Health Systems & Concierge Medicine: Strategy, Service Lines, and the Future of Primary Care

Michael Tetreault: Imagine buying your kid a toy only to find the batteries aren't included. Or buying furniture but it's missing the tools to build it. Frustrating, right? Now, imagine that exact same feeling, but you're paying way more. That is what buying business software usually feels like. Fragmented, disconnected, and incredibly expensive. Odoo, uh, completely changes that. Odoo is a complete, fully integrated business suite where all your apps actually talk to each other. We're talking automated lead routing for your sales team, seamless AI integration, and an intuitive point and click website builder. It's everything your business needs to scale, saving you time, headaches and money. Stop piecing your software together. Go to odoo.com that's o d o o.com to learn more. Welcome back to the Doctrine or Leadership Podcast. I'm your host, Michael Tetro, Editor in Chief of Concierge Medicine Today, and I'm excited about today's conversation because it is one of those MacGyver interviews. Because we're going inside the boardrooms and the strategy sessions of major health systems today with my friend, our guest, Alex Muckerman. He understands how major health systems operate. And I want to ask you a question that more hospital executives and physician leaders are starting to take seriously. What role should concierge medicine play in the future of our organization? And our guest today is Alex Mockerman. He's a senior manager at ECG Management Consultants, one of the most respected healthcare strategy and management consulting firms in the country. Alex is a friend, but he's also a recognized expert in strategy for ambulatory medical group operations and even concierge medicine service line development. He's like a MacGyver is kind of what I call him, and he's spent so many years now designing and implementing concierge and membership based medicine models for health systems and medical groups of all sizes. And he's published some of the most thoughtful data driven analysis in our industry on how health systems can approach this space and this topic and this important conversation in healthcare concierge medicine strategically. This is not a conversation about hype. It's going to be a conversation about getting into the weeds of strategy, sustainability and what it actually takes for health systems to enter and succeed in the concierge medicine space. So if you're a physician, a practice leader, an administrator, you work in a health system wherever your role is in healthcare today. You need to understand where concierge medicine and membership programs fit into today's market. And Alex is going to lead that conversation. So let's dive in.

Narrator: This podcast is produced by Concierge Medicine Today, LLC. All rights reserved. Concierge Medicine Today, or CMT, was founded in 2007 and serves as the industry's trade publication and annual medical conference organizer. Please note the information shared on this podcast and across all CMT platforms is intended for general informational purposes only and may contain errors or omissions. Nothing in this podcast nor across CMT platforms constitutes medical, financial, legal, nor professional advice in CMT is not liable for any inaccuracies. CMT encourages listeners to conduct their own research and consult trusted advisors before taking any action based on the content presented. No mention, interview, or link should be considered an endorsement. This content is primarily intended for a healthcare audience and may not apply to all listeners. Thanks for tuning in.

Michael Tetreault: Well, good morning OR Good evening, Dr. Nation. You're listening to Concierge Medicine, today's DocPreneur Leadership podcast. I was going to say progress, but today our guest is Alex Muckerman and he is with ECG and we'll put the links on how to connect with him and LinkedIn and all that kind of stuff. He's like the MacGyver to me and my description of him when I talk to doctors and they want somebody who understands the healthcare marketplace place, understands business and understands the concierge medicine and other subscription based healthcare delivery models, especially when it concerns health systems and patients as we know are, uh, changing how they buy healthcare. Concierge medicine isn't a practice model anymore. It's become a leadership decision and we see this playing out in so many places and spaces and today, even in today's years, and this has really kind of been around for a while in the concierge space, but more in the last few years. Health systems are really rethinking access, experience and sustainability and administrators are being asked to design models that work in the real world, not just on paper. So in our conversation today with Alex, we're going to unpack and explore what demand signals are actually showing up, why health systems are moving more decisively now in these directions where planning often goes sideways for the health system and the physicians, and what the next chapter of direct to consumer and employer based healthcare may look like for doctors. So again, the goal isn't to necessarily start a model or sell a model, it's to understand the moment we're in. Alex, you're going to help us do that. Thanks for being our guest today.

Alex Muckerman: Oh my God, thanks for uh, having me here, Michael. Um, love, love the podcast. You got some great, great guests on. Love that kind of breadth of guests that you have on uh, the physician side, the losing side, the legal side, sewer side. Uh, your podcast is green and love attending forum Conservation Medicine forum every year. Um, the forum was an eye opener to me when I first attended oh I want to say seven or eight years ago uh for the first time of boy there's a whole uh other large group of people out there that one are already doing this that uh, are like minded like me. That's kind of seed and value of concierge medicine and other direct consumer membership medicine models and um, a great resource for individuals that are looking to learn um, get their you know they're, they're considering getting into this. They want to learn more, learn from people who have been doing this for a long time. Um, best practices create resources. So I can't thank you enough for all the hard work you put in for um organizing and setting that up and every year and I always look forward to it every October and can't uh, encourage you listeners enough to attend. Um, whether you're in the industry or thinking about um going in or just interested business nerd that loves um the business model like myself to great group of people and great learning environment.

Michael Tetreault: Well thank you, that means a lot and we appreciate that. I'll share that with the team. Um, and you become kind of an alumnus and a familiar face in the audience in the rooms. Uh because it's like after the first couple of years of attending it's kind of like well be careful. Michael might put you up there on stage to speak about what your expertise is in.

Alex Muckerman: So you think about that with a lot of work conferences. But boy I can't wait to come uh to Alfra in Cummings every year to go to this conference. It's enjoyable for me.

Michael Tetreault: Well and being that you're such in such unique seat on the bus, um, you know you see trends and indicators from your position uh outside of your window about consumer demand for concierge medicine services. What are some of those, those trends that you're seeing, those indicators that you bump into and you're like well that's interesting what's happening in your neck of the woods.

