My journey’s a little circuitous to Albany, having grown up in South Africa. I went to medical school in South Africa, did a short stint at a family practice, 60 miles north of North Dakota, waiting for my green card. I completed a partial general surgery residency in New York City. Before coming up to Albany, I completed my ENT Head and Neck surgery residency here and loved the Adirondacks, the upstate New York area. I had a great opportunity to take over the practice of a solo practitioner and have lived in upstate New York since that time. We developed a great platform in comprehensive otolaryngology here, growing the practice to now our 10th physician and onboarding our 20th physician assistant. We have a very diverse, broadbased, comprehensive type of practice and we can certainly talk more about the offerings and ancillaries and other care services that we provide. It’s been a very rewarding, important journey, and we’re glad to be providing care to upstate New York and contiguous communities in southern Vermont, Western Massachusetts, and the like.
What makes the ENT market opportunity special?
14,000 providers in the United States. Otolaryngology head and neck surgery being a small specialty only accounts for 1.4% of the healthcare spend, and yet there is considerable diversity and opportunity within the field given the range of service offerings
included in comprehensive ENT care.
Allergy represents a meaningful service line. Integrating allergy
into an ENT practice requires a thoughtful approach to manage
for potential tensions between ENT and allergy providers.
Comprehensive ENT service offering are conducive to improved outcomes for both patents and payers
The market is today and is likely to remain fee-for-service
Offer comprehensive care
Build traction with non-traditional referral sources
I’m a strategic advisor for Albany ENT and Allergy Services. I’ve been with the practice for four years. I’ve been in ENT for 18 years, having previously worked with ENT and Allergy Associates, which is the largest Ear, Nose and Throat practice in the country. I have my MBA from NYU Stern. I’m a fellow of the American College of Medical Practice Executives, and I’m very happy to be here.
I grew up in South Africa and took a somewhat indirect route to Albany. After attending medical school in South Africa, I spent some time working at a family practice in a small town north of North Dakota while waiting for my green card. I then completed a partial residency in general surgery in New York City. Following that, I pursued a residency in ENT Head and Neck surgery in Albany, where I fell in love with the Adirondacks and the upstate New York area. I had the opportunity to take over a solo practitioner’s practice and have been living in upstate New York ever since. Over the years, our practice has grown significantly, and we now have 10 physicians and 20 physician assistants. We offer a wide range of comprehensive otolaryngology services and are proud to serve the communities in upstate New York, southern Vermont, Western Massachusetts, and beyond. It has been a fulfilling and important journey for us.
My involvement in clinical medicine has always been the passion that has driven me in the field. I’ve always found the integration and balance brought perspective on healthcare otolaryngology and head and neck surgery as well. I am very much influenced by my counterbalancing love of organized medicine and healthcare leadership. And I think the two have made me a better clinician, better surgeon, and better healthcare leader. I was a past president of the American Academy of Otolaryngology-Head and Neck Surgery, a 14,000-physician body. I’ve been involved at the local level in both academic and private practice endeavors and various national and state and other organizations, including outside of direct ENT involvement as president of the intersocietal accreditation commission for CT imaging, for example. We helped bring CT imaging and standards to the ENT community quite some time ago. It helps inform my ability to provide better care and understand the environment including healthcare policy, the challenges in healthcare, the opportunities as it relates to research, the provision of cutting-edge drug and device development, and just a better general perspective on what the overall landscape looks like in both future care delivery options and adhering to best practices, clinical guidelines and so on.
Those are all helpful, useful perspectives that I think enable me to provide better care and better leadership in the field and in our practice and region in general.
I think it’s a little bit of each of those. What has been important to me in the field is specialty unity at a time when everybody’s competing for patients and the healthcare dollar. We’ve been able to bring together subspecialty groups within the practice.
We’ve been able to enhance our national and international profile. So, to your point, from a recruiting perspective, that’s been extraordinarily helpful. It helps me stay abreast of coding policy, healthcare policy, and regulatory change in the entire environment so that I’m able to plan ahead, see ahead, and know what’s coming in our field and at the national level to be able to adapt. As a result, we’ve modified how we do things and what our verticals look like in terms of ancillaries to better prepare for impending changes. And all of those components have helped us better fortify the practice for change ahead. In so doing, we strengthen our ability to improve care delivery, patient outcomes, and the patient journey, lower the cost of care, and improve revenue at the same time. So, I think it’s a very broad- based approach that has allowed us to increase the value of the practice and, in so doing, improve the patient experience and the quality of the care that we deliver.
