use a, a GSK and Merck. So you find a set of contracts that will provide your portfolio and that the cost then gets at a, at the best possible way for you to acquire the next step on top. And, and it should be the same no matter which PBG you're with.

Now, as long as those PPGs are on those market share based contracts, if you're working with one of the larger ones, maybe you're part of a hospital system and you're affiliate and you get put onto I can say like a Premier or a Vizient there's been a big consolidation of those larger GPOs out.

Their prices are actually gonna be higher because they're volume based and it's gonna be on a per location basis. So you still get a discount compared to what you would be getting if you were getting it through, say, a distributor directly without a G P O. But that, that's the, the acquisition cost for us in, in those areas.

Okay. Then lastly, on top of that, you would hopefully get some sort of rebate structure from your group purchasing organization that would then lower the cost even more. So those are the three factors on the expenditure side that you can look at from a GPOs perspective on how using those economies of scale can get that product from the manufacturer into your office and hopefully sitting in your refrigerator or freezer and getting ready to be used to be put in the arm or mouth of your patients.

And, and so 

[00:24:52] Dr. Bravo: What is a realistic, expectation if you're buying vaccines, three to 5% is a, about the most you're gonna be able to lower that acquisition cost?

[00:25:03] Andy: Oh, no. You can get up to 46% discounts on some products if you factor in everything. I would say soup to nuts on that. So from the discount, the discounts extend more towards products where there is not a competitor. So almost everybody's making a hepatitis B product out there. So when you're dealing with these committed contracts with which we're, we're mostly talking about you promise to buy one manufacturer's hepatitis B, maybe at a 6% discount.

But then their sole source product that they have, you can get a 40% discount on because they have the margins to work with that. So we're, we're really pushing hard to keep the cost down because we know that it is imperative for our margins because it takes so long for us to get paid on all these activities, but the, the discounts on the invoice are really, really just the start o of that whole process.

 I'd have to go back and look at all the pricing that we pay through our G P O but that, that's more or less, what happens is when you have a competing product and you commit to buying that from one manufacturer, you get a discount on your. On their sole source products, which can be quite substantial.

I think H P V is a good example of that. So the contract discount on H P V, cuz there's not really a competitor for it out there from Merck's perspective, you get a higher discount than you are on something there where there is competition out there. So. Okay. 

[00:26:47] Dr. Bravo: If you weren't wearing the G P O hat, you were just, you know, the managing the practice, would you do what business ana business people say, get a quote every year for, you know, from three different people to see which one is a better contract 

[00:27:04] Andy: for you?

 I do do that for our practice, so it's It's something that actually does take a lot of effort. So you, you just can't look at the acquisition cost, the expense. You have to also look at the reimbursement. So you guys Dr. Rogo, you did ask like, why is the reimbursement so different? You can find that from one manufacturer to another manufacturer, the reimbursement for the same, say, hepatitis product is different, you know, the different C P T code pays.

Yeah. It's, it's shocking. So and actually also too, if you're a little bit more in the adult space and maybe do not vaccinate as much, your contracts may not specify, you know, the appropriate reimbursement amount on there. So it's, it's pretty imperative. To take the time and look at that portfolio of all of the vaccines that you're giving from the acquisition cost, from buying them, from, to storing them, to disposing of them, to what you're getting paid for 'em to make sure that that margin is, is acceptable.

You know, there were times where we did analysis and we're like, oh yes, we're gonna save $40,000 by, you know, switching to this particular line or the other particular line just to find out that we'd lose about $80,000 in reimbursements. So we would've saved 40 on one side, but lost 80, so we would've netted out a negative 40 on that whole process.

So it is a chore to do that. But I'm gonna 

[00:28:39] Dr. Bravo: pick your brain on, don't, but 

[00:28:40] Andy: hold on one second. Don't, don't. The vaccine manufacturers know this. They do. So why do they do that? It 

[00:28:47] Dr. Bravo: sounds like, 

[00:28:49] Andy: That is one of those great mis one of those, one of those great mysteries that I've, I've never quite understood.

[00:28:57] Dr. Rogu: How, how, how can somebody in good conscience go to Dr. Bravo and say, okay, if you change to my vaccine, Dr. Roku special will give you 50% discount on buying it. But I know that your insurance company contracts will not reimburse for it. They don't know that. He says 

[00:29:13] Dr. Bravo: he does. They do. No, he knows that. But they don't know 

[00:29:16] Andy: that.