Alex Muckerman: Sure, yeah. Um, and just kind of background. So uh, I work for ECG Management Consultants. We're a healthcare management consulting firm um, uh that mainly just operates within the US and my. I've been working in the industry for uh 14 years now and my niche is in medical group homes improvement and specifically concierge medicine and other membership medicine uh services. So um, you know we as far as indicators concierge medicine is a little tough. There's not uh, as great published market statistics about uh, consumer demands, about providers that are in continuous medicine practices compared, uh, to internal medicine, family medicine, other specialties, uh, because there's no database for that. These are family medicine, internal medicine, pediatrics positions that uh, they registered, they have those certifications but there's uh, no have centralized certification for concierge medicine. So all to say is tracking, um, supply and demand in these practices is tough and most are still independent. Uh, so that makes it tougher as well. So um, when we, as far as what I see is demand, uh, when I'm working with a client, when I'm working with the health system or practice, when they're looking to learn more about their market, um, maybe they're starting a new practice in the market, looking to grow. They want to see who's out there and you know, see what other practices are doing, um, what they're, what they're defining as concierge medicine, uh, what their price points are, you know, learn if they have full panels or not, what their panel sizes are. So I do a lot of research, market research, ah, secret shopping, calling uh, into practices. And what I'm just seeing over the years is even going to see looking at markets, the same markets, uh, one, two, three years, um, from when I prior did. I'm just seeing the volume of practices that I'm seeing in my research grow and grow and grow. So it's, you know, and those practices are not just stealing pieces of a pie, clearly. It's, we're, we're growing the pieces. So um, they're sticking around and growing and we're seeing more and more. So that's a good indicator that they're growing. And as far as like why, why is this happening? Um, you know, it's no secret that kind of everyone involved in concierge medicine comes out a winner here. It's consumers who are looking for something that's different than the traditional model. They're looking for a more personalized care experience. They're looking for more um, attention and access from their provider. A lot of providers are wanting this model because they want to provide that same level of care. But in a traditional model they can't do that. When their panel size is 2000, they're seeing 30 patients a day. They uh, just don't have the hours in the data to make that happen. So um, you know, it's, it's when you see a win, win all around from both the provider and consumer side, it's it's no kind of secret to why this is flourishing. Um, there's also kind of the general access issue in our country with accessing primary care. ECG did a study last year. Um, we did um, secret shopping calls to traditional primary care practices around the country. And um, you know, the average wait times are to get into a new practice is 30, is at least 30 days in the best market. When we talk about a specialist, it's even higher. So consumers, and even when you're in a practice, just getting availability for a new acute issue or new problem can be days or weeks. And you know, for the consumer, that's not acceptable. It's not what they want. They want to feel better. They want to, um, and talk about that. They would rather have a more proactive approach to their health and managing, um, their symptoms rather than a reactionary approach.

Michael Tetreault: Um, it sounds so simple, but from a business metaphor, I think you'll get it. Uh, one of my mentors described it as we will pay for something and we will find a way to pay for something if we really truly need or moreover want it. And you think of a teenager in search of an iPhone. I have two teenagers. And when the next iPhone, we don't do new, new stuff. We kind of like, don't like mom gets a new one. And then it's the trickle down effect in our family of who gets different phones. So eventually everybody gets a new phone. But you know, one of those things that we see the value as a patient, as a consumer in. Okay, yeah, there's benefits to, you know, retail healthcare and going into a CVS or Walgreens back in the day, which wasn't that long ago where we wanted price transparency. And now we starting to see medical offices, whether it's primary care, family medicine, pediatrics, some specialties that have patients with chronic conditions can work in this concierge medicine space. And we also see that, you know, nurses and PAs are getting into this model as well. Um, how have health systems that I'm kind of interested, like to be the fly on the wall in those boardroom conversations or those phone calls where it's like somebody from the health system calls you and says, so tell me about this thing, concierge medicine that you're doing in this area or this stage or this with this hospital. How have health systems evolved with regard to the concierge medicine and um, especially direct consumer and employer practice models in general. So you can riff on that. There's a couple of things in there.

Alex Muckerman: Yeah, great question. So there's um, whether we like it or not, whether we agree with it or not. There's always been this um, stigma of concierge medicine, um, where it's a, you know, a lot of people view it as a uh, service for more wealthy consumers, higher income consumers that they have the ability to pay to have better access, um, more attention that others can't afford. And um, a lot of health systems who you know, most are not for profits, uh, they um, you know, are designed to care for their communities, uh, regardless of um, ability to pay. They you know, take a lot of charity care, they take a lot of Medicare, Medicare and Medicaid patients, um, and are trying to really operate, uh, without you know, the lens of whether you, you know, how, what your insurance coverage is or whether you can pay. That is kind of a stigma that groups have tried to avoid for a very, very long time and have uh, as a result they kind of let independence lead the way with concierge medicine. And um, that happened for 20 years or 20.

Michael Tetreault: It needed to be proven right. It needed to be it Innovation. We spoke with a concierge document who's focused on precision medicine just last week, a couple of weeks ago, and she said look, every innovation starts in a focus setting before it becomes more en masse or acceptable. And that's not elitism, that's just how progress and innovation works.

Alex Muckerman: And on the business side there was also kind of, it didn't. A small panel practice for a provider really doesn't align with the economics of a uh, health system where you want to drive. They are a volume business where they want high um, volume patients to be referred to their specialists and their specialists can do a lot of procedures in their ORs, where they get good reimbursement, where they're seeing a lot of encounters from their imaging centers and the labs and pharmacies and their infusion centers when they're getting a lot of um, the positive margins that they, you know, that are critical to their financial success. So just been the um, economics of the business from a volume perspective didn't align with what their traditional business model was. So those two attributes have made health systems kind of a laggard in the concierge medicine world. However, that has changed a lot in the last 10, 15 years. Um, I think Virginia Mason in Seattle, first health system to really step into this. Um, and very, very quickly you saw um, more and more academic and larger community based systems say hey, we should start looking at this. And there's a huge value proposition to um, why they Want to look in this, you know one, every health system employed medical group uh from a traditional practice loses money. Um their direct margin is a loss. The health system makes it up on the back end by uh, getting good margin on their procedures ors, um imaging encounters, inpatient stays, those type of things. But they need the medical group to um, drive business to those higher margin services. Um but the direct practice itself loses money typically call that a net investment that helps make um. In contrast though concierge medicine generates a direct practice margin uh which is very attractive. So groups that are looking to reduce that net investment or improve their operating margin close in that group C concierge medicine and other direct consumer director employer models uh that have a positive margin as these cost centers that can help reverse the trend there. So there's a kind of a direct financial um justification. There was also kind of a indirect value that um, concierge concern, like I would say one it's um, can be used as kind of an innovation center because there's a positive margin to it. You can test new um care models, new um, care techniques that might require a little bit of investment up front to make uh, to test out. But you have this small captive very engaged patient population that provides uh, a good kind of pilot testing ground for new care innovations and you could potentially roll um, um system wide. You think about telemedicine. You know first teledesine was, was pioneered in concierge medicine practice that had the extra margin buffer to have a um, you know, virtual solution that they could have you know virtual video visits with. So um, great example of how kind of concierge medicine can lead the way on things that can be eventually became commonplace in traditional practices.

