Orthobiologics: Ethical Questions You Should Not Ignore | Conversations in Regen Episode 10

These are the ethical questions you should not ignore if you care about better patient outcomes.

Withholding orthobiologics is unethical → Visit My Website https://pxl.to/AD/tq8nuql

Are we unintentionally limiting patient access to life-changing care? Should regenerative treatments like orthobiologics remain cash-only? What happens when financial bias influences medical recommendations? In this in-depth discussion with Dr. Michael Khadavi, I explore the ethical questions you should not ignore in orthobiologic medicine and regenerative medicine. From the real-world challenges of PRP therapy and orthobiologics injections, to navigating PRP insurance coverage, we uncover how physicians can ethically integrate advanced treatments into a cash based medical practice without sacrificing accessibility or clinical integrity. You’ll hear our personal experiences transitioning from insurance-based models to cash based healthcare, weighing cash pay vs insurance, and how running a medical practice in today’s climate requires balancing innovation, patient needs, and profitability. Whether you’re building a medical practice from scratch or looking for ways on how to improve your medical practice, this conversation offers insight into orthopedic innovations, the realities of orthopedic medical services, and the business strategies that can help you thrive in a competitive healthcare landscape.

In this episode, you’ll discover how patient perception, value-based decision-making, and transparency shape success in a cash based medical clinic. We tackle the controversy of whether cash pay medical services shut out the average patient, and why we believe it’s unethical to withhold effective orthobiologics treatments simply because insurance won’t cover them. Through examples from my orthopedic medical practice, we discuss the surprising demographics that say “yes” to self-pay procedures and the practical systems for offering orthobiologics injections to all patients without making assumptions about their financial capability. You’ll also hear our strategies for ensuring clinical quality when scaling services—whether through physician extenders, leveraging AI for efficiency, or creating fellowship-level training to maintain standards in this fast-evolving field.

We also dive into the future of regenerative medicine, why orthopedic innovations like PRP therapy could be first-line treatments in the coming years, and how transparency in pricing can differentiate your orthopedic medical practice in a crowded market. You’ll gain a behind-the-scenes look at the mindset shifts required for building a cash based healthcare model that prioritizes patient autonomy while sustaining a profitable practice. This conversation is for any physician, practice manager, or healthcare entrepreneur who wants to lead the way in ethical, effective, and financially sound orthopedic medical services.

If you’re ready to rethink the way you approach orthobiologic medicine and regenerative care, this discussion will give you actionable ideas you can implement immediately. Watch until the end for tips on patient communication, overcoming business roadblocks, and creating systems that allow you to serve more people at a higher level. Connect with me to continue the conversation—leave a comment with your thoughts, like this episode, subscribe for more in-depth discussions, and explore the rest of my channel for strategies on running and improving your medical practice. Let’s keep pushing the boundaries of what’s possible in orthopedic innovations and cash pay medical services.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

_______________________________________________________

Follow us and subscribe to our links below ⏬⏬⏬

Website: businessoforthobiologics.com
Apple Podcast: apple.co/3Azvt3R
Spotify: spoti.fi/3oICYmh
Youtube: bit.ly/drariana

Transcript

SPEAKER_01 0:00

One of the things we can do is just be really transparent.

SPEAKER_00 0:03

I go so far to say, and I say this with every bit of genuine bottom of my heart belief that it is unethical to not offer orthobiologic in a situation that it could be beneficial.