The doctors don't. It's an information disparity for sure. Andy knows that, but 

[00:29:21] Dr. Bravo: I mean, and you know, this is business people are like, we'll give you this. We wanna sell it. We don't care if you make money or not, that's your problem.

[00:29:28] Andy: , I think like that's why kind of shedding the light and why asking what a G P O does is, you know, we look at those things and it, like I said, it sits in the background. It's like something you guys as doctors kind of want to think about, but don't have the time to, there's just no more bandwidth.

And so finding and shedding light and on that is really important for, you know, everybody's sanity a little bit, but also for delivering that highest quality care. It's like a complicated, you have to have very specific industry knowledge of. What are the products out there? Who makes, what, how does it compete?

Right? What is the matrix of every vaccine that we're, that we're you know, buying how does that schedule work? Getting people in, making sure we're getting reimbursed for them. You know, it's a huge h DDIs measure too. So, you know, it's a, it's a big part of our, of our practices 

[00:30:18] Dr. Rogu: you know, you know what confuses me still? Cause I do a lot of the contracting negotiations, right? Mm-hmm. I think everybody focuses on let me buy the vaccines for a cheaper price so I can bill out an insurance company. I think the problem lays in the insurance contracts with the individual physician groups. Yeah, because like for CPT codes, for office visits, it's very simple.

It's a percentage above or below Medicare. Yeah. Particular s with the vaccines. It's a average wholesale price. Red book This, the w the other one that you said, the whack, no. The CDC price a, you know, sometimes they'll, I I assume one company where we'll pay 120% above what Mr. Insurance carrier's rate is.

There has to be a, a centralized number. There's not, there's not. So it's like five moving targets. So 

[00:31:12] Dr. Bravo: look, there is, 

[00:31:13] Dr. Rogu: so, which is the best one when you do an insurance negotiation, you should have a percentage above. 

[00:31:18] Dr. Bravo: No, he just told you, you have to look at each contract versus what vaccines you get. Right. And see what your margins are. And then you have to make a decision

[00:31:27] Dr. Rogu: . No, no, no, no. It's the wrong, but you have to go at the beginning, at the contract level. So when you're negotiating a contract, like I'm doing one right now, but I want to know vaccines should be paid as a percentage above what Cuz there's no Medicare value for vaccines. Mm. Has to be a medi, a value of something. 

[00:31:50] Dr. Bravo: But George, you're gonna sign a contract for three years, the three, three, you know, year lease, Galatian uhhuh, and you have no idea what the vaccine market's gonna do next year. So I just say, you know, just say that you're paying a hundred dollars for the I P V, which is 150% of what the c d C list price is.

[00:32:08] Dr. Rogu: Well, that's it. It's, they don't use the listing. And next year, next year, next year, the I PV goes to 175 and now you're losing $25 on every I P V. Well, that, that has happened. So you don't, cause you don't control both sides. But essentially what is wrong with this market is that it is not on market like any of retail market.

So if I'm Sony or I'm Apple, apple doesn't do this, but Sony did and I'm going to send it, sell a tv, I send it to Best Buy and I go, you're gonna buy it for $500, but your list price has to be seven 50. Right. You have, you know, it's usually a thousand dollars and retail's a hundred percent markup, cuz that, that people say, oh, that's outrageous.

No, they gotta pay the rent. They gotta pay employees. They gotta hold that inventory until it gets sold. They gotta collect the money from the customer. But that doesn't happen in vaccines. See, the vaccine market was transparent and functioning. The c d C would come out with a wholesale list price and every insurance in the company country would have to pay, you know, twice as much for that vaccine and a discussion.

And then you, you know, it would be profitable for physicians to get vaccines. But that's how it works. It just is the mess. It's a So how do you calculate, do 

[00:33:30] Andy: you have a popul every, every other country in the world except for the United States and maybe one other one has a governmental body that does that.

We, we don't have one here in the United 

[00:33:39] Dr. Bravo: States. So how, how do you calculate this? Do you have a calculator? You throw all the numbers into it? 

[00:33:45] Andy: Well, yeah, but yeah, so we you know, we try to do it on an annual basis where we can look back at the year and look at the margins for each of the C p T codes or the vaccines that we're giving you know, jump into your favorite practice management system.

Hopefully you can get some reports on that. And you know, George, even as you were saying, like you mm-hmm. You expect to be paid on a contract, something. We're not looking at every individual transaction, and I know because there's averages and we get the statistical, we don't get paid the same for everybody right.