Michael Tetreault: Um, we're not to where my question, my next question is pointing but I'm going on a rabbit trail on this one related to what you're saying because it makes me think more of a futurist perspective. And it may not happen in you and I's careers but we may start to see the shift of it. But with so many health system owned practices, mandates too strong of a word, Encourage might be the word. It's maybe too soft of a word to say or maybe it's more we strongly encourage you or we are requiring some practices. You can't convert them all. And then. And they're not going to get into the conversion business. There are plenty of experts and great organizations that do that. Um, but you could start to see one day it may happen, it may not. Where the health systems look at the, they look at the spreadsheet, right? That's what they do. And they're seeing, wow, these patients are happy. And the doctors, oh my goodness, like the real threat here is not concierge care or any other subscription based model. It's the normalization of burnout. And if we can, it may take them a while to get there beyond the spreadsheet, to have that empathy for the physicians that they are owning these practices for. But to say, hey, we would like you to move your, your patients in your practice more to a concierge type of model. And we still, you know, own the practice. We, you know, blah, blah, blah, however that contractually that's beyond my skills. But could you see that happening where it's like, yeah, 20% of this health system physician practices in the marketplace are concierge. Now again, we're, we're talking maybe a five years, 30 years down the road. But you do you understand where I'm headed with this?

Alex Muckerman: I think there's probably a limit on that one because um, there's still majority of the market that doesn't have the um, um, disposable income or means, wealth, means to pay out of pocket for this. Um, and not enough employers are funding these programs yet. So um, you know, as far as just the means to afford a membership practice, uh, we're not there yet. And um, there's still um, you know, so, and so the community that the larger percentage of the community still needs to be served. Um, and in the current reimbursement environment, that fee for service, traditional model still, uh, that supports a higher, that requires higher throughputs, higher panel practices still is an optimal model for. But I can definitely see um, as maybe health system. And as they think about, right. Sizing their impatient footprints, maybe downsize a little bit, um, not needing as high volumes to make their downstream services, um, operationally and financially successful. Then you start thinking about, all right, we don't need as much uh, volumes to make that success and a nicer, smaller footprint is easier for us to manage. It's a little bit less complex. And that fits, right, for making maybe instead of 2% of our medical group being concierge, maybe it's 5, 10, 15, 20%.

Michael Tetreault: Um, right now we're probably below 5. Right, we're probably below the 5% or in, you know, like they're not holding on to these practices. There's not a lot. Yes, there's a lot more than there were. You know, uh, even 15, 20 years ago. I remember interviewing one of the founders of this Kind of health system model. And it was a. One of my favorite interviews besides this one of course. And you know, he was just talking about how the health systems and the challenges and the, the discussions and the things. We all hate meetings, right? That had to happen in order for it to be successful. But it was um.

Alex Muckerman: But I'll, I'll tell you the big aha.

Michael Tetreault: Uh-huh.

Alex Muckerman: For a lot of health systems. And the big value driver that a lot of systems are seeing is not just the direct value that they're getting from members and the profit margin on the direct practice, it's the indirect value that they're receiving m from members who um, maybe are you know, are very engaged with the system that are. Maybe have been donors in the past that are community leaders that provide a

Michael Tetreault: lot of um, employer their employers themselves

Alex Muckerman: that um, drive a lot of philanthropy and um, positive community involvement to the system that is that cares. You know, a lot of these health. Most of these health systems are not for profits. They have foundation development teams and a significant portion of their operations are funded by, through philanthropy. And a great way to have uh, engaged members to increase their touch points with the organization to see the wonderful side of the high quality care that they're getting is through these concierge medicine practices. So a lot of groups are standing up these practices to say hey, we want to increase our donor engagement. We want to really um, be attracted to attract more of these people and take care of people that are sustaining our operations here. And so it's not just the direct benefit and the direct clients. They're seen as a way to increase stickiness with gunners, um and m that are just as essential to making their health system missions um, a success.

Michael Tetreault: Well what about the referral side of that too? I mean a lot of these patients who are parts of concierge practices have chronic conditions. They need to see their doc on a regular basis. So you kind of keep those things under the umbrella, so to speak. Is that right? Were you finding that they're still doing that?

Alex Muckerman: And most concierge medicine members come with um, good payer mix. So even though it's a smaller amount that's ah, per practice, you're getting a higher uh, more um, advantageous favorable payer mix out of that group. So still attributing to both top and bottom line performance from the housing perspective.

Michael Tetreault: It's interesting, you know, reversing the trajectory of uh, you know, how we've been doing things in health care. We've really normalized burnout, you know, like that, that to me is more of a, of a threat to our patient care. You know, and it's, I think that there's not a, you know, like I would love a doctor to spend more than 10 minutes with me. Like, please don't put your hand on the door just yet. You know, please walk in with a smile instead of looking at the medical chart to remember my name. Right. And I, you know, health systems and, and the people who work there often get a bad rap. And there are reasons, there are certainly hall pass reasons to complain. Absolutely. And uh, you and I have heard those firsthand. We're not, we're not naive to that. And um, but I think that good leadership is happening in some of these spaces and places within health systems. And by definition good leadership means, you know, that you start reflecting on what's working well, like how can we make what we do a little bit better. And not everybody comes in with that mindset into a health system position where they are overseeing physicians. Um, but they're taking action. And this is one of the ways that they're having conversations with Alex Muckerman of ECG and you know, talking about these things like how can we do a little bit better than we have been? Um, and so it kind of gets into our next uh, question which is operationally because you answered my question before that, which is why are healthcare systems or why are health systems more intentional and aggressive now about adopting concierge medicine? So before I jump into the next question, is there anything else on that topic that you wanted to make sure we covered?

Alex Muckerman: I would say just, you know, and health systems haven't been um, totally out of the direct to employer, direct consumer market, um, forever. You know, they've kind of led the way with executive health. And executive health is a little bit different m the concierge medicine. Executive health traditionally um, are more asynchronous one time visits that are very intense, you know, very comprehensive physical, anywhere from a very extensive examination, an extended lab, um, testing, ah, imaging testing from primary care all the way from, you know, a two, three day visit with every medicine specialist that a health system has during their full workup and coming out with a um, complete um, examination report and a really proactive um, personal uh, health, personalized health plan for the next year or two years. On what patients?

Michael Tetreault: Yeah, you kind of come out with homework.

