Podcast: Jim Greenwood

This month I sat down with retired Vision Source President and CEO, Jim Greenwood to get his perspective on:

  • Private Equity

  • Vision Source

  • Healthcare

You can check out our conversation here, by searching "Eyecode Media" in your favorite podcast app, or you can read it below:

Christopher Wolfe, OD, FAAO, Dipl: Hello and welcome to the Chris Wolfe podcast on EyeCode media.

Today, I had a great discussion with Jim Greenwood, who is the retired CEO of vision source, and he was brought into vision source in 2013 to really guide them into the new realm of healthcare delivery systems and quality payments and the ability to move.

The cost of health curve downward. And so we had a really great discussion, mainly about private equity. And so that's what we're going to focus on here. You know, he, Jim has a very good perspective from his history, even before vision source was. With a group of 50 individual physicians that provided care for essentially workman's comp, um, drug testing, those sorts of things for local businesses.

And that, uh, he grew that, um, as their CEO to 1500 physicians. And it was owned by private equity, it was called Concentra. And so. He kind of tells the story of what has happened to private equity and how over time and what we saw happen in the 90s and in the two thousands. And then, um, and what he sees going on today, as well as some of the end goals that he thinks is likely to occur or what's likely the driving force beyond that.

So with that, please enjoy our conversation. As always, subscribe to the podcast. She, it's a five star review and support those.

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Part of this was the options we had available, and part of it was cost, at least my perception of the costs. What I was forgetting is that patient's wearing a one day lens are still wearing their lenses for 14 to 16 hours, and it would benefit from a more oxygen permeable lens. You may have the perception as I did that a one day lens made with silk or hydrogen material are going to be too costly for our patients.

However, studies show that patients want us to offer them the healthiest options regardless of price. I make it simple to the patient. I explain why I'm prescribing a particular lens based on their complaints or based on what I'm seeing clinically. It sounds like this, Bob, you're wearing a contact lens for most of your day, and in the past we didn't have as many options for putting you in a daily events that also allows for optimal oxygen transmission.

We now have an option. It does this. Is this cost-effective as older lenses that you're in? I would love to see how this lens feels to you and looks on your eye. Done. That's the conversation and I haven't had one patient who is not wanting to try it. Clarity one day isn't affordable silicone hydrogel lens.

Our patients are thankful. We discussed with check out the show links for references and see for yourself how to move beyond cost and focus on what's best for our patients.

When I was public accounting CPA and then went to work for a bank that was buying failed banks from the SDIC in the late 1980s throughout Texas. And then bank one now, chase bought us and the CFO for whom I worked at the bank got into healthcare. Okay. A private equity firm had acquired an emergency room management company.

They manage emergency rooms for hospitals, and that same private equity firm. Subsequently invested in what became Concentra, Concentra urgent care. So I joined in April of 1993 this private equity backed physician business that was acquiring practices. At the time I joined as chief financial officer. We had about 30 physicians doing about 30 million in revenue.

Most of it in Texas. And that company today survived like many that didn't in the 1990s. And that didn't survive. And now has 1500 physicians seeing, you know, 50,000 patients a day in virtually every state. So while I was there, Chris, for 20 years, four years as a CFO, and then 10 years as the person responsible for acquisitions, and then became the chief encouragement officer in 2007 we grew from 30 physicians employed.

To a thousand employed physicians at another 500 physical therapists. What do you think? Why do you think that that model works in medicine and is is different in dentistry or optometry? Well, that model worked. W we had about nine competitors. Just like in optometry today, there's a dozen companies, right?

Trying to buy optometric practices. But it's so dependent on the team, the leadership team, the who are working with the clinicians. We had a founding physician who was very entrepreneurial, great, charismatic, leader, visionary, but he met a business person who became the CEO and they were truly partners.

The business person said, you take care of the medicine. We'll take care of the business and we'll work together. It was very outcomes focused. We wanted to have high quality and we would chase acquisitions against those other eight or nine companies and do all of our work and maybe bid $5 million and somebody else would bid 8 million and we would say, what did we miss?

Well. Problem was we didn't really miss anything. We asked the right questions, and two or three years later, the company that paid too much and didn't have the right leadership team and couldn't execute against a plan failed. So we would walk through empty business, empty office buildings, looking at records and buy it from the banks.

Right? That's why I'm so passionate about helping our doctors at vision source asks the right questions. Yeah. The thing that really was a catalyst for me last summer was when one of our 57 year old doctors called, he sent me an email and said, Hey Jim, I've got a proposal from a private equity firm. I'd like to talk to you about it.

I re immediately responded, say, yeah, let's talk tomorrow. So I spent 30 minutes on the phone with this doctor, 57 been practicing for 30 years at two locations. Couple of million dollars in revenue, and I asked him some fundamental questions that he hadn't thought of. For example, yeah. Who are you going to report to?

Where are you going to practice? He assumed he would practice in his two locations, but what I explained was because the acquire or had locations throughout the state. Where he, where he was located. Odds of were that they would move him around. So I said, in your employment contract as it dictate where you're going to work.

Then I asked him, how many patients a day are they going to ask you to see? He said, I don't know. I said, how many patients today do you see today? He said, 16 to 18 comprehensive exams. I say, well, what's it going to be like when they ask you to double that? Because that's one of the levers they use to prove the practices that they acquired, generate value.

And he said, Jim, I'm tired after see an 18 patients. And my, my response was, well, what do you, how do you define quality in terms of the care you deliver to your patients and is doubling the volume going to be? Are you going to be able to deliver the same quality. It was just something to know. So the, the interesting part about that is that, um, when, uh, when I think about the, um, the kind of background of how all that works, the, um, you never really think about those sorts of issues.