On those contracts. So we just have to look at an average and make sure that we're number one, not losing, and then how do we maximize those margins and. In terms of like conversations with the manufacturers are like, well, if you can get reimbursed more, if we can get the cost down. Vaccines getting more vaccines into arms works out well for everybody across the board.

Works out clinically, works out financially. The manufacturers sell more things. And then population wise, we have a healthier population on our, our, our patients are better. So it, it is definitely one of those frustrating things that we have to go through all this effort to do something that's so positive.

But, but that's what we have to do. We, we literally have to make sure that our contracts and because it is such a big expense not only that, but we have we were doing a lot of hmo and the HMO would have like some staff members that were our doctors that would come in like, Hey, can we, can we look at what pricing you guys are paying for these?

Because they wanted to vary the pricing that they were reimbursing us for those products, which is something nobody should do. Like if somebody who pays you money wants to know what you pay for something, do not tell them, do not give that information to them and they have no right. And there's actually laws that say they have to adequately reimburse for that.

Actually, I think the C E D C website do, or the AAP has, has a vaccine guide on how to make sure that those are and maybe I can find that for you guys in a little bit to make sure you're adequately reimbursed for those things. So 

[00:36:04] Dr. Bravo: you lo you look at this once a year and then you lo you look at different. GPOs for your, for your practice. Yeah. And the contracts, and then you try to balance what's best. You, you might take a dollar loss in one vaccine, but you're making 50 bucks in another one that ends up making you a bigger loss. Yeah. 

[00:36:22] Andy: And, and definitely the, the doctors that, that are managing the practice might choose one product that might cost more smaller margins, but has some other benefits to it.

I think the meningococcal B vaccines, we recently maybe about a year and a half ago, switched from the Pfizer product over to the G S K product because it is a series of vaccines and the window to deliver that was smaller with a GSK product. So, but it cost a little bit more, and so the margins went down.

A little bit, but they figured it would be better to get the vaccine series completion done in a shorter window. You know, so there are other value propositions besides just the dollar amount. And, and it'll also be interesting too. I think in the vaccine space, we're gonna see a lot of changes in the next year.

So even those G P O contracts should be hopefully brought to the front of mind. Number one, you know, the covid vaccine is gonna be coming out and no longer supplied by the governments or counties or whom, whomever people are getting it nowadays. So that would be one aspect to it. And those contracts that you're on are gonna probably start including those if you guys are on G P O contracts.

The other big one that's gonna be coming around is the R S V vaccines that are coming out. I wanna say there's five or six of 'em in the pipeline. One of 'em is one of 'em has already been approved for the older 60 plus population, but those will be definitely coming down into the pediatric office soon, and they'll also kind of factor into those.

So there'll be some changes in the portfolio changes in the vaccine schedule with R S V coming down. So I think that's gonna be 

[00:38:04] Dr. Bravo: a game changer. The RSV vaccine's gonna be a game changer. Yeah. 

[00:38:07] Andy: Yeah. 

[00:38:08] Dr. Bravo: Yeah. And and the pneumococcal vaccines also changing, right? Yeah. Those, that's gonna be very confusing.

I don't, I don't understand the nuances of that, , but the number of pneumococcal antigens and the vaccines 

[00:38:22] Andy: change. Yep. You're going from 13 to 15 to 20 to 23 to getting know Yeah. With, with the Pneumococcal vaccine, I get hustled by both departments. I won't mention their names, but you guys don't know who they are.

I get the new boy that comes up. If you flip to our Pneumococcal vaccine, we'll give you a big, they're gonna attach it to a discount to the other, mm-hmm. Heavy vaccine. The h you know, the one that prevents the answer. Now the other guys that you've been using for the Pneumococcal disease, rather than being smart and giving a dramatic discount to their vaccines, they don't do that.

They're just gonna give you a little bit of a discount, which will be just a little bit less than what the other guys are gonna, are gonna attach it to our big vaccines. Yeah. It's like, you know, I just give them a hard time. I said, you guys, you want us to use their vaccines? Drop the price. I don't know. It goes on deaf ears. 

[00:39:17] Dr. Rogu: These are just the sales reps. 