Alex Muckerman: Yeah, you come across homework that um, you know, transitions nicely to primary care provider to kind of oversee and um, provide, you know, ongoing maintenance for over that time period versus concierge medicine um for a primary care that's, that's more you know, taking care of the patient the other 364 days of the year uh, for traditional primary care. And so while you know the reason health systems were more comfortable going through it was executive health was it was direct to employer and it was clearly not covered by uh, payers. This is, these are for routine uh, visits that don't meet medical necessity. Uh, but employers wanted their um, employees and executives to be healthy and take a more proactive preventative approach. And so because it didn't meet medical necessity with more routine and focused on prevention, that's why health plans didn't cover it and why it made sense for that to the financial responsibility shift to employers and um, consumers which made health systems feel more comfortable entering that and they also had the providers already employed to make that possible. So um, concierge medicine is a nice complementary service to executive health because like I said it can take the um, while it has the same kind of more personalized approach towards medicine, um, you know, going above and beyond what the kind of traditional medical necessity standard care is as well as attention and time that patients get to ask questions and providers get to customize uh one get to know the you know, the individual's uh, personal and health goals and apply a personalized plan for that patient to help meet and achieve their goals. So um, it's a nice um, half full complementary circle there as well as other wellness services, premium services like massage therapy, acupuncture, um, um, physical um exercise, nutrition and some of these other direct to consumer services that um, kind of make this really nice complementary flywheel that um, is becoming more and more attractive to consumers which you know the health systems have a great opportunity to offer because one, they've, they've been doing second health for a while. Uh, they've got a great name brand in the community. And because they also have an integrated specialty network when patients do have problems, it's nice that they have the ability to tap into that um, when they need. So um, you know the pathway for health systems into this to get into concierge medicine was a little bit differently but they're kind of seeing the consumer benefit of it and they're thinking about more of patients as consumers. And this is what more and more consumers are demanding now. So they're seeing the need to uh, adapt and if they don't adapt their competitors are going to and they're going to lose atoms.

Michael Tetreault: Yeah, yeah, for sure. Well you work with ah, a number of health systems, you know about a number of concierge programs within, ah, the umbrellas of these health systems in these, you know, playgrounds with a fence, so to speak. Um, and that's a good thing, you know, like, hey, there's every, every fence has an opening and a closing too, you know, so the physicians aren't. Don't have to feel stuck. There is an interesting thing I've observed from again, my seat on the bus is that within the health system, you know, those concierge doctors, typically, I mean, you and I get a luxury when we work in healthcare. We're one of the probably couple few hundred folks who work in this space that, you know, from a business perspective that we get to work with. 98% of the, of our day is m. Met with happy, having communication with happy doctors. Right. Like, it's not the grumbling and the, you know, the moaning and groaning. And let me tell you my story about how difficult my job is. So we get, you know, that really unique way it helps us from a sustainability, our career, you know, path is like, yeah, I like going to work. I like helping, I like interviewing folks like yourself. Um, do you find that the, the talk about the career satisfaction, the physician satisfaction kind of mindset within a health system physician who's operating a concierge practice based on those that you've worked with? I can speak from my own experience. Um, usually they're always very happy, you know, but they always kind of somewhat. There are some who still feel like they have a boss, you know, and that there's, there's, there's that too. But it's just dramatically different and better in a career satisfaction way than it was in a traditional plan reimbursed environment where, you know, they're seeing loads and loads of patients every week.

Alex Muckerman: Yeah. And, you know, it's not right for every, uh, physician, but boy, the ones that, um, you know, are interested in and spending more time, um, really getting to know their patients, going above and beyond and want to practice that style of medicine. This aligns well. And yeah, so you'll, you'll get a lot of physicians who, you know, they, they want to do this style of medicine. They just need the economics and a reimbursement environment that aligns with that. And so, and, you know, concentration medicine fits well with that. Or the ones who succeed and do well at, uh, transition over and are a natural fit. You know, transitioning from a panel where they were seeing 1800, 2000 plus patients going 30 patients a day, um, to more of a, you know, four, five, 600 panel seeing eight to 10 patients a day, um, it's life changing. That's the style of medicine. They thought about growing up, they thought about going into medical school, wanted to practice coming out of medical school. Um, but because of our very complex and um, and um, convoluted reimbursement environment in our healthcare industry in the United States, that just wasn't possible. And you know, as far as not, um, and so it's very nice. And you know, a lot of providers, you know, some are entrepreneurs and they do well staying independent, that's, that's where they like to go. But you know, a lot of providers, they just want to focus on patient care and they don't want to have to worry about the business side and just want to focus on seeing patients every day. And that's, that's why a lot of providers go work for a health system because they, they can do that. Um, all that administrative duties are offload to administrative staff.

Michael Tetreault: Uh, you know, it's interesting. I'm sorry, I want to make sure I don't forget my thought. But. And it parallels with what you're saying. You know, concierge medicine has gotten such a bad rap about, you know, criticism around access. And I think that framing that misses the bigger issue because access isn't just about volume size or panel size. It's about whether physicians can sustainably remain in a practice practice at all. And it by maybe by. And again, maybe you're having these conversations with, you know, this is, this is the fly on the wall conversation that you get into 15 minutes later or 15 hours later, because it's multiple conversations and meetings, um, with these health systems to explain what's happening in this space. And that is, look, we're, this, you're kind of in a unique position, uh, because you have these doctors who want to go into concierge under your health system umbrella because you're increasing access. You're not limiting the patients anymore. Right. Like those, we have other physicians who can service those patients, you know, who are, who want to remain in that traditional plan reimbursed model. But for those who want the increased accessibility which accesses, you know, more of a compliance, there's all. We can go on a side track about that and we have another interviews and so on. But you kind of almost see the, the access issue as, okay, that's an interesting marketing, maybe that's not compliant or I don't know. But you know, you almost see it. Uh, do you understand what I'm saying?

Alex Muckerman: There Sure. I mean, and the access issues is again. Yeah, you're right. We could go on a tangent that then there's the whole industry supply problem of there's just not enough physicians and why are we training more physicians and there are more medical schools, but there's a lot of root causes around. That's why that's happening.

Michael Tetreault: Um, and are these physicians who move into concierge or decide to do this, like, are they the ones having the conversations with the administrators first? Or is it the administrators coming to them and saying, do it, and then are they starting with zero patients?