SPEAKER_01 0:17

People always say the medical system is broken, but I don't believe it's broken at all. It is performing exactly as it was designed. He is a board certified sports medicine and physical medicine and rehabilitation specialist. I took this from his LinkedIn. He's a fellowship director, lifelong learner, and standard on giants' shoulders, which is one of my favorites. I love that. He's Stanford trained sports medicine physician and from Overland Park, Kansas. He is a leader in sports medicine. He's a national educator and consultant. And he is currently heading the charge with the Toby conference that's coming up in about four weeks. So if you have not registered, please, please register. It is a massively important conversation that you can't afford to miss. And he is really passionate about providing innovative care for his community members and professional athletes. All right, so for those of you who don't know me, I'm Dr. Ariana Demers. I'm a board certified fellowship trained sports medicine orthopedic surgeon and passionate about regenerative medicine. I love to teach and train in orthoson guided training as well as orthobiologics. Those of you who have nothing to do this weekend, I'm going to be teaching at Orthosono. So if you would need a touch-up on your ultrasonography and Orthosono in Las Vegas is one of my favorite courses. It's a two and a half day regenerative medicine and ultrasound training course. So if you haven't ever been, you should go. It's the www.orthosono.com. No, I don't get any royalties, but it is a good time. So if you're looking for a touch up or you're just beginning, that is the place to really bring your skills to the next level. Of note, I have been successful in moving my rural practice. I live in rural California, a town of 20,000 away from insurance-based care, and I focus on cash-based procedures in the office. So the biggest passion that I have is helping other physicians incorporate orthobiologics seamlessly into their practices because I do think this is the future, and I want to help all physicians be able to provide these services. So I really appreciate everyone joining us. This has been great, and really, this is an exciting time. This is a fireside chat. This is, you know, off the record, if you will. And we get to explore some controversial topics in both orthobiologics, regenerative medicine, ultrasound, and then hopefully gain some insights that you can implement in your practice immediately. And of course, we'll have a live QA session as well. So my belief is that orthobiologic treatments will be first line treatment for musculoskeletal care in the next five years. First line. And no, it's not going to get rid of all of the surgeries. That's not going to happen. It's a continuum of care, right? From rehabilitation through orthobiologics. And then finally, when everything has failed, if everything fails, surgical intervention. And really, I want to bring everybody's attention that it's not the same pie. And so everybody is very worried about their piece of the pie. Oh, you know, if so-and-so does these treatments, it's gonna take my patients away from me. And really honestly, there's plenty to go around. And so this just allows us to treat our patients where they're at and serve our patients better with less invasive care, more natural options. So successful integration is sometimes difficult, right? How many of you have said, I want to add orthobiologics to my practice, but maybe I don't know the science. Maybe I don't know the technique. How am I successful? Maybe you've tried some things and it hasn't gone as well as you would have liked. Maybe you've tried a little bit of marketing and your return on investment was zero. Maybe you feel weird talking about money and you're like, I'm not a salesperson. I don't know anything about sales that didn't go to business school. And maybe you just thought, well, I'm just not good at business. And that may or may not be true, but it's not your fault. We didn't learn this in school. And maybe some of you are struggling with how that you know that this orthobiologics is the way to go, but how to be successful at it, right? And this is a $4 billion orthobiologics market out there. How do we capture part of that and capitalize on that market to bring that to our patients? Maybe some people are thinking we deserve more. Why is this so darn hard? So if you are struggling with the business piece, just pop in the chat what it you guys think is the hardest part of the business. You know, sometimes it's abdicating control to others, right? We're all kind of control freaks. Sometimes it's that, you know, we want to put our head in the sand and we don't want to talk about the money. But money's just money. What we think about it is a whole different ballgame. So, how do we win at this, right? Everybody likes to win. So, how do we win at this? We we need a system. And this is my system that I have created, and we're not gonna go over this, but we are gonna get you a little further down this journey to be wildly successful, and we're gonna talk a little bit about that or the biologics knowledge, and maybe a little bit about cash practice. So, we do need a system, and we are gonna get started today. So, Mike, let's get down to business. And I have some questions for you. Okay, so lots of people talk about the fact that this is a cash-only business. And the question is, is cash-only orthobiologics model shutting out the average patient?

SPEAKER_00 7:43

First, I need to formally say thanks for having me here. I would have, if I knew what was involved in orthobiologics in these questions you have right here 10 years ago, I would have paid my weight in gold to get the answers that are in your podcasts. Oh am I. So getting to this first questions, the average patient, no. That's an easy question. And if you don't mind me just talking a little more here, yes, please. Most people think about this in terms of who can afford a cash-based treatment. And in in my experience, and when I talk to anyone else, that's not it's really hard to predict who is willing to pay a thousand or six thousand or whatever depending on what the procedure is and how much the cost is. People have different values, and some people will spend their money on one thing, some will spend their money on something else. And so I I always caution physicians not to make a judgment on who might be interested in paying whatever big or small cash-based bill, offer it to everyone, and I offer it in a 20 or 30 second bit that just explains what it is, very briefly explains the upsides and downsides, and I know what the dollar sign is. I'm not gonna be shy about it, but it's I go over all that stuff, but it's very expensive. This is the cost, and then at that point, what happens is the patients weed themselves out if they're not interested. Oh, that that's not that's not in my next year for expenses, or you know, tell me more.

SPEAKER_01 9:33

Yeah, that's so interesting. So you and I have I I have some things to learn from you because in my consultation, I'm sure everyone has heard me say that my consultation takes 36 minutes, whether I like it or not. It takes a long time for me to thoroughly clarify and talk about what the best options and what all of the options are for a given diagnosis or diagnoses. And so, you know, you probably have noticed that I talk fast. And so I'm talking pretty quickly about these things, and I swear, like clockwork, 36 minutes, whether I like it or not. So your 30-second blurb, man, I maybe need to pare it down a little bit.

SPEAKER_00 10:20

Well, the two the two patients who are the fastest visits, and I don't pride myself on speed either, but the two who are the quickest are the ones who say no, absolutely not, not interested, no way, and then the ones who say, I don't want surgery and I don't want cortisone. So, whatever you I trust you, my best friend, my physical therapist, whoever recommended me to you, whatever you really recommend, treat me like your sister. And and that's easy too. I still, of course, go through the necessary informed consent. They need to know what they're getting into and why I recommend it. And of course, I still briefly go over well, this is what's involved in a cuff repair, this is what's involved in a knee replacement, this is why I'm not excited about putting steroid in your joint.