[00:39:18] Andy: Yeah. And you know, there's, there's always the non-inferiority, you know, there's I dunno if you guys remember the old movie something about Mary, when the guy's like, talk, I got this great idea for, for this new workout. I'm gonna gonna call it like eight minute abs and you're gonna get a great ab workout in eight minutes.

And then, well, what happens if somebody comes out with seven minute abs? And that's kind of seeing what we're, what we're seeing here is, you know, they, they are proving efficacy. I get to look in, watch a lot of those medical directors present. You know, does the extra antigens help prevent, I would say the, the most dramatic increase has already happened, but there are some subset subsets of the population that would benefit from more antigens and, you know, it just keeps on growing up and up and up and up.

It will be interesting to see how it all plays out. But yeah, like I said, we're, we're, we are the only country here in the United States that really doesn't have a governmental body that does what GPOs do. So GPOs, the function in every other country is done by the government in terms of saying, this is how much it's gonna cost, this is how much you're gonna get reimbursed for it.

But hopefully your GPO is fighting for you on that situation to increase those margins and also make you most aware of what. You know, what's coming down the pipeline, how is it gonna affect your workflow? You know, understanding switching costs and then hopefully looking at reimbursement as well, you know, either giving you the tools or you know, the G P O that we work with actually helps us do that analysis.

[00:40:53] Dr. Rogu: So, but GPOs are not limited just to vaccines. You, you got everything there. Tests. Yeah. Yeah. But, but not 

[00:41:00] Dr. Bravo: every, not every G P O does that some, no, I mean, some do, some don't. It depends on how they're structured. 

[00:41:09] Andy: Yes., like I said, they do come in a whole bunch of different flavors. Some of them can give you procurement systems and some of 'em can do office supplies, medical supplies you know, other, other services out there. I know the one we're with does have. Contracts with developmental screening also vision screening. So, you know, from our perspective, you wanna be aligned with a GPO , making your practice run easier. I mean, the more you can dedicate towards spending time with your patients and not having to do the backend and understanding of all the nuances of these contracts and these arrangements, then you can spend more time with your patients, which is ultimately what I think we want to do in our practice.

Yeah. Can you tell us what G p o you're with? 

So, so, I, I have, before you go there, I got a bunch of questions. Alright. Okay. 

So 

[00:42:04] Dr. Bravo: I'm fascinated. How do you do this calculation? Do you have. Do, you give the G P O a set of codes and then they run it for you? H how's the mechanics of that? 

[00:42:15] Andy: So you run it in house 

[00:42:17] Dr. Bravo: and then tell the gpo 

[00:42:19] Andy: our, our you guys are very familiar with P C C cuz I know CHIP'S been on here. Chip and I been friends for, you know, 25 years. And so our practice management system was run through P C C. We go pull the report off of our, our C P T codes, which gives us an average of what we're getting reimbursed for those C P T codes. Those correlate directly usually to, you know, what Penta cell is which we're using is 9 0 6 9 8.

I think I'm just pulling that out of somewhere. And just look at how the margins run on that. So from our cost, and we build in a little bit for our storage, and we try to minimize our inventory. So that means we're not storing too much. Also helps the cash flows. So try to seasonally adjust our inventory levels and then compare it to what we're getting reimbursed just for the product alone.

So we're not talking the administration stuff on there. Then we look at the additional administration levels on that one. So that that's, I mean, we have an Excel spreadsheet or actually it's a Google sheet that does that, and that's how we compare it. What the G P O would do is you would have to supply those average reimbursements per payer that you have.

So I wanna say we take our top seven payers in our practice and do that across the board to see how the margins work out, and then we review it on an annual basis. And you know, just to make sure that we're not losing money on it, but also to, you know, evaluate what, what the GPOs out there. And I mean, so Chip and I 

[00:43:59] Dr. Bravo: disagree on this one cuz okay.

We run it through Tableau and I can tell you, I can tell you what R B K Pediatrics makes or loses in any quarter on any vaccine. You know, just everything's out in a dashboard, but I don't use the, the vaccine administration fee. Yeah. Because I think, okay, I'm first comparing, are you making money or losing money in the product then every factor that you said, right?

I mean, you may be losing a couple of bucks, but it's the right thing to do for the patient. And you know, then the Vaccine Administration is a whole other revenue center. Okay. Which is harder to figure out whether you're making money or not. I mean, somebody's giving you whatever, 25, 30, 40 bucks to administer a vaccine.