Alex Muckerman: Uh, typically not. So, yeah, I've, there's one, One client particular I work with that it was the physician who raised his hand saying, hey, we're not doing this. Um, this is how I want to practice medicine. Um, we're in a great market for this and I would like to do it, you know, if, um, you know, there's no threat that everyone's like, hey, um, you know, I'm, I'm not happy with, you know, the way I'm currently doing this. So, um, you know, I would like to do it here. I don't want to do it independently. I like working here. Um, I like, just focus on patient care, but I would like to do it in this, you know, this style of medicine. And when you frame it like that, administrators kind of understand. They also don't want to lose those positions, um, potentially to, you know, either competitors that are willing to employ them or to do their own, uh, practice. So they think, hey, you know, let's, let's. And if it's explained to them the right way, they understand it. And more and more are becoming open to it and it's becoming normal place for health systems that have a membership, um, medicine, you know, silver slime that has cashiers mostly. Another, um, D2C and DD practice models under it. So, um, you know, and then you, um, know what you, what you really don't want is a physician leaving medicine altogether. They're so burned out that, uh, they say, hey, I'm just not going to practice medicine anymore. I'll go be a, uh, a florist.

Michael Tetreault: That's one I heard he's going to go help his wife become a better florist.

Alex Muckerman: Yeah, I'll be, I'll go be a cmo, Chief Medical Officer at some company and I'm not going to see patients anymore. I'll be a, you know, I'll do something else and uses my medical degree, but not in practicing medicine. Those are the, of the situation that I think you're more concerned about someone completely leaving the practice of medicine altogether versus a different style of medicine where they're going to feel more, um, yeah, they're going to do it for longer. They're going to, um, feel more rewarded in their career, um, and the patients that are going to be in their priorities are going to enjoy it just as much.

Michael Tetreault: So the next question. We have a couple more questions for Alex Muckerman. He's with ECG Management Consultants. We'll put the links in the show notes, as well as how to get in touch with Alex and learn more. But this is really where you come in, where Alex and your team come in. Because operationally, what do health systems, uh, need to do differently to support? Right. Like, this is. This is like, you know, well, you kind of need an. A MacGyver, like an Alex Muckerman, you know, who understands the nuances of these models in the. Within the health systems. Because, you know, we think this is a great idea. We think, doc, you should do this, but we need a little help, too. So they're asking, they're coming to you with open hearts and hands and saying, I need a. We need. We need a little insight here. So what do, uh, how can they support, activate and sustain these practices?

Alex Muckerman: Yeah, this is. This is the fun part. So, yeah, they say yes, makes sense. We understand the benefit, the value of going to the concierge medicine, and we got maybe a doc that, um, you know, we have maybe not. Uh, but we. We want to get into this. Okay, great. What is concierge medicine? You know? Well, how do you. How is your system going to define concierge medicine? Well, what are the services that you're going to offer? Um, how many patients do you want to serve in your practice? Well, what should the price be? Uh, how. How what? You know, these are all, you know, how are we. How are we going to find these patients? You know, what's. Do we need to have a different, um, you know, when you think about the clinic location, does it need to be different than our current practice approach? We need different staff. Um, are these patients going to demand a different way to engage, uh, with the practice? Do we need new tools, new communication tools to deliver these services? And then from a compliance perspective, how do we, you know, are we going to continue to, you know, accept insurance from these people? If so, how do we do that the right way? So there's all these different operational, um, legal compliance, financial, um, components that need to be. And how are we going to Pay physicians, You know, most physicians are paid in um, health system environments on a, you know, productivity typically like have RVU based practice. That, that model was working consciousness. So how are we going to pay the docs and how are we going to make it attractive? Um, but also, you know, we're sharing the benefit with the system as well. So all these ways of um, how to design and execute the practice, these are question marks that healthcare administrators, health system administrators just don't always have the answers to. Because while they're very good at standing up a, a new internal medicine or family medicine practice, they've been doing it for years. They're well oiled in that department. Um, doing the kind of blocking and tackling for starting, starting a membership practice. Very, very different. It requires a different tool set. And those are the things that I help groups think about. It's you know, thinking. All right, what's important to the health system. Let's use that to guide how we're going to define concierge medicine here. And what's the package of services that we're going to offer in our concierge medicine practice? We're going to look in the market to say hey, with this membership, um, service that we're going to offer, how does that compare to competitors? Is it more than what competitors are doing? Is it less? What are those practices pricing? Um, are those practices full? So are consumers actually interested in those services? Because that could be an indicator about what services we should offer. Um, how are we going to find these people? Um, typically we've just been relying on payers to direct patients to us, but now we kind of have to get the word out about what we're doing and market a little bit differently. So what existing marketing channels, both um, and advertising, both paid and non paid, can we use to get the word out before we get to that point where we have a full practice and we're using word of mouth as the major lead source for new patients.

Michael Tetreault: Um, and yeah, and unfortunately healthcare, you

Alex Muckerman: know, how the practice, what staff do we need to go, you know, that that portrays a, a clinical experience that's above and beyond that, you know, signals, you know, value that patients are expecting. Um, all these questions and we kind of work, kind of go through this planning process, um, to help these systems, um, build it the right way the first time so that um, you know, when they're coming to market, they're coming to market with a well thought, well baked service offering that um, their confidence is going to succeed in the long term.

Michael Tetreault: Well, I have about four more questions for you. I could go on forever because they're so. This is so good and it's such a rare. Again, this is such a rare niche space. Somebody said uh, after the conference last October, there's like moving into concierge. Medicine is not for the faint of heart. It is, you know, it is, is a herculean effort in some, in some places. And um, where do you see administrators that you're working with and talk to get caught up in the weeds of the planning process?

Alex Muckerman: Oh, good question. Um, yeah, I mean I think it's like goes down the basics. Like I think they, because they don't know, um, because they don't have a playbook. You know, all these groups have, you know, standard operating procedures and playbooks on how to start new practices. There is no playbook here. So uh, in healthcare you don't like uncertainty? Um, um, it's always, it's not the industry that has the most creative bunch of um, administrators or operators. It's a lot of people that are great on execution and uh, following protocols and evidence based practices. And um, you know, it's not a group that um, uh, is used to starting something new and innovating. And so I think just all of the, all those design aspects and planning aspects that I, that I just touched on, that's where they get hung up on and they get um, concerned about what they don't know. And those uh, could be, you know, hesitations and roadblocks that prevent these from ever getting off the ground. And you know, a lot of them, you know, this is an important, you know, John's very important room. They don't want to mess up and they're tendencies just to stake the status quo and say, you know, this is, seems really complex. Um, I see the potential benefit but I'm not sure, um, it's a good, you know, a good outcome is going to come. And even more so I don't really know how to take it from A to B to increase the likelihood of this being a success. So um, I'm just hesitant and you know, either going to delay or maybe even not go down this pathway all altogether and miss out on the tremendous upside that could be uh, from starting a concierge medicine practice. So I think that's where they just get hung up on this overall complexity, uncertainty of it all.