SPEAKER_01 11:08

Don't miss out. Please subscribe to our newsletter now to stay ahead of the world of orthobiologics. You can find the link below. Additionally, if you're ready to start this journey with me in my orthobiologics masterclass, come join us. Right. Yeah. Man, I tell you what, being very unexcited about steroids is you know a growing experience these days. The more science that comes out regarding the detriments of cortisone, I have probably decreased my use of cortisone by about 95-98% in the last six to eight years. You y'all have to remember, I grew up in orthopedics, right? Where cortisone was used for everything. If you had a joint that could take cortisone, by all means, we had to put it in there. So I use cortisone across the board, like it was going out of style. And really, I have shifted that probably 98%. I use it in a very, very, very small subset of my patients. But yeah, I think talking about it takes a while. And you're right, the ones are like, hey, I want the thing that you do. And you're like, oh, okay, I want this. Here's the thing. They're like, great, I don't care how much it costs, ready, go. And you're like, oh, perfect. But yeah, I would agree that it is not shutting out the average patient. And what I would say to patients and to physicians specifically is in my town, and it's legitimately a town, the median income is 33,000. And yet I have been able to do very well in providing these patients with cash-based orthobiologic services year over year over year over year. And what you said to begin with is it's all about value, right? And these people can't afford not to work, right? And so they're looking for these options to that where they don't have to take downtime, they don't have to be sidelined. And if we now have something that the outcomes are approaching surgical benefit, like, man, okay, we'll we'll we'll try that a hundred times out of a hundred. So yeah, I I think that for the working class, I think this is actually a better option. And I always, you know, they always ask me, like, well, why didn't anyone else tell me about this? I'm like, well, that's a whole nother ball game.

SPEAKER_00 13:49

But I I go so far to say, and I say this with every bit of genuine bottom of my heart belief that it is unethical to not offer ortho biologic in a situation that it could be beneficial.

SPEAKER_01 14:07

Yeah. I I, you know, you and I agree. We're right, we're we're having a little conversation with some uh publications, but ultimately I agree. I think it is unethical. And really, when we get tripped up about money, I think the the thought process that I lend physicians is, and you can say it even out loud, if everything was free, this is what I would recommend as your best option. And leave it at that. You don't have to talk about the money, you don't have to even give them a dollar amount, but what you can do is recommend what you think would be the best option. And the other thing is like if I was me or if it was my family, what would I recommend for them? Well, and I always joke because I do pay my parents in PRP when they come and visit and they've watched my my kid, they're like, hey, can we get the the thing? That's really been helpful for me. But yeah, that's that I think that's a great question and a great answer, which is no, we're not shutting out the average patient. I think this is the perfect option for the average patient.

SPEAKER_00 15:19

So if we are I agree with everything you just said. So if we if we're not shutting out the rich and we're not shutting out the middle class, I would argue we're not shutting out the lower income either. There are so many situations that I've had where the family puts together their income because so-and-so can't get surgery, or they firm someone else in their family had bad outcome, complication with the knee replacement, a friend of theirs had a bad outcome with a rotator cuff repair, and they they firmly want to avoid that, but at the same time, they want their family member to be better, and they pull resources and they make it happen, and those are so I don't rule out anybody, I give the same spiel no matter what I might guess that their income might be.

SPEAKER_01 16:18

Yeah, you know, I've been surprised. I recently shared an experience where I'm a bit uh embarrassed to say that I made a snap judgment on one of my patients, and I was like, okay, well, I'm gonna offer her PRP because of like the cellular is probably out of their price range. And so I went through this whole thing and and really she needed an intra-osseus BMC treatment, right? And she had self-selected, she didn't want surgery. She she was like, I can't have surgery, I'm not having surgery. I absolutely not. And so I'm offering this thing, and I was like, biting the bullet. Well, I'm like, but everything, if everything was free, you know, I'd recommend this. So like, well, why can't we have that then? I was like, ah, I'm such a jerk. Because I have biased, and I'm now going to offer that to you. But man, this is what I do, and I talk to everybody that comes in my clinic is coming looking for this, and yet I still get stuck in my biases sometimes. So you're right, offering it to everybody. So we still have questions, Nike. Should this access be democratized instead of reserving it for those who can afford it? Meaning maybe it should be covered by insurance. What say you?