Gavin and I both believe in a dyad leadership structure that allows physician governance with lay leadership that focuses on the tactical initiatives that improve patient access in specialty medicine. So, I think that there’s a really good blend of my prior practice management experience and Gavin’s clinical expertise to solve problems together. Gavin and I spend a lot of time together thinking about and having really in-depth conversations about how to achieve some of these goals and what the vision for both the practice and our future MSO is. In terms of tactical deployment, we get aligned and then we work with the senior leadership team to deploy those tactical initiatives. Gavin, what are your thoughts on that and how we work together?
I would agree with that. When Drew was in his former leadership role in the largest ENT practice in the country, we collaborated on many different issues specific to New York state, as well as regulatory health policy and other opportunities for improvement at the national level. So, we’ve been working together in some capacity for close to 15 years and then, more specifically, in the strategic advisory role. And even more recently, I’ve ramped up that level of involvement. So, the dyad structure is very much a very close collaboration. I think we work well off of each other’s skill sets, and it’s a very collaborative, informed, mutually respectful, and highly productive relationship. And there’s a lot that I learned from Drew and that he brings to the table. I think we really need to collaborate to achieve the goals that we are seeking. His background and mine really gel well, with mine being clinical and having various leadership roles in different organizations. Drew brings many skillsets to the table that help us navigate the complexities of the changing healthcare environment we deal with.
Gavin and I just returned from a conference in Alexandria, which was on private practice ENT management and the business of medicine. What became clear from some of the panels that Gavin and I were on is that where Gavin really excels is advocating for our profession, fostering a culture of continuous learning and improvement, bringing this clinical wisdom, guidance, and mentorship to me to be able to do what I do every day. I think that that structure works well when running large medical groups and
MSOs.
I think that there are two categories. There are the verticals of ancillary services and practice optimization, and then there are kind of the business functional areas that have opportunities for improvement. In terms of revenue lines, one of the biggest drivers of revenue would be better business systems, superior EHR, the submission of clean claims, all these KPIs that drive growth procedures per visit, the use of in-office modalities and making sure that you’re billing for the codes commensurate with the work being performed. In addition, we are looking at a number of ancillary services in allergy, sleep, speech, CT, audiology, and hearing aids, which are complimentary verticals to the practice of ENT and otolaryngology surgery on the expense side and just on the running of the day-to-day business. I found a lot of portability in some of the things that the functional areas that we’re able to make improvements in and make investments in. Those included managed care contracting, building up the finance team, improving human resources and leveraging policies and procedures to run the business, looking at the workflows at the front desk, medical assistance, health informatics, and just better workflow streamlining the EHR. Those are large, and a lot of those areas are specialty agnostic. So, we have this roadmap that allows us to focus on individual initiatives through a strategic plan. I think that building on my experience at ENT & Allergy and growing that practice from 60 to 250 doctors and from 26 clinics to 46 clinics, I think bodes well for my pedigree and my ability to really offer a consultative approach and work with management and physicians to get to a better product and to build a better mousetrap.
I think the focus will always be the patient journey, clinical care, and clinical outcomes. We are a very patient-centered practice. Our motto is that we are invested in the community and in your health. We can scale that, and that’s the goal via the MSO and other verticals, including urgent care. And I’m sure we’ll talk a little bit about that as well. However, what I would like to see, and I think the opportunity exists, is through the MSO; I think there are different opportunities. There are de novo opportunities, bolt-on opportunities and franchising this urgent care concept, which I think is a huge opportunity now in the field to increase access and lower cost. From an MSO perspective, there’s a lot of opportunity there. In a post-pandemic environment, there are a lot of practices that have significant exposure operationally, strategically and financially.
We are a smaller healthcare community than, for example, internal medicine, cardiology, and other larger surgical subspecialties. So, being able to provide that administrative support through an MSO, whether it’s revenue cycle management, IT, and so on, whether it’s carte blanche or a menu-based opportunity, I think all of those are opportunities for us to scale, grow, invest in the future of the practice and what those models look like, certainly within the upstate New York and well beyond. That’s where the vision is developed – we want to develop a national footprint and consolidate and provide a different mousetrap, if you will, relative to a traditional private equity MSO and other offerings that exist because practices have little opportunity and choice. When pressed, we are all trying to consolidate, improve expenses, and extract margin. And there’s only an amount that one can do in that regard, whether it’s in the hospital environment, academia, or private practice. We believe that we can develop and provide a better alternative to those in need. The time is now, and certainly in the next two to five years, and by ten years, we would hope to have consolidated that model and established a very profound footprint in the healthcare arena as relates to our field.