How much time's involved? I mean, less time to actually go measure how much staff time is what the syringe cost, what the needle cost, you know? Well they actually 

[00:44:58] Andy: did that study at one point that that's where they came out. 

[00:45:00] Dr. Bravo: Medicare value. Yeah. So, you know, I look at just as a whole thing, not the average.

Cuz you'd be surprised how, , not in a large practice like yours or Georgia's, but in a smaller practice it really does take five or 10 missed reimbursements to wipe pot your margins. Especially if it's the h PV or yeah, they're very expensive. You know, I like to know that, to try to get the billing department to go chase after that.

Basically cuz I'm offended, I really do feel that they're picking my pocket and that makes me upset. So that's how we look at it. But Chip says you should always put the vaccine administration fees there as part of your margins. I think you can separate them out and then look at them. It's a second margin.

I mean, yeah, look them together and look at, you know, are you doing good and convenient for the patients and are you comfortable using that product? 

[00:45:51] Andy: Now, 

[00:45:52] Dr. Bravo: You wear a lot of hats. I do. You manage a big group in two offices and then you work with the G P O. So how would people reach you if they wanted to?

[00:46:07] Andy: , I actually don't work for the G P O. Okay. , practice Well is a, is a large community of healthcare providers, which is where I'm at. I have conversations like this. I talk to people. We do happen to have a G P O attached to practice, well it's called pbg.

And we did that for a variety of reasons. So it started out actually as a G P O, it was actually called Pediatric Federation that started 25, 27 years ago. It was probably one of the first organizations to take the G P O model and apply it to vaccines. That pediatric federation organization, which was started by about 40 physicians in the San Francisco Bay Area, all pediatricians in the I would say probably eighties that organization was really formed to help pediatricians just deal with managed care and deal with the ideas that the healthcare industry was changing and just how do we practice better.

One of the things that came out of that was probably one of the first vaccine GPOs in the country over the last 20 years, those two, because of regulations and because of the, desire to provide both the community aspect and the education aspect and the support. Kind of split the two one into the G P O P B G and then one into the community.

So I'm more on the practice well side. We do have people that are hyper-focused , on contracting with vaccines and reimbursement and having constant conversations with the manufacturers about what's going on. So that's the, that's the group that I'm most familiar with. And I would say one of the, the key things about the Practice Well organization as well as PBG is they're both, don't have any profit.

It's been very physician focused, is made by physicians for people just like you. It's process because it doesn't need to make any money. It gives back very massive amounts of rebates. So we're all in this together. We all are in the trenches. You know, here in the tech world, they used to call it eat your own dog food.

I prefer to drink your own champagne. But the problems that you guys are, you know the problems that you are, experiencing is the same problems that we have all over the country as people who work in practices. And so having a G P O that can negotiate and kind of fight for us on our behalf for lowering pricing, helping our margins, allowing the doctors to have the choice between saying I might spend a little bit more on this, but it's the product I want to use.

And getting people set up so that they can provide the best amount of care is really the goal of all of those organizations still have like a dashboard that shows physicians you're saving by using this product. You're getting this much, because I know with a lot of You know, GPOs and stuff, they just send you a check at the end of the year and say, Hey, you saved, here's $5,000 for your troubles.

Sure, yeah. What it's from, you dunno where it's from. We get, we, we do get statements and we do provide statements. So from the practice side, every time rebates are roed and earned you know, actually we just go to the Practice Wealth website. We have our bank account in there and they deposit it and then a statement comes saying like, Hey, this is what you spent on your products and services through this G P O broken down, it's actually part of the requirements of the law.

So hopefully everybody should be getting those. And in terms of savings, it's actually very difficult because as I think Herb was saying, you know, the reimbursements in the San Francisco Bay area are gonna be much higher because of our fixed costs in there. You know, our, our employment costs are higher, our rent costs are higher, so, you know, based off of our, our value units, we're gonna be a little bit higher.

 I do love the fact that you're using Tableau full disclosure. My wife does work for Salesforce and Tableau is a Salesforce product, but I do like that you have gone so far and plugged in your values. I mean, if you've got a good solution, I would love to extrapolate that across to, you know, the 20, 30,000 physicians that are part of practice well in PVG right now.

 I agree. Like I'm all about putting more information out there at the fingertips. I think I've heard it a couple times, data is king, helps make decision. And to 

[00:50:52] Dr. Bravo: To George's point is. And your point there's too many thoughts, but first of all, I'm gonna start with we need to learn from other industries.