SPEAKER_00 17:46

Yeah, what an awesome and loaded topic. I mean, this is they can go on for days with this one because first off, you know, in an ideal world, yeah, everything would be free for everybody: food, transportation, healthcare, and certainly our healthcare system is imperfect, far from perfect, and I am far from having the right answers for that. But yes, in an ideal world, everyone would be able to afford this. It is simply healthier for a knee joint to put PRP or for or intraosseous, if appropriate. My favorite treatment that I do. Uh simply healthier to do that than really anything else we could put in the joint or do to the joint. So we get to some really challenging practical questions though. Uh if insurance company pays the same rate to everybody, uh what's uh who's gonna cut corners? Who's gonna count their platelets? Who's gonna use a centrifuge that has fewer platelets? Who's gonna use ultrasound guidance? Who's gonna take the time and care to really do the full history and exam and imaging and have that full discussion of what is the best treatment? This is where I'm gonna put the platelets. Let's just talk platelets here. Am I putting them in your joint? Am I putting them in your patellar tenum? Am I putting them in your baker's cyst, your degenerative meniscus? And right now I have to say it's nice having the luxury uh in the cash-based orthobiologic model that I'm in, where I don't have to think of any of those things. I have one goal with my patients, which is to get them better as best as I can. And whatever the treatment is, that's gonna get them the most better. That's what I choose. I know that's certainly what Dr. Demers chooses. And we get a lot of there are a lot of challenges that come up with this discussion. Innovation is not cheap. It's certainly not cheap. And if you know, if you just pick a number, if someone said, Well, I'm gonna pay 800 bucks for PRP, my PRP cost is a little more than that, and I know at $800 I could not break even actually doing having the full lab, having the ultrasound, ultrasounds that I have, having the space, the staff that I have, my staff I've trained, my lead athletic trainer has been with me for eight years, and I've sent him to orthobiologic courses with me. He could probably give this spiel and podcast as well as I could. And these things aren't cheap. And so that there's there are too many corners to risk cutting if we just assigned a blanket dollar amount.

SPEAKER_01 20:40

Yeah, it's super, super insightful. I and I agree, and I haven't thought of that in that exact framework. I'm maybe a little bit more negative, Nancy, because you know, when patients ask me when it's gonna be covered by insurance, I tell them, gosh, I hope it's never gonna be covered, because then someone else besides you and me get to decide whether this is the right treatment for you. And we have not benefited, both patients and physicians have not benefited from the medical system. People always say the medical system is broken, but I don't believe it's broken at all. It is performing exactly as it was designed. It was designed to make money. The problem was it wasn't designed for doctors or patients. And so unfortunately, the patients and the doctors get left out in the cold and they don't, they're not part of the conversation. And so I agree that currently, as insurance companies are, especially the for-profit insurance companies, I think it's a bad idea to have it be covered. And I think that from a price standpoint, you're right. $800 doesn't cut the mustard. I tell my patients, When I'm seeing them under their Medicare benefits, listen, this is a money-losing proposition. The fact that I can spend time with you is a luxury that I have built into the other part of my practice. And we are subsidizing this current visit. And your insurance company doesn't value this option enough to cover it, regardless of what you think. That's why it's outside the system. So yeah, really interesting framework. And I think I know a number of our colleagues have taken it upon themselves to quote democratize it, meaning you can choose to give it away for free for or have a scholarship fund. That's what I do. I I allow my other patients to pay it forward to those who may not have the means. I ask them if they want to round up. And they're a great idea.

SPEAKER_00 22:57

That's such a good idea.

SPEAKER_01 22:58

Yeah, right? Like, and some of them round up like a couple of cents and some round up a couple thousand. And you know, it's like, hey man, you know, whatever is right for you to pay it forward to patients that may not have the opportunity to have this treatment, we would just request that you round up to whatever dollar amount you think is correct. And, you know, if they're like, oh gosh, can't do that, no problem. We just want to offer that ability for someone else for our scholarship. So that's another way to do it. And sometimes I think I've heard it that money can sometimes help with impact, right? And so if you charge appropriately, you then are able to multiply your impact because of it. So we are not quite done here, Mike. We have more questions. So here's my question: Are physicians going cash-based for patient care or prof for profit margins?

SPEAKER_00 24:04

I'm not sure that they're mutually exclusive options.

SPEAKER_01 24:08

No, I set you up.

SPEAKER_00 24:09

Yeah, I know, I know what you're doing. And the thing with profit margins and patient care is innovation really should be rewarded. And I certainly like to think of myself as an innovator in how I use my PRP systems and my protocols and my rehab protocols and all of these things. And I'm not in the most lucrative practice in the country, but certainly it pays the bills. And I have the luxury in this model of having one priority. I have one priority, and it's patient care. And if I have to spend longer with somebody, so be it. There are certainly patients of yours, Ariana, and mine who have definitely not been a net positive from the financial side, but we take good care of these people and they get better. Now I will say there are always these hawks out there who are not really in it for the right reasons. And that's another reason. I going back to the last question, that's another if there was a flat price for PRP and it was covered by all insurances, well, we know people are gonna cut corners, we know people are gonna throw real patient care out the window, and they're gonna just turn it into a mass production orthobiologics factory. Everyone fits a certain cookie-cutter size and shape. And so right now we just have this luxury of really being able to focus on patient care. I know in Kansas City there have been Kansas City's my home, there have been several national or wannabe national companies come in with franchises, and I know everyone's heard of QC Kinetics. There have been several others that come in, and it's very obvious what their goals are. The patients are not seen by a physician, let alone a subspecialty orthopedic musculoskeletal physician, and some of the treatments just don't even make sense. They'll sometimes, I don't know if you know a lie implies knowing that they're telling an untruth, but they're telling untruths regularly about allographs, about PRP, about whatever their plasma treatments are. And those companies generally are run by businessmen and not physicians, but certainly there are physicians out there who are just after their profit margin and they're not doing all the so I think this is an even more complex question because while for the most part most of us physicians are doing the right thing and hopefully they're getting paid for their work, there are certainly some bad eggs that we just have to watch after, watch out for. And if someone finds a good way to police ourselves, then that's should also be an obligation of ours.