Just in terms of commonality, ENT & Allergy has a very strong framework for geographically contiguous bolt-on acquisitions and a recruitment vehicle to onboard physicians within that area. I think that what Albany ENT, or as you mentioned, a name to be
determined, will be a regional and national framework that does not require geographic continuity and does allow us to homogenize a number of centralized administrative services while optimizing operational efficiency focused on the strategic growth of
those practices and to deploy some of these best practices online scheduling same-day access and next day access better systems, better technology systems, a data warehouse with KPIs that allows real-time observations and tactical strategies to help improve
these practices. I think the vision includes the ability to have those things be portable across practices that don’t necessarily require the management to be local.
We opted not to. As part of our MSO, we’ve made a strategic decision that we really wanted to retain control of the culture decision-making processes. We had a number of interactions with private equity and with a health plan in terms of making JV acquisitions
and becoming a platform that was backed by outside capital. While we’re not against raising money for the purpose of improving management, we’re really against this model of impairing physician income by doing a financial engineering play of scraping
EBITDA and then having an outside investor owning a piece of those earnings in perpetuity. We want to build a better business. While that may create liquidity for the business itself in the form of an MSO, we really wanted to build the business now and
pursue organic growth by making investments in the management structure and then having physicians join that MSO without a private equity partnership. So that’s the current thinking.
I think Drew highlighted some of the concerns from the physician’s perspective because of both mine and Drew’s national exposure and involvement in talking to several other practices and individuals who have gone the private equity route. Having had several
interactions ourselves, particularly pre-pandemic and during the early stages of the pandemic,
we made that strategic decision to avoid private equity for the reasons that Drew alluded to. And I think some of the concerns in retrospect for some who have gone that route are capitalizing a significant part of the practice and EBITDA, scraping and
floor backs, and other structural concerns, relinquishing control, and concerns about what income repair looks like. It’s a great concept. It’s very difficult to operationalize. It’s reducing FTEs and increasing churn, and that’s not a preferred model
for how one practices on a day-to-day basis in an era of burnout, errors in declining reimbursement, and workforce issues. So, we would like to retain control and maintain the culture of the practice. ENT is different from other fields to the extent that,
as I mentioned, we are only 14,000 strong in the United States. It’s a very diverse field. It’s half medicine, half surgery; it’s very procedurally oriented in the office. It’s half adults and half kids, and it lends itself well to ancillaries. So different
from other practices or fields within medicine, we have a very robust allergy practice and immunotherapy. We provide hearing and balance testing and therapies, as well as speech and swallowing. We have onsite conventional CT imaging. We have the ambulatory
surgery center upstairs. We have a very well-developed APP physician assistant model in our practice.
And I think all of those things, if they can be done on a consistent basis, replicated, and proliferated, are our hedge against traditional private equity where we can retain control, retain quality, and ensure the optimal outcome. The other concern is
what happens at the second bite; you continue to relinquish control. You have no idea what that looks like. As a recruitment tool in a difficult environment, we’ve heard from a lot of residents, fellows, and early grads that they’re concerned about what
a private equity opportunity looks like in terms of their onboarding and future opportunities. So, is there an alternative in terms of funding and capital, whether it’s partnering with a family office or another non-traditional form of capitalization?
We are certainly open to that, and that may well become a consideration in the future, but as it relates to strict private equity in its current format, it is not something that we are keen to pursue or implement at this time.