So in every other industry, they are coaches that keep you accountable and drive change through your organization. It doesn't matter if you're c e o of a 500 company, they got coaches. You are a real estate broker. They got coaches. You are, you are a wife of a doctor that plays at the country club, tennis.

They got coaches. Because someone else watching you hit the tennis ball, gives them another perspective and they can change your behavior so that you're more successful when and I love Chip hard. I think he's one of the most phenomenally intelligent people in our industry, but. He's a data on nerd.

Yeah. Mm. I can hear he dumps reams of spreadsheets and I'm pretty good with spreadsheets, but I get a headache. And the busy physician managing a practice needs tableau because they need to visualize that data quickly. They can't be going through a bunch of data in spreadsheets. They don't, their mind doesn't work like that.

They're tired at the end of the day. They, they're not Chip hart. Yeah. You know, it's, it's a different skillset, right. It's, you know, I don't think Chip could see any ear infection, but, but you know, we all have our talents. So if, if it's not visualized, the data's not visualized, which is what you were saying.

If you can't drive the data to the person that needs to put together the quality, what's best for the community, what's best for the practice, quickly make a decision. It it's trash. That's where, where we're, that's where the disconnect is. So we have built this dashboard. I, I don't think it's ready for prime time, but anytime you wanna a Zoom call with us, I'll show you what we've 

[00:52:51] Andy: done.

Yeah. It's probably it, the, the complication of doing that across multiple different types of practices is like the standardization. So somebody's on, on pcc they get one set of reports. Somebody's on op, you're, you're, 

[00:53:09] Dr. Bravo: you're talking like a pediatrician. That is not true. Not in Tableau. Because as long as you give me the spreadsheet for your ar for your practice , in the same columns as all the other practices, give it to me.

I can upload it in less than 30 seconds. Yeah, you get pretty pictures. Alright. If you give me your re, you know, your c p T codes with the reimbursement, the provider, the diagnosis, and the, the columns have to be exactly the same, but beyond that it's just the dump into a file folder and the numbers pop up.

Yep. But what I wanted to ask more is, I'm all confused about practice. Well practice well is the community okay? Right. And so you work with practice well to help the community of independent pediatricians and they do aggregation more than just the vaccine. If someone, so if someone wanted to reach out to you at practice, well where would they find you?

[00:54:12] Andy: Practice well.org is probably the best place. We have our phone on there too. You can just email me. I have an Andrew at practice, well, another person I work with, Joey, who is also steeped in pediatrics Joey at Practice Well and together we've been doing this for, I think he's been doing it for almost 10, 15 years as well.

So those are probably the two main contacts. And then if you have questions about anything, it doesn't necessarily need to be about vaccines. We've probably heard it and there's, and 

[00:54:46] Dr. Bravo: is there a cost of joining the community? Oh, oh, no. 

[00:54:48] Andy: Oh, no, no. Definitely not. I just 

[00:54:51] Dr. Bravo: go in there, put my name, my email, and I'm part of the community and exactly.

I can reach out to people in that community. Okay. You 

[00:54:59] Andy: can, you can, you can reach out. Actually most people go to the, to our website to kind of explore all the benefits of membership. You know, we have call em cards up there that say, oh, hey, I'm interested in what's the you know, compliance, I gotta figure out how to organize my employee handbook.

You know, we'll have some, some resources or some people to do it. You know, there are, there are organizations out there that do that. Or, you know, I would say most people are coming in to figure out about vaccines, what to use, because that is such a cost and always on the top of people's minds. But yeah, me.

So, so I 

[00:55:36] Dr. Bravo: wanted to join this community. I'd just go to practice, well.org.com. Dot 

[00:55:40] Andy: org. Cause it's, you can go to.com, but it'll, it'll rotate you over to, to, okay. It'll just, cause 

[00:55:45] Dr. Bravo: it's a not-for-profit entity, so it's a top. Okay. Yeah. And then if I wanted to figure out, you know you know, by the end of the fiscal year, what the G P O could do for their vaccines.

Who, where would I go for that? 

[00:56:02] Andy: Just give us a call actually, is what most people will do. Or you can you know, reach out to us through our chat. And it really depends on how you're 

[00:56:11] Dr. Bravo: prac again at, at practice. Well, I would go at practice. Well, yeah. So I just go one place for both. Mm-hmm. And I would say, I wanna know what, you know, I could do with you guys.