SPEAKER_01 27:15

Yeah, honestly, Mike, I 100% agree that it's not mutually exclusive. And I would go so far as to point out that there are a number of professional services that it is 100% acceptable to charge money. And if you're really good at it, you charge more money. If you think of an amazing lawyer, oh, totally worth it. I paid 10 times what I pay for the you know, Joe guy down the street. That's acceptable, that's expected, right? You get what you pay for, and ultimately it's unclear how we got so far off the track because we are professionals just like every other professional service, right? And yet we are held to a different standard. We are expected to not talk about money, we are expected to not really work for money, we're expected to give it away for free and live like paupers and not make money for all of the things that we know and have sacrificed years and years and years and years and years and years and years of our lives to attain that knowledge. And so there is a break in that system. And I'll be interested to see, you know, there is the, you know, my husband is a physician as well, and he's part of the hospital board, and he's an OBGYN, right? And so these some of these new cuts are really concerning for certain specialties. And he was like, Well, hopefully we'll be okay because we're rural and we're underserved for you know, but maybe not, it's hard to say. But it's like, well, yeah, how is it that we are somehow not allowed to charge for our services?

SPEAKER_00 29:18

Here's a question. And of course, it's the logic that is the most interesting here, but let's say you charge $2,000 for a certain orthobiologic procedure, and guy down the road charges $8,000 for the exact, let's just say it's the exact same thing. Let's just say he has the brains to think through and be thoughtful with his indications, have that conversation with the patient that has the heme analyzer, has ultrasound, let's say it's your clone down the what are your thoughts on the morals ethics behind behind that?

SPEAKER_01 29:54

Yeah, interesting. And the other piece of that is the psychology of how people's thought processes go with that. Because pricing and the cost of things somehow conveys quality, right? And so when you go on Amazon and you search a thing and you're like, okay, well, I never want to buy the cheap one because there's something wrong with it. And you buy like the middle or the middle good one, unless you're like, no, I want the best of the best. This can't fail. I want the top of the top. And then you're like, actually, I'm gonna go to the website and buy it. If that's the top of the top, I'm not gonna get it on Amazon. I'm gonna go to a website and buy it and know that it's backed with a guarantee and I'm getting the exact thing and I'm willing to pay for it. My friend Dr. McGee always talks about the Stella Artois conversation, the advertisement says it's reassuringly expensive. And it's like, oh my goodness, that's so true though. Because if you see a BMW for sale for, you know, five grand, you're thinking, hmm, there's something wrong with this picture, right? Because that's not the actual value. And so the race to the bottom, when people are calling, they're like, well, how much do you charge for PRP? Or how you know it's like, well, first of all, we don't charge for PRP, we charge for a treatment, and this is a physician, and this is what we do. But the race to the bottom starts to talk about what people can perceive as quality or lack thereof. So there's so much when it comes to pricing, when it comes to quality, when it comes to value regarding profit margins, regarding patient care. And I agree it's not mutually exclusive at all. I gotta pay my people to take good care of my patients, I gotta have profit margins, or I hate I can't run on nothing. Belling bar and duct tape ain't gonna get it done.

SPEAKER_00 31:56

Yeah, I agree with everything you just said, and uh, it's just interesting in the insurance world how a small or even medium-sized private practice, if I go do a knee injection, let's say a 99203 new patient and then a knee injection, I might get paid a third of what someone at the big hospital down the road that would for the exact same service. So this is kind of the great equalizer, it really is. And on that same topic, I have the exact same thoughts and feelings that Dr. Ariana Demurs has, which means I must be thinking correctly here. We live in a world where patients doctor shop happens, they can make their own choices. What is wrong? To me, there is a big line between being truthful and transparent, and the other side of that line where you're hiding or providing the wrong information, incorrect information. And as long as you're being transparent and truthful, then pricing is ethical, completely ethical. They know what they're getting into, they know what the product is, and again, the product is not just what you're squirting in with a needle, the product is it's the whole package, it's the rapport that you develop with them, it's the counseling session, it's the indications. What are the indications you're doing this for? And then, of course, it's the actual injection itself, the rehab protocol, the recovery, your availability with them in the next several months. So, pricing, I I personally I will I'll go down in flames on this one. I don't see any way that pricing is unethical with really anything, as long as there is good values behind it with honesty and transparency.