I think that’s a great question, and that’s what makes our field exciting. Otolaryngology head and neck surgery being a small specialty only accounts for 1.4% of the healthcare spend, and yet we have so much diversity and opportunity within the field
to do all of those things. So, from a clinical perspective, I’m really excited about allergies. For example, probably 70 to 80% of what a general otolaryngologist sees on a day-to- day basis has an allergy mediator diathesis. And so whether one knows
it or not, we are treating allergies every day as oleic allergists, not board-certified. So-called medical allergists, we sub-certify through our allergy academy and provide comprehensive allergy management. And for us, it’s probably one of our largest
ancillary services from a revenue standpoint. In addition, it’s an outstanding clinical modality resulting in improved patient outcomes, less sinus surgery, and things of that nature; believe it or not, there are certainly fewer revision surgeries and
just improved outcomes, whether it’s allergy, asthma, or quality of life. So, we currently have close to 4,000 patients on immunotherapy, and that is a massive footprint for an independent private practice that is able to affect that degree of change.
Patients love it. The insurers love it because the patient journey, episodes of care, asthma flareups, ER visits, et cetera are significantly improved in that model. On the other hand, equally exciting is the opportunity when we built our new office,
it’s a 54,000 square foot facility. 34,000 square foot is designed for clinical space, and we have a walk-in ENT Urgent Care that opened five years ago, immediately before the pandemic. That served us very well. That’s a unique model that improves access,
the patient journey, and quality and outcomes, providing higher access and higher quality care at a lower cost. And so we see anything up to 60 or 70 a day just by virtue of the walk-in urgent care option. We had patients through the pandemic who were
expressly diverted from hospital ERs and other urgent cares because of the quality of the service, the ease of access, and the outcomes. What’s interesting in partnering and looking to JV and do other opportunities in the space is that this has garnered
the attention of the healthcare insurance environment, and we are able to profoundly impact the cost of care by redistributing or redirecting those patients to a lower cost of care site of care opportunity and in orders of magnitude, lower cost of care
and improving outcomes.
Each of those patients has other clinical needs because of the diversity of ears, nose, throat, head, and neck. So, we are treating multiple different clinical systems, offering ancillaries in each of those. And then just lastly, the ambulatory surgery
space in our field is really important, particularly in the value-based environment, and the opportunity to reduce the cost of care, improve outcomes, and lower the healthcare spend as relates to surgical procedures, an enormous opportunity for us to
renegotiate those bundles and so on for the procedures that we do. So each of these provides unique opportunities, and certainly drug and device and clinical trials, they are uniquely independent, exciting, improved care, lower cost access, improves and revenue along with that.
In terms of segmentation, I would agree with Gavin’s ranking with prioritizing allergy, and I would add audiology and hearing aids to that list of migrating patients along existing care pathways. These are new patients who come to the practice. We’ve
done a longitudinal study of the lifetime value of a patient through those services and looked at both the revenue per visit and then revenue over a five-year period, and certainly, allergy and the diagnostic audiology and hearing aids are passive income
for our partners. I’m super excited about the urgent care because these are patients that we’re not currently seeing today, so it doesn’t even appear on the lifetime value chart because without this patient access, the online scheduling, the walk-in clinic,
these are patients that are really points of attrition for today. So, making investments in these de novo urgent cares and putting them in centers of excellence that we have today represent real opportunities.
There’s this dichotomy of practices, some of whom have hired board-certified allergists to round out their model and some of whom pursue an RN allergy, which is the ENT supervised nurses doing percutaneous and intradural testing, sublingual and subcutaneous immunotherapy and really providing this gamut of allergy services under otolaryngology supervision. There’s no right answer, but I would agree with you that the ones who have invested in the board-certified allergists do have a little bit more baggage.
So we’ve chosen the one where there’s this seamless ability for ENTs to refer patients to the allergy department and then have those patients resume their care back with the ENTs, and that offers a number of clinical benefits, which Gavin is better equipped to answer, including the fact that we don’t really focus so much on some of the things that the board-certified allergists focus on airway and asthma foods and things like that. We can really focus on allergy-mediated comorbidities, which intersect with
chronic rhinitis and rhino sinusitis. So, Gavin, maybe you can just comment on these two schools of thought. The boardcertified allergists versus ENT supervisor.
That’s a great observation and, I think, a realistic concern amongst general otolaryngologists. I think when thinking about this in our academic otolaryngologists, hospitalbased otolaryngologists typically do not focus on the allergy component. They have an allergy and immunology department; they have an audiology department, CT, and so on. So, historically, they have been used to referring those patients out. I think this is more of an opportunity in the private practice arena. Interestingly, allergy
and immunology are taught and learned in our residency, but I think that the focus has only increased more recently. Historically, it was not an overly emphasized area of education and training. We have the American Academy of Allergy, which is dedicated to training and certifying subcertifying ENT doctors in allergy. I think, to an extent, it’s market-specific, and I have an appetite for pursuing allergy. Some folks just do not want to deal with the so-called combined airway allergy, which affects not
only the nose and sinuses but the lungs as well.