Michael Tetreault: And um, what I'm hearing is they need to, if you, if they're a physician, they need to start this conversation early because it might be, it's not something that like Healthcare is slow to adapt because of, you know, uncertainty, like you said, and risk averse. You know, like, well, we don't want to rock the boat. How are we going to pay for that? What are we going to do? Like, how's that going to work? All these questions come into the room with you and you're there to answer them, of course. But it's one of those things, well, who do we even talk to? You know? And so I would say, if you're a physician listening, you're working with the health system and you're like, I could leave, I could go, I could stay, I'll just stay. Oh, I just don't know if I want to keep staying in this unsustainable path because it's burning me out. Um, you know, these models are really raising the bar for patient satisfaction, for physician satisfaction on both sides of the exam room. And doctors are staying in place a lot longer. And patients are reminded when they see these doctors kneecap to kneecap on the, in the exam room, they're reminded what it feels like to genuinely feel cared for again. And so, you know, start this conversation early, bring in experts like Alex and his team there at ECG Management Consultants. And this isn't, uh, a sponsor. This is just because we believe in education. We believe that there are people out there, physicians, team members out there, like, forward this to somebody that, you know, that you had a conversation with. And they're frustrated, but they're like, yeah, I never even thought about talking to my higher ups or my equals about this. Like, maybe there's a couple of doctors that would love to do this type of model and stay where they're at, like, what you were talking about. So anything else you want to add to that before we round up our lightning round of questions?

Alex Muckerman: 100%. And I have way more conversations with physicians that, and administrators who I don't end up working with. But we just, you know, I love, um, helping individuals, I hope, who are wanting to pursue this. And physicians out there, you know, your voice means a lot. And, you know, if you put yourself in the perspective of the administrators of your system, you know, your operational leaders, you know, they, they want to grow their service lines, they want to grow their business, and they're looking for, uh, you know, new growth pathways that are going to, you know, help their system, uh, thrive and make their service lines that they oversee look better. And, boy, if your physician that raises their hand comes to them with a fantastic idea, um, you know, about concierge medicine, about a growth opportunity that they haven't thought about, that they maybe felt not confident enough to raise by themselves because they didn't have a strong physician leader to go along with them. Um, you would be, um, you know, don't underestimate your voice and the power that you have to make things happen. Um, multiple of the clients that I worked at, the reason the practice started, because the physician raised their hand and said, this is something that I'm interested. That is something I want to do. I'm happy to champion this. I'm happy to put in the time to make this happen.

Michael Tetreault: Um, so informally, based on the number that you've talked to and worked with. And again, there's not a huge number out there, but there's enough of them out there where we can make an assumption to guesstimate to say, okay, eight out of every 10 or how many are raising their hands and saying, uh, the physician brought this to us and we thought it was a great idea.

Alex Muckerman: Oh, I would say it's probably, I would say it's probably half like. Right.

Michael Tetreault: That's what I was thinking. Yeah.

Alex Muckerman: Because, you know, and the great.

Michael Tetreault: Which is high, by the way. That's a great return on investment.

Alex Muckerman: And eboy, it's so much of a. Easier transition into a new concierge practice when you have an existing physician within the health system that has a panel, um, that they're going to transition into. Because one, you're going to start with a bolus of patients in, in your, in your practice, and you're not starting from a new patient. A concierge panel of zero. So immediately their, their proforma and the financial projections are going to look so much better than starting something from complete scratch with a new physician. So, um, you know, physicians, and they

Michael Tetreault: don't want to lose a physician. I mean, yes, they let them go all the time.

Alex Muckerman: Yeah. And, um, again, there's delicate ways. There's really important ways I think, for the health systems to do this. Right. Like, even if you're, if you're transitioning physician, I think from the community perspective, you want to build it in a way that's net new. So even if you're transitioning a traditional, um, internal med or family med, um, physician into concierge medicine, I think it's critical that you backfill that position, um, or ensure that there's enough excess capacity within your remain primary care provider workforce to take those patients and transition their care seamlessly, um, so that you're not leaving any patients without, um, care. So I think that's really important. Making um, sure that it's built in that new way.

Michael Tetreault: That is good. All right, now we're moving into our

Alex Muckerman: light power of physician raising their hands, saying that I'm interested in this.

Michael Tetreault: Yeah. Um, well now we're going to move into our lightning round of questions. You can be however brief or long winded as you would like to, um, we ask a couple of these questions to all of our guests. Uh, the last couple of questions. Um, so where do I start? Because they're good. All right, so let's start with this rapid fire 1. How do health systems measure return on investment once they have a concierge program?

Alex Muckerman: Sure. Um, yeah, easy way direct is direct margin of that cost center or cost centers that make up the concierge medicine practice. Um, right. So your um, expenses being provider expense, support staff expense, uh, non labor expense, and the revenue of course being membership billing, any fear of service that you're doing for your members and um, any other kind of ad hoc costs that are being generated practice. So that's the direct value. Um, you're also going to measure, um, you know, downstream. You know, potentially measure downstream value that you're getting from uh, referrals, um, um, you know, imaging, um, other downstream services. You also want to track, um, um, film profit dollars that are coming from members, um, and year over year gross, um, growth from that amount. Um, and you know, there could be other strategic value that you're getting of caring for patients that are super important, super important to the community. Um, so there's other kind of strategic value that can be generated from um, the practice as well, as well as, you know, physicians, you know, also having more time. Maybe they're um, able to do more community events and generate value and explore.

Michael Tetreault: I love that you didn't go with the touchy feely answer. Well, of course it's going to be patient satisfaction. I love that you started with the metrics because that is important and I'm a business guy.

Alex Muckerman: But yes, there, there is all the, you know, it is. I talked about it being an innovation ground for you know, care offerings. It's totally that as well.

Michael Tetreault: Yeah.

Alex Muckerman: But yes, it's, it's. I don't want to overstep kind of the financial value.