SPEAKER_01 33:50

Don't miss out. Please subscribe to our newsletter now to stay ahead of the world of orthobiologics. You can find the link below. Additionally, if you're ready to start this journey with me in my orthobiologics masterclass, come join us. Yeah, absolutely. Absolutely. Well, we have more questions. And that this is the question because this is what I think some people are struggling with right now is how can you ethically scale a cash practice while maintain that clinical integrity and accessibility? You know, personally, I am struggling with this right now, right? As my as the demand increases, there's only one of me, right? And how do I get the word out for the larger public? How do I teach other doctors how to be successful? How do I, you know, beat that drum that every injection should be ultrasound guided? And if you're not using it, you've lost your ever-loving mind, and maintain access for my patients. And so I am currently in this middle of this, but still maintaining that clinical integrity and obviously the accessibility. Like, uh unfortunately, you it you end up booking out, and how do we do that in an ethical way? You know, in an insurance-based world, we use physician extenders, we shorten the time. Like, there's lots of techniques in the insurance-based world to scale. I think that what I struggle with, and what I wish, and what I'm gonna put a plea out to everybody, is we need more people who are learning how to do this well. And you know, how do we do that? How do we ethically be able to scale the interventional ortho biologics world, this experience for the greater public?

SPEAKER_00 35:57

Yep. I think you're doing it. I think you're doing it right. You're doing it right now, you're doing it this weekend in Las Vegas at the Ortho Sonic course. You're doing it at Toby. We'll be there together at Toby in August 21st to 23rd. 10% off for the next six days.

SPEAKER_01 36:15

Anyone else, anyone who you all gotta hurry up? Get your tickets.

SPEAKER_00 36:20

I don't have any control over the pricing, but I do know that's the biggest discount that I've ever seen for Toby. It just popped up. So, yeah, it's there's only so much that one human can do in their clinical practice. I think within your clinical practice, yes, you want to be efficient. You know, my clinical team, it's big. I have a scribe, she handles all the most of the lab stuff for my orthobiologics, and then she puts it all in an Excel spreadsheet. So I can do a really nice, you know, about once a week I stay up late looking at my Excel spreadsheet to see what are my platelets, what are my platelet capture looking like? How many platelet, what's the average platelets I'm putting in on this? What are white cells looking at? And so I have someone who does or does that organizes that for me. I don't need I don't need to do that. I have two athletic trainers who work and they're amazing, totally amazing, and they're so good with patients. One of them has been again been with me eight eight years and has gone to an orthopiotics course and has heard me blabber on and on so many times. So he actually he's the first phone call for most patients that come in, but he's always I'm always uh open to talking with them, and he makes sure they know if they want to talk with me, I'm there. But most questions are pretty well are with third, we probably have a top 40 list of questions that we get, and he knows those answers, and they have a relationship with him and myself. So I think being efficient is so important, but beyond that, it's easy for us physicians to feel pressured to carry the world on our shoulders.

SPEAKER_01 38:05

Yeah, yeah, I agree. I have a couple of thoughts, and one is not controversial, well, maybe a little bit, but I think with AI, there's gonna be a very big opportunity to help with the scaling and relegating the things that don't need our high level acuity consideration. Everything else goes to AI. And like you were just talking about crunching the numbers. I'm like, why are you doing crunching numbers? Tell AI to do it. Holy smokes. What are your thoughts on utilizing AI to help with the scale?

SPEAKER_00 38:53

I I don't know. I don't know what and when and how we're really gonna have the ability for AI to help with intake, history taking, overread our x-rays and imaging for us.

SPEAKER_01 39:10

Oh, that's happening now, brother. Let the radiologists know they are on notice. Holy moly. Have you seen that?

SPEAKER_00 39:18

I've I've seen some of it, yeah. Yeah, I have used it for some of my x-rays. I don't have it in a routine way. Well, it just automatically happens. You know, I still have to take it and copy paste it and look over there and look at it. So it's not fast, it's not super quick.

SPEAKER_01 39:36

Yeah, yeah.

SPEAKER_00 39:37

I'd love to hear. I feel like you might be hinting at some ideas you have here.

SPEAKER_01 39:42

So I am obsessed with innovation and I am obsessed with efficiency. And, you know, in a small town, my team is phenomenal, but my talent pool is small, right? So I have really kind of hand-picked and hand trained all of the people that I have, but I'm limited, I'm constrained. And so one of my values of our company is that we perform at the very highest level based on our expertise and our licenseure. And so, what that means, and I just had this conversation with my team last week, is I said, you know, as we're scaling, as we're bringing on another doctor, my goal is to hire zero additional humans. And they're like dying. They're like, how is that gonna be possible? But how that's gonna be possible is AI can actually allow one human to 10x their output because of the way that you it can be harnessed and trained to take massive data input and be trained to put the output as a thought assistant, as a, you know, the the things that you don't actually need to do. You just need to think of the things that need to be done, right? Um, I just finished reading a book called The AI Driven Leader, phenomenal book, really, really a very cool book. And man, my wheels are like, oh my god, this is the newest. But that's I think one way that we can start to harness AI to start scaling orthobiologics. The other more controversial topic, and I'd love to your opinion on this, is you know, our physician extenders, our nurse practitioners, our PAs, like where what role can they play? Should they play? Are they playing? I have a nurse practitioner myself, she's phenomenal, and I struggle with what where's that line? What should we be doing? And I know when we were, you know, I was president of IOF, we talked and you know said, okay, so should we train PAs and MPs? Should we not train them? Yep, should we like if they're gonna do it anyway, shouldn't we equip them with the best knowledge? Like, I don't know the answer to all of this, but I do wrestle with that question. What are your thoughts?