Patients have significant allergies, including stinging insects, venom anaphylaxis, and peanut anaphylaxis. There are a variety of aspirin sensitivity in addition to allergy-related ear, nose, and throat problems, sinus disease, nasal congestion, nasal
drainage, ear disease, and skin rashes. A lot of ENTs sort of say, “I don’t want to deal with all of that. I want to take care of general ENT, I want to do sinus surgery, treat kids, put ear tubes in, and so on.” So, the appetite for treating those patients
and learning and implementing allergies into the practice is a logistical challenge and a preference to avoid.
Absolutely. And just one other comment on the allergy side of this: the perception amongst ENTs is that if I start providing allergy services in my practice, the traditional referrers, the allergists who send me patients who need sinus surgery and have
nasal polyps, and so on, will no longer do that. And I think it’s a matter of establishing relationships within the medical community, within one’s practice environment. It’s also very well known and documented in the literature that there are not enough people providing allergy care in the United States, and allergy continues to increase at 10% per annum in terms of the number of patients, and it’s a vastly underserved population. We’ve not seen that to be the case. We get the same number of referrals
from allergists for airway evaluations, sinus surgery, and nasal polyp removal because nobody else can do it. That’s the reality. So, it’s an unfounded fear from a practice quality and personal satisfaction level when providing comprehensive care to the
patient. I think that is immeasurable. From the patient’s perspective, you come, you see me today, and a week from now, you’re getting your allergy skin test in the same office. Two weeks later, you may start allergy immunotherapy if appropriate.
And that’s coming under increased regulatory observation.
People are becoming much more aware of that and
recommending that side of care opportunity as well.
To those points, one should also do one’s due diligence on existing practices and get as much information about the market as possible. Relationship management, I think, is an important part of this within the otolaryngology group that one is particularly considering. Physicians are difficult in terms of concepts of change and integration, and I think it’s a little bit of a journey, so educating and demonstrating opportunity is important. Something that Drew mentioned is that we have a lot of non-traditional competitors in our space, Walgreens and CVS MinuteClinics. We’re living in an employer-based insurance model, with higher patient responsibility in terms of payment. So I think when we consider all of those things in terms of approaching different markets, considering where those referrals are coming from, it may be easier going forward than has traditionally been the case because we may have more leverage by virtue of the things that we see and do and the ability to do them in the office that we are less reliant on the referral based odel and by perpetuating the urgent care online appointment scheduling same day next day concept, driving access, lowering cost, improving quality. I think adoption in other markets might be easier and, from a scale perspective, more doable than one might think, but not without challenges. And I think you raised some excellent points.
I can just speak a little bit about my prior experience where the footprint was all the way from the Jersey shore up to New York, upstate Hudson Valley, and then all the way across to East Hampton, where there were different relationships. We did have
a boardcertified allergy model. We did have different referral patterns, primary care, and I think there were a number of strategies that we used, and this will only partially answer your questions using the example of just let’s start with referring doctors and how we even get patients. So non-traditional referral sources in terms of the pharmacies, the urgent cares, the school nurses, and really marketing to a broad audience where a lot of the healthcare is consumer-driven, not coming from the PCPs downstream, the partnerships with the health plans, the narrow networks with the academic medical centers, the IPAs, the managed care contracting, to really have a collaboration with physicians who are part of that, those other collaborative specialties.
So we were successful in making inroads there. Gavin, what are
your thoughts on some of those questions?
To those points, one should also do one’s due diligence on existing practices and get as much information about the market as possible. Relationship management, I think, is an important part of this within the otolaryngology group that one is particularly considering. Physicians are difficult in terms of concepts of change and integration, and I think it’s a little bit of a journey, so educating and demonstrating opportunity is important. Something that Drew mentioned is that we have a lot of non-traditional competitors in our space, Walgreens and CVS MinuteClinics. We’re living in an employer-based insurance model, with higher patient responsibility in terms of payment. So I think when we consider all of those things in terms of approaching different markets, considering where those referrals are coming from, it may be easier going forward than has traditionally been the case because we may have more leverage by virtue of the things that we see and do and the ability to do them in the office that we are less reliant on the referral based odel and by perpetuating the urgent care online appointment scheduling same day next day concept, driving access, lowering cost, improving quality. I think adoption in other markets might be easier and, from a scale perspective, more doable than one might think, but not without challenges. And I think you raised some excellent points.