Michael Tetreault: Absolutely. Because we need businesses in our local community servicing. Yeah, yeah. And we want doctors to stay in business because they are one of the top five most influential voices, at least to me and my family, behind my wife and kids. Like we don't need you to go and burn out, you know, because burnout early retirement, which happens more often. Right. There's, there's more burnout in early retirement and reduced clinical hours that have been rationed over the years than there are concierge doctors who uh, will ever fill that void. Right. So that the criticism about that exacerbating the physician shortage is kind of laughable in my opinion. But you know, these membership based programs, if you're, you know, administrator, you're a physician listening to this, please share. Again, start the conversation early. But when they're, when these programs are structured correctly, these concierge medicine programs within your existing framework, under your existing structure, they can restore time, continuity and really give that professional, you know, that you're relying on, that you want to keep happy and employed, durability, you know, like they want to keep staying there. And I think that a system that looks equitable on paper but steadily drives an experienced position right out the door, that's not protecting, you know, your community, protecting your numbers, protecting access. That's just, you're just very good at measuring those things at that point. So, um, our sec. Our next question has to. Is related to um, do you do any succession exits? Like do you have those types of conversations with physicians? It could be outside of the health system bubble, but we're finding that more and more, um, like you talked about earlier, you have a great article about concierge medicine, how to move into it and navigate these waters on your ecg, um, blog and we'll link to that article as well. Um, but we're also. That's the entry. Right. Then you have a number of physicians who have been doing this for 10, 15, 20, 30 years and now they're wanting to finish. Well, they're looking for a uh, successor, they're looking to sell their practice. Are you guys there at ECG management doing anything related to those types of situations that's separate from health systems?

Alex Muckerman: Sure, yeah. We have a dedicated M and A practice that um, has done some concierge uh, medicine succession planning for physicians. And it's interesting, you know, um, it's totally depends the value of, you know, if you're an independent provider, uh, with concentration national practice, the value of your concentration national practice is incredible. Is very different, um, depending on who the buyer is big time. If the buyer is a, uh, another um, a physician who wants to get into the game and wants a turnkey solution, value is very high. That practice because you're, you're effectively selling the cash flows of that practice, um, and you know, offering a very low risk, um, you know, good Return, very predictable return uh, business to this individuals and uh, it's similar to a private equity company or venture capital.

Michael Tetreault: I was just gonna ask.

Alex Muckerman: Yes, as well. Um, versus you know, if you're selling to a health system, most health systems are not going to buy uh, or you know, value future state cash flows. They're going to think about purchasing the assets in your practice. Um, and, and they just, they don't, you know, they don't purchase that way. And so um, you know selling to them maybe the value might not be as much. Um now you can, if you're willing to stay on for a couple of years and you know, you don't want the headache of running the business but you still want to practice medicine. Um, you know it could be a good alternative but uh, they're going to value it a whole lot differently than what an independent um, practitioner or private equity or venture capital company is going to. Uh, so I would say you know, when you're thinking about succession plan, think about who you're um, you know, positioning or purchase to and you know whether you're. And it could take different forms, right. You could take uh, on a partner or a position employee for a portion of the time and uh, kind of transition the value of the practice over time. It could be a clean sale. There's different structures to how that can work out. Um, and um, so I would say you know, go, go with an advisor who can help you think about the pros and cons of different structures, um, targeting to different buyers. And there's no one size solution there. There's kind of different structures and so um, a well trained advisor on any front can help you kind of sift through. Hey, what's the right pathway for you? That makes sense both professionally thinking about the remainder of your career that you want to keep working as well as um, what your goals are for extracting value, monetizing your practice.

Michael Tetreault: Uh, yeah, don't do it alone. Like you should have a board of advisors around you giving on your team. Right. Like you, you're to use a baseball. Like you should go to a dugout, right.

Alex Muckerman: It's completely worth it. Um, and you're going to get, you're going to be steering the right direction. You're going to have peace of mind that you know, you're, you're um, putting your best foot forward. You know, this is a one time event and you don't want to mess it up. Yeah, yeah.

Michael Tetreault: You only sell your practice if you're lucky a couple of times in your life. Right.

Alex Muckerman: The maximum value.

Michael Tetreault: Yeah. And you only get to sell your practice a couple of times in your life if you're lucky. Right. Maybe you don't even have one that's worth selling. Um, all right, so last couple of questions. Um, thank you for covering the private equity because I just had written that down. But you're welcome to add that additional, uh, insights into this last or the second to last question. Um, what do you see in the future for direct to consumer, direct to employer practice models? In the US we recently had this whole HSA thing, uh, related to direct primary care. But again, don't confuse concierge medicine with direct primary care. There is two pathways right now happening in direct primary care which is very different, um, you know, than your concierge medicine practice. And maybe you're welcome to touch from your perspective the how you're answering those, uh, FAQs difference between Concierge DPC and, which is more of the purist, no insurance, no Medicare model. And also the direct to employer, which is usually sometimes now being more, uh, scalable for practice that partners with employers. But then there's that whole kind of like, well, I'm not just getting the subscription anymore, I'm also getting paid by that subscription, is getting paid by the employer. And that kind of means I'm boss. I'm a boss to them too. But that one's taken off too. So riff on that a little bit and then we have two short fun little questions for you there at the end.