SPEAKER_00 42:22

I think as long as physicians are struggling and wrestling with this question, that they're gonna make a great decision. Personally, I also have a PA. My PA of eight years just retired to become a stay-at-home mom, and so I have a new, totally awesome PA that's just a couple months in. So I can say the last five or six years from my last PA, she had a great handle on first off, doing a good history, physical exam, coming up with a solid differential diagnosis, knowing how confident she was that she knew the plan, had a good plan in front of her. And if she was less than 95% confident, she would tap me. And so the last five or six years, she really didn't bug me too much to go over in detail patients with her. The next, and she knew she knew my indications for orthobiologics and my beliefs and impressions from the literature on indications for different orthobiologics. Now, the next question is so I use mine as to help me treat patients, and orthobiologics are obviously just a huge part of it because of the power in orthobiologics. Now the next question is procedures. And we have had the same discussions for our Toby workshop, August 21, 2025. Anybody listening? Do we allow advanced practice providers to train in our workshop? And I I certainly believe there are APPs who are perfectly skilled enough to do most orthobiologics that I do. I know APPs who do a great job doing bone mirror aspirations. It's really not that hard. I think a bone mirror aspiration is about as hard as a blood draw. I've actually struggled more on blood draws than I have with bone mirror aspirations, so that says anything. And my PA, my former PA has her RMSK. She's done a million knee injects. She helps me, teaches local and regional ultrasound courses. She can do a perfect intra-articular hip, intra-articular knee, AC. She actually put PRP in my own rotator cuff, so clearly I trust her to do that. All the basics and moderate level stuff, a PA can absolutely be trained to do. There are two problems. The first is if a patient's spending cash, they often want that physician. Whether or not the physician is better. And if you I think the main I still say think my main purpose in the medical system is our physician's main purpose in the medical system is our brain and not as much our hands. Because procedures, whatever level of difficulty a procedure is, almost any physician can learn any procedure. I could teach everything I do, give me 12 months with physical medicine rehab. That's my residence, that's my residency that I'm in. Give me 12 months, and I can teach a fellow everything I do. I'm pretty darn close to as good as I do. My current sports fellow actually is getting higher TNC counts in his bone marrow aspirations than I am averaged over the last three months. So apparently they can do them better than I am. But yeah, they still want the physician to do it. Now, is there a model of care where the PA goes and does the bone marrow aspiration or it does some part, or I think it's certainly feasible. There are problems, and we just we don't have good standards for physicians on what training is appropriate and required for us, let alone do we have them for advanced practice providers. So just lots of challenges, but it's not a no for me.

SPEAKER_01 46:17

Great. Yeah, absolutely. I think you know this is a work in progress, and what's true today probably won't be true next week. The speed of at which this field is changing is awesome and exciting, and for newcomers, hard to get a handle on. I know when I started, I was like, holy cow, I'm in the deep end of the swimming pool on this one. And you work really, really, really, really hard to kind of get that acumen of knowledge collection. And so as we are going along, I think having fellowships, I think is really important. And I do believe that this will be, you know, there that there are clear guidelines, there are clear indications, clear floor for training for entry to this option for care. I don't think we have done it, defined it yet. And I think this in the next five years, we will be able to define it, what it takes, what kind of curriculum everybody's working from AAP MR, and everyone is really, really working for curriculum. And thank the Lord, because you know, curriculum's hard, and then enforcement and adoption is a whole different ballgame. So awesome, awesome, awesome. So the question is is what is the next step, right? Like this is all good and fine. This is talking about money and what should we should do, but let's be a little bit more practical, right? So I wanted to just talk about this practice launch system. Mike, thank you so much for joining me in this whole discussion. Man, it is you're right, we were separated at birth, I think. And this has been so good to share your perspective and your frameworks and your thought processes on how we grow this field. And this is such an exciting field. And for me, I do believe that cash-based practice and orthobiologic treatments are the secret sauce not only for great patient outcomes, but happy doctors.

SPEAKER_00 48:20

It's such an honor, Ariana. And I just have to say again, what I would have given to have access to this kind of material when I just came out of my fellowship. Holy moly.