Mm-hmm. And then someone would reach out and ask for my C p t analysis to see Yeah. Where we're at. 

[00:56:28] Andy: Okay. Yeah. We, we, I think that what I think Kathy would be the one that was doing it and she'd be you know, if you guys do need help with that, she has some spreadsheets that she can send you over that you can plug in and do your own analysis.

Or if you wanna just supply us with with an output. Of your practice management systems reports, then we'll go ahead and plug that in for you. Yeah. 

[00:56:49] Dr. Bravo: And so, and that again is a free consultation. Yeah. Yeah. So I give you my data and you say, we could save you money and we can't save you money. Yeah. 

[00:57:01] Andy: And then I've, I've never seen it not save money.

[00:57:03] Dr. Bravo: And then there's also a differentiator, right, which is relationships. Practice well as G P O might be able to save me a thousand dollars a year, but I've been doing business with Joe for 10 years and their relationship is worth a thousand dollars. You know, so sometimes service and relationships will make a difference if a difference in, in savings is not phenomenal.

Right. 

[00:57:26] Andy: Well, I don't think you would need to end, end your relationship with Joe. It's not like you have a different method of procuring whatever you are procuring. So you'd still work with Joe. So if Joe was your. Merck rep, or I don't know, your rep. Just say you 

[00:57:43] Dr. Bravo: just as a competitor gpo.

[00:57:45] Andy: Competitor gpo. Oh, another G P O. Yeah. If you have a good relationship, y you know, honestly, to us the most important thing is that you are on A G P O. Okay. Because we want you guys to succeed. We need everybody to practice the best medicine they can. And being on A G P O, even if it's not the most optimized, is the best start.

I still talk to practices across the country out there that are way overpaying for vaccines and other services by not being on A G P O or perhaps their rep from a distributor puts them on a G P O but not the right one because they've been incentivized in a different way. So that is a very quick low hanging fruit that you can change around the, you know, the GPOs out there, the big ones that are available on the physician buying group side is fairly close.

However, it's all gonna boil down to that rebate. Everybody's gonna have to pay for people and pay for things and pay for, for their stakeholders, shareholders, private equity, whoever's banking, all of that. So that's why I think we have a little bit of an advantage within practice well, is that any funds that are unused go back to the provider or whoever bought those particular products and services in the form of a rebate, which you can use.

So 

[00:59:06] Dr. Bravo: now what if hold 

[00:59:07] Andy: on, herb. What if somebody already uses a product or a service that's on practice? Well, and then they sign up with practice. Well, do they automatically get a discount or, mm-hmm. 

[00:59:18] Dr. Bravo: Yeah, 

[00:59:19] Andy: yeah. Discount. And I would say on the practice file platform, if we're looking through all of the benefits that are offered on there mm-hmm.

Almost all of them earn rebates. I would say there's two or three categories of benefits on the practice file platform that can't due to legalities. And those are usually around the hr benefit, so like your, your health insurance for your employees can't earn rebates. , it's an illegal thing that was established by the the insurance commissions of each state.

So, yeah. But everything else earns rebates and you know, I would say new benefits are being added onto that platform across of 'em, some of 'em GPO style, some of them I know that they're working on other products and services out there that are geared specifically for the healthcare professionals.

So it's not just for your practice, it's also for the people that work at your practice. So your receptionist to your MAs, to your advice nurse, can also benefit from being practice well members. So I think those are gonna be launched here in the next couple months. , is 

[01:00:25] Dr. Bravo: there a a point where someone is a practice?

If a small practice is better served by a company like Canid that buys your vaccines, they negotiate a price and you know you don't have to manage the cash flow it. 

[01:00:43] Andy: From the analysis that we, we've done as a practice that I've done as a practice, you lose a lot of the margin and it's already pretty thin.

So they would have to be doing a lot of services to make up for that. 

[01:00:57] Dr. Bravo: So I'm just gonna interrupt you for a second. Can, doesn't take the admin fee. They just take, they, they just wanna function like a humongous G P O and take that, that management hassle out of your hands. And then when I'm thinking about this, I'm thinking about the solo practitioners.

There's still some solo practitioners out mm-hmm. That are 70% Medicaid, which means that they're buying such a small amount of vaccines. That there's really very little margin for them. It's just the headache of contracting and doing it all. And if they can focus that time on something else and make their practice better, yes.