Alex Muckerman: Yeah, I mean this is a great, this is a fun question. Um, I think it all, all boils down to, hey, the consumers out there want this. Um, consumers are, and health, you know, healthcare consumers are dissatisfied with traditional model, the status quo model. It's not, uh, it's complex, it's tough to access, it's tough to deal with and it's not generating ideal outcomes. Concierge medicine, BBC and these other membership um, practice models and environments are offering a different um, service out there that is meeting the needs of consumers and just where consumers are interested are going to put their money in, that's going to grow. And so I see. And you're seeing, because of that, whether it's policy, you're seeing the HSA changes that happen with dpc. I, I see that expanding. You see the current administration talking about expanding HSA UM accounts and the uses of those funds. You know, I'm not a lawyer. I'm not going to comment on, you know, what a qualified medical expense is, but there's plenty of legal Opinions out there that's that promote um network um concierge medicine and other membership um fees as being qualified medical expenses that can be used and you can use AHSA and FSA funds for um the you know latest round of the um big beautiful bill. You know just wanted to step further to explicitly call out direct primary care. I see that you know continuing to grow and you know hopefully there's more call outs for concierge medicine alongside direct primary care in the future there. Um so you know which will further increase you know as you get more tax advantaged payment mechanisms for that that increases the pool of consumers that are going to want this. So they already wanted on the service side but now it's matching the reimbursement side that makes it feasible. Uh and then I also see you mentioned on the employer side um you know just with I heard in my firm um the you know biggest expense bucket that grows and grows every year that outpaces everything else is healthcare expenditures. And you know more and more firms are looking at this growing percentage of their overhead and say hey we need to do something about this and need to be you know take a more uh active and management role in our healthcare expenditures of our employer, of our employees and you know great way that we could do this is through a more proactive um approach uh towards primary care and our patients healthcare and take a more long term approach instead of taking this reactionary simple based approach, you know status quo model. And you know I fully see and we're already seeing this of some employers starting to carve out primary care of their you know typical uh their health insurance product, um keeping specialty emergency acute care in um more of a traditional plan model. But for primary care saying hey let's think of a different reimbursement approach that better incentivizes the provider um to actively manage our patients care, provide this more personalized care that is our employees are um demanding and that leads to better health outcomes that keeps our employees at work, um, that keeps them more healthy and that's something that they want for their both their professional and personal lives. And so I see that growing way more um I see employers um as part of a standard benefits package offering either stipend or directly contracting with um primary care employers to provide this style of medicine to their employees. And that being eventually a core benefit just like retirement accounts, just like health insurance is uh currently as a staple that is going to be a requirement for uh attracting high um high value talent and um, which will further you know increase um Demand for providers, which will increase supply and continuing to see this industry grow. And um, so kind of the policy side as well as the employer side, again it's all driven by consumer demand and consumers are demanding this. So policy and the employer market will follow that because that's what people want. And people want a better um, care environment and innovation, uh, is ripe here. So I definitely see that growing and it's exciting to be around. And again, when the service and the product, that's a win win for everyone around, um, it seems like a no brainer to me and um, kind of easy to see where the tailwinds are going to.

Michael Tetreault: And if you're wondering as a physician, like, well, could I make this work? Regardless of your station or your lane that you're currently in, whether you're independent, you're curious, you're working under a health system. The physicians who thrive in concierge medicine really have four simple character traits. They're curious about their patients. They have humility as leaders, uh, and they have gratitude for the people that they serve. And they have such a giant big heart for their community. Because at the end of the day, it's not just about medicine. It's about the people that they're serving. And we, me, you and me, we're family guys, right? Got kids, wives, people that look out for us. We're going to need that to be cheaper. Like we're going to need healthcare to be cheaper. But we need these places and these incubators like we talked about where earlier on to be places of innovation that, you know what, I think we could take this over here. You know, like, I don't necessarily agree with that or that what that program is doing, but gosh, they sure know how to serve. They sure know how to serve their patients. They sure know how to treat their physicians. Well. Um, so what book is in your audible library right now that you would recommend or that you hand out to doctors? Most, um, or hospitals, uh, administrator folks that you talk to. You're like, you got to read this before we have our next conversation.

Alex Muckerman: Oh, uh, I don't know if I'm recommending books to anyone, but uh, book I'm reading right now, I had a fantastic professor and um, went to uh, Olin Business School at Washington, uh, university here in St. Louis. And I had a great professor, John Horn, who he taught microeconomics m. Macroeconomics and competitive, um, industry analysis. And he just put out a great new book called uh, about a year ago called Inside the Competitor Mindset. Um, great Way just like if you are an entrepreneur or have a business or just are nerd like a business like me. Um, it's, you know, you always have to think about um, especially you're running a business and you have a competitor who did something and we say why did they do that? It doesn't make sense why they did that and boy they're going to regret that. John, um, trying to put you in the shoes of them saying I guarantee there's a reason why they didn't. If you really think about, you really do put yourself in their shoes that you can think about the reason why they did that and it's probably for a different reason you are ah, doing what you're doing. Uh, but it's important to understand why they might be doing that so that you can probably react and uh, position yourself. So it's a great way of putting yourself into other competitors shoes to understand why they're doing things so that you can put your business uh, for me, my clients uh, in a better position to succeed. So um, inside the competitors mindset.

Michael Tetreault: John, we're going to put that, I'm going to add that one to the book uh, list probably for um, this uh, spring because we have a book list that we release at Concierge Medicine today. And we'll put the link also to how to get in touch with you, um, how to read your article that you wrote a couple of years ago that's still getting great traction. Um, and our final question for you Alex is one we ask of every one of our guests. It's a familiar one since you're, you've been to the events over the years is what do you want to be known for?

Alex Muckerman: Be a tremendous husband and a great father. That if I could be known for that I would be super happy. That would be super worried. I'm, I'm a guy that ah, that defines um, my life by my family and um, that's the most important thing life. I, I love what I do professionally but it's a means to, to spend you know, quality time with my family and help help them thrive and see their goals succeed. So that's the most important to me professionally. Um, you know I would like to be known as a guy who um, who followed the passion, um, loved what he did and um, love to be, you know, people liked working with him and he did great work. That would be great. But above all it's to be a great family man, a great partner to my wife and a great father. Mentioned her.

Michael Tetreault: Wow, thank you. That uh, resonates with me. And, you know, I, one, one guy who sits in, you know, in the same kind of, uh, aisle way in the, on the bus as you. Uh, you know, we have a unique view out our window, a unique seat on our bus, and we get to work with happy physicians. And by being a good father, by being a good husband, by being, you know, in those places and available to those individuals, it makes us more enjoyable because I can be grumpy pants too. It makes us a better lever to the physicians and the people and the staff that we're trying to help when we go to the office. And so you've been a wonderful guest today. And as I was saying, I don't do long form, more than an hour interviews, but when I do, they're really, really good. And this happened to be one of those. And Alex, you just, um, this has been a conversation that I've been wanting to have with you for years now, and so I'm glad that our schedules matched up. Um, and again, if you're a physician listening, um, or you work in a health system or your physician that's just kind of shaking his head and curious and like, I gotta do something different too, hey, forward this on to your folks, you know, at the hospital, or forward this onto your colleagues and have a conversation. Start the conversation early. Um, and I think what we've learned today is that the future belongs to those in healthcare who are leaders, who remove every single unnecessary obstacle for the patient and build systems, regardless of where they might be at, regardless of their price point. That makes servanthood and gratitude for, for the patient and for the physician in healthcare repeatable and relatable. And so, as we say on here a lot, it is no longer about being the best physician, the best doctor in the world anymore. It's about being the best doctor for the world, for your patients, and for your local community. Alex, thank you so much for being our guest today.

Alex Muckerman: Of course, my big surroundings. But, um, have me back anytime. Love, love chatting with you.

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