SPEAKER_01 48:31

Well, yeah, me too. This is when I built this darn thing because I will I was again swimming in the deep end of the swimming pool. It's like, how do I do this? And I'm evolving every day, and my practice is evolving every day. But we have to be able to how to use this knowledge. How do we get the right patients? How do we even create a cash-based business? We were not taught this. And yes, it seems easy, but like it's like, okay, it's this much. How do I take your money? And really, you can just take cash or you can take credit cards, but you there has to be a way for you to do this. And then having that conversation, whether it's a 30-minute, 30-second conversation or a 36-minute conversation, to be able to clearly communicate the benefits and the value for your patients so that they understand what their money is actually allowing them to do, that it's getting them to the destination of living better, of having less pain, having better function. And then obviously putting it all together for success. So I wanted to just offer if you want the fast track to all of this, we're gonna be doing the business of orthobiologics live at Toby. If you have to go to the lab, by all means go to the labs. If you don't want to go to the labs or you've already gone to the labs and you're wondering how the heck to be successful in business, please come join me. This is a full day event. How to integrate PRP seamlessly in your workflow, the step-by-step roadmap to get the right patients, right pricing, and run a profitable, successful orthobiologics business. So please, please, please. This is our price. We don't shy away from price. This is what we do. We absolutely want to equip you with all of the benefits. I'm going to put a little QR code up there. If anyone's interested, please scan the QR code. Mike, you can scan the QR code too if you want. We would love to have you, but I'm pretty sure you're teaching. And then I just wanted to say thank you so much. I'm going to open it up to our questions. I do have a couple. We're about, we have about, we can always go over, but we have four minutes until we're ending. Dr. Gaddis weighed in, um, and he said, I don't think adopting the current insurance-based model is the wisest approach. Orthobiologics could provide an opportunity to rethink the current insurance and healthcare model. Sort of like how the founding fathers rethought our government. This can be the maybe the catalyst, right? For a different way, proving that maybe a different way forward is accessible to all. And then maybe not offering cash-based services is unethical. What are your thoughts on that? I mean, that's pretty big shoes to fill here.

SPEAKER_00 51:43

Well, starting from the end, certainly I have fairly firm beliefs that not offering orthobiologics is actually unethical. We're making a financial decision for our patients that only our patients can make. We we do not have that ability, and only our patients, we are ethically bound to autonomy, and that's but for our patients.

SPEAKER_01 52:09

And we are not their fiduciary, honestly. This is that is not our job. We are not the fiduciary for our patients. Some people think some doctors think they are a fiduciary for their patients, they are not. Yeah, they are bound to provide the best options for health care. Yeah, they are the healthcare guide.

SPEAKER_00 52:31

Yep. Yep.

SPEAKER_01 52:34

Awesome.

SPEAKER_00 52:35

Now, as far as it's an interesting idea for orthobiologics and the cash-based model leading the way in changing the healthcare system. And I don't consider myself to be too bright on healthcare system topics and changes because boy, is it complex. And no matter who I speak with, there's someone smarter who can convince me that my own thoughts and feelings are not inferior to his or hers. Can I defer to Dr. Demurs on tackling that one?

SPEAKER_01 53:11

Oh, yeah, yeah. I'm not sure I have the answers, but I do know that, you know, orthobiologics and cash-based practices for me has been the catalyst for significant improvement in quality of life for my patients, significant improvement in quality of life for myself, and significant improvement in quality of life for my employees. And so I do believe it is the vehicle for change. So maybe it's a small change, maybe there's a small number of changes along the way, but I think it is a catalyst, and we should all be really excited about the possibility that the thing that we're already doing, the thing that we know is the right thing to do for our patients and for our employees and for ourselves, also is has the opportunity to maybe push for change at a bigger level. So, yeah, very exciting. There's another comment in this chat regarding the hardest part of the business of Wortherbiologics, is fighting the snake oil salesman. Patients don't know the difference. And what I would urge everybody to do, this is gonna be the takeaway. This is gonna be one of those like things is one of the things we can do is just be really transparent. I think one of the things that the FDA has asked, and the FTC, which is Truth in Advertising, has asked us to do is be clear on what we're actually talking about. And so what we have done, and what I'm going to urge you all to do, is any patient facing advertisements, websites, anything, just run it through Chat GPT and ask it to please create a version that is FDA and FTC compliant. And what it will help you do is be quite transparent and it'll keep you safe from the crawler bots that are looking to maybe penalize some folks. But uh and AI for me is I'm obsessed with it as well. But I think if we can just have massive transparency of what it can and cannot do, who should and shouldn't have it, and that it's part of a continuum of care and let the patient decide, I think is the best option.

SPEAKER_00 55:45

Absolutely. Transparency, honesty, and just being really good at what you do. If you do those things in every way in your clinic and outside your clinic, patients are gonna come. Of course, you might be a little slower than if you're sleazy and you're in getting started. But patients are gonna come and they're gonna be very genuine referrals. And you're gonna go home and you're gonna sleep at night thinking you just did a great job today and over the week. And you know, if you think to when you're on your deathbed, what do you want in your life? It's not it's nothing but just being honest and transparent and having just great ethics every moment of your work in your life. Patience will absolutely come.

SPEAKER_01 56:33

Yeah, make a massive impact. Like, right? We want to know that we're part of something bigger than ourselves, that we're doing the right things. So, Mike, thanks again. This is Michael Kadabi, and I really appreciate the conversation. It's been fantastic. Everybody from the crowd, thanks so much for joining us. This has been the business of orthobiologics and conversations in regenerative medicine. Please come visit. I'd love to see you in four weeks. That's August 21st. The Business of Orthobiologics Live at Toby. Learn how to be successful. Thanks so much, and we'll see you in a couple of weeks for the next Conversations region. Thanks again.

SPEAKER_00 57:16

Thanks for having me.