And better you know, if you're losing $3,000 a year and someone else is managing my $50,000 in, in vaccine inventory mm-hmm. Take 

[01:01:50] Andy: it for sure. I do see that. I see that happening in a couple situations. So in the more of the concierge scene where you know, insurance billing may not be an option as well as possibly where you wouldn't use an entire box of a particular vaccine.

You have to buy a box at 10 because they only sell 'em at a box at 10, but you only give, you know, six the course of the year. So those situations I think are great situations for that. But I'm, I'm not personally very familiar with that. I am, you know, I've gone from two to 10 doctors and I think that's kind of the, the sweet spot that we're, so I think when 

[01:02:34] Dr. Bravo: you're, when you're, you know, 5, 10, 20, 30 providers, it's worth your time to manage this.

But when you're a small practice and 75, 80% is Medicaid you're making very little out of that. 

[01:02:47] Andy: Yeah. Tax 

[01:02:48] Dr. Bravo: and it's, it's distracting. It's just one more thing you have to deal with. It's, to your point earlier for physicians to lead their organizations, the data has to be clear and quick so they can go back into the exam room and do what they want to do, which is take care of kids.

Correct. Yeah. 

[01:03:07] Andy: Right. That's, that's the end. Our, our unofficial model motto at practice well is being able to walk into your practice and practice medicine. You know, that's, that's the goal that this whole group was formed around, you know, and it's getting harder and harder to do that every month, every year.

You know, there's geographic issues. Like I know at our practice we tend to train our staff really well, and then they go and get taken away by people who can pay 'em a lot more money because they are Stanford or some other large hospital system. So, 

[01:03:45] Dr. Bravo: Everybody has that problem. And that problem's been around for 15 years or 20 years.

 And unfortunately when the economy tanks, it's great for the medical practice cuz you got really smart college aged students who can't find jobs and they're show up on time, they're eager to work. Mm-hmm. And when the economy heats up and unemployment's low, it's tremendously harder to find entry level people to run your business.

And we are a people business both we take care of people and we employ people to take care of people. So it makes it very difficult. What else do you want to share with our audience that I haven't asked you? And I could, I could talk to you for another couple 

[01:04:26] Andy: hours. Yeah. Well, first of all, thank you guys for all that you do.

And you know, I do have a deep respect for all of the pediatricians and, you know, really looking at the sacrifice that goes on to, to deliver the care. So that's one thing that I appreciate and I've definitely come to appreciate over the last, you know, 10, 20 years is just how much effort goes into providing it and, you know, how much sacrifice goes on.

So first of all, thank you for doing that. The the other stuff I feel like these problems are solvable and I think It's just how do we come up with those solutions and get 'em out there so people can remain independent, can have the. The life that they, dreamed about when they were going through medical school.

Getting more people into primary care and pediatrics and those are my goals, I think, in the situation. And I think that's kind of what we represent from both our practice, from the efforts that we're putting forth at practice well at pvg. Mm-hmm. Is really, you know, that's the focus.

How do we keep our population healthy? How do we, you know, move forward with this to the best of our ability? 

[01:05:41] Dr. Bravo: I feel it's gotten a lot easier to manage a practice. Oh, definitely. Because automation has helped and now I can get the reports I need to see where things are headed.

Mm-hmm. You know, I can't remember who we were talking to that I used Medisoft back in 2000 and it could only print reports. There was no comma delineated reports coming out of my billing system. So then you had to type it into a spreadsheet to run the numbers, to calculate, you know, your days in ar .

I'm like, well, how's this possible that I can't get a spreadsheet out of the, my billing software? Well, you couldn't. Yeah. At least today we get reports and we can run numbers and, you know, we can see the gaps and then we can make it different. 

[01:06:31] Andy: Now you have information overload. 

[01:06:33] Dr. Bravo: Well, that is, that is true.

This has been wonderful. Yeah. Well your dad has done a great job 

[01:06:39] Andy: raising a great man. Wow. Thank you. And I'll tell him he'll be watching this one whenever it comes out on, hopefully in the next couple days. We like you. We'll make 

[01:06:47] Dr. Bravo: it come out quick. I'll do my best to get it out soon. And thank you for your time.

And anytime you want, we'll show you the dashboard. Just 

[01:06:54] Andy: let me know. Yeah, I'm, I'm very interested in, I probably know three or four more people that would love to, to figure it out and, and. Like I said, make, make this product available or make the template available. You know, get it out there so people can start making those good decisions.