Yeah, so there’s a number of vehicles that we use. We do not use a headhunter. We do post through our national academy through Healthy Careers, but some of the most successful ways that we’ve recruited have been direct outreach to some of the residency
programs, the program coordinator, and the program chair directly. Gavin is giving a talk to over 40 residents next week, where we’re going to do a dinner and learn. We give out a $75 GrubHub certificate, and then we do an icebreaker where everyone talks
about what they’re eating that night. It allows them to want to attend. But we usually do a business of medicine lecture. This one happens to be about questions that residents should be asking when they come out of their programs and about their future
employers. And so it’s a soft sell, but we post our jobs through the programs directly. We have relationships with the program coordinators. Gavin has relationships with the clinicians. And I think building those relationships with the programs, particularly
in the northeast, upstate Buffalo, down some of the downstate programs, things like that.
I would agree with that. That is a definite challenge in our field in general and upstate New York in particular. I think one of the things that has helped us here also is a conscious decision of mine to integrate into organized medicine, our academies,
and the various specialty societies in the United States and in New York as well. We have a very high profile for our practice, and the model we have with our APP program, all the verticals; we have a single footprint with 50 exam rooms and, multiple
providers onsite, and multiple ancillaries on site is pretty unique. It’s probably the largest single site in the United States, and we have visitors from around the country coming to visit and look at our model. So we have a lot of exposure, which has
been very helpful in our promotion. We have made a point of developing our brand and brand recognition locally, regionally, and around the country. And that’s helped direct traffic. We do these resident talks with 40 to 50 residents twice a year, and
any opportunity at the annual academy meetings and subspecialty meetings during the course of the year has helped provide great exposure.
I love the point you made about the PAs, which is that we have these relationships with the PA programs as well. And we’ve started to develop relationships with some of the nursing programs because our allergy program is heavily reliant on the ability
to recruit LPNs and BSNs and RNs. So the residency programs, the PA programs and the nursing programs and building those relationships directly provides a significant advantage.
Because we are such a small part of the healthcare spend and healthcare community in general, value-based payment and bundles currently do not exist in our field, particularly at scale. So, this is an individualized approach that we are currently working
on with our largest local carriers.
We are hoping to renegotiate bundles and value-based models, particularly as they relate to our field and our practice in this community. Those measures and issues will certainly come to the field as a whole at the national level, but that is still quite
some time away from working with the American College of Surgeons on alternative payment methodology and so on. It’s been a very complicated, slow process, and there’s really nothing in existence right now. So we are developing those at the local level moving forward based on the data that we have, our experience with our ASC, and the urgent care area.
I think that ENT will still be in a fee-for-service environment in the foreseeable future. We’re starting to see opportunities to partner with health plans in terms of offering enhancements in the ENT space to some of our improved access services like
urgent care. We’re starting to see the development of smaller, narrow networks that typically offer high deductible health plans but only include physicians of lower costs who use lower imaging and have badges of honor for being a lower-cost provider.
So we’re striving to make sure that we’re part of those networks and that we are demonstrating our value proposition in terms of being a quality and lower-cost provider, whether that’s because we’ve kept patients out of the emergency department or
otherwise. And then I think that we’re starting to see some things around very early risk-based concepts where you get a PMPM fee, but I just think that it’s not on par with what we’ve seen in orthopedics and cardiology, some derm – it has not really
hit ENT yet nationally. So, in terms of our local payer landscape, I think we’re seeing continued fees for service with some opportunities for partnership and covered services that are preferential for us.
And one other comment, I think a point that Drew touched on: we live in an era of medical consumerism and ratings and so on. So, reputation management as it relates to referrals or patient traffic is important. But I think rethinking relationships with
nontraditional competitors in the field, such as Walgreens and CBS, working more directly with employers at scale, where we see Walmart referring their orthopedics to HIS in New York City and cardiac surgery to Cleveland Clinic. I think if we can develop
those kinds of relationships and redirect referrals based on quality and value, that’s a great opportunity moving forward as well.
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