And you also think about the, um, the . Sorry. Those guys are our meetings. Hey guys, we're, um, we're actually right over here and they'll serve ya and get everything and get everything going. We're just doing a quick preliminary, this is Jim Greenwood.

Thanks for telling me those early. Makes so yeah, we're doing a podcast, maximizing three cheers for vision source. Uh, but yeah, we've got, the doors are closed, but you can just pull them open and then they'll, um, bill, uh, they'll come grab you a drink. Do you guys want a drink? I'll go grab it. Bye. This might be the best podcast ever.

There's a, there's the back and to the left, there's a door that you've had on it on it. She'll come out. Um, so, uh, so the thing I think about with that is that, Mmm. Those are things that people don't really realize. And it doesn't, my impression would be that it wouldn't happen all at once. It would be, Oh, we can increase our revenue by 5%.

With one patient, right? Like, okay, we're going to add one patient across the board every day. That's what we're going to do. And then pretty soon it's like, okay, well next time we need to increase revenue, it's another patient and another patient. And so, um, have you, what did he think about that? And then what did, have you seen the, the implications of that has that actually come to fruition?

So I, as I asked him this series of questions, another important question, Chris, that I. Mentioned, or something that he should do in terms of his homework, was to ask the potential buyer for a list of other physicians, other optometrists who've sold to them maybe two years ago, and see what life is like after.

Because when that person is talking to you about trying to buy your practice, you're only going to hear the good stuff. And if you're not equipped, this is a once in a lifetime decision and so many ODS. Uh, haven't gotten the experience and the knowledge to ask the right questions. Yeah. So they really know what they're getting into.

And then maybe the most important question I asked him, Chris, was, all right, you're 57, you're taking home X per year as an owner, right. And a doctor, have you done the math to compare getting this lump sum today? And then becoming an employee at say 17% of revenue for the next five, six, seven years. Have you compared that to owning it for another five years and selling it?

Even if it's at a lower valuation or multiple, five years from now, you're, you're still going to be better off cause that's the math. Yeah. That's the, that's the kind of get is. We are seeing valuations like there never been, and like they're never going to be right. That's the sort of tagline that I've heard is like, I can't, they're never going to pay this much for practices anymore.

And your, your point is even if they don't, and you stay an owner in front of their five years, you're still, and you grow that just what you've been growing, you're still going to be on the top side. Yep. And again, hear me, I'm not. Telling people not to sell their practice if somebodies 64 years old or if they're just fed up with the business aspects of running a practice and they just want to be an employee.

But so many vision source doctors are really are good business people as well as being good doctors. And. They get, they get excited when two or three people are calling them wanting to buy their practice and throwing numbers around. Another important question, Chris, is how much of that consideration is in cash?

Most of the time it's 70% or so and there's some hook for the other 30% whether it's debt or equity in the business that's acquiring them. And my, my point there is. Hmm. More than half of these things are going to struggle because it's hard to find the leadership teams to execute to do well. They're all going to be highly leveraged with a lot of debt, and if they don't do a good job with integrating all these practices and managing them well and driving, you know, more EBITDA, more profitability to the practices they acquire.

They're going to get into a situation where that equity might be worth zero. If you go back to the 1990s you know, I like to look at history when we were doing this at Concentra in the 1990s. So many of these physician practice management companies were going public there. IPO after IPO, after IPO, and if you look at the top 10 public companies in 1997 names like PhyCor and med partners and PRG and American oncology of the top ten eight of them fail.

Eight. Wow. And the other two merged become us oncology. So my point there is you can expect that equity that you get when you sell your practice to really be worth something. History will tell you that there's a pretty good chance it could be worth zero. Yeah. What is the, what's the end game? So, so I, um, last week on the podcast I talked to David Nelson and he is with Kepler and, um, and he, he actually used to be a vision source.

He's a great doc. He's got a long history in our profession. Um, but I tried to get to the end game. So like I, and I've asked this a couple times on the podcast on with people to try to foresee like what's going to happen, because there's two things that, in my mind is one is that you can't save your way to profitability.

Like they can't pay all of these. So if I can restate this, if I pay 10 times EBITDA, essentially what I'm saying is I'm willing to give you now 10 years of business profitability. To buy your practice, and that means that I'm gonna either have to hold on to it for 11 years or 10 years in a month, right.

To make my money back, or I'm going to have to flip it sooner than that and, and make 15 EBITDA or whatever the, whatever the multiple is. And so then I think, okay, well, what's the end game? You know, is there. Is it that everybody is going to end up in an IPO and then then it's like we've, we've spread the, the risk over so many people that we don't really care anymore.

We've made our profit. We're out. I mean, what is that the end game for all of them? I mean, I just, I feel like you can't, you know, and then the other thing, if I can make this point, is that. We really pay attention to our practice because I'm in there every day and I'm watching, okay, well how much are we spending?

How much are we generating? How much, and I know that. It's really challenging from afar to care as much about that individual practice. Um, yeah, it would be if, if it were in my hands. So because it's removed, if I have enough of them, okay, well maybe I'm losing a percent here, a percent there. So what's the end game?

You can't, you can't continue to just cost a good save your way. What do you think? That's a fabulous question. And you're right. These private equity firms as owners generally have a five year time horizon, give or take. Sometimes an opportunity will present itself and they'll sell a business after three years because they've acquired, right?

They've grown those practices, their meat reaching the peak of profitability, and they typically will sell them to a larger private equity firm. My eye doctor is a great example. They've been around good business. 650 million in revenue with Atlas as the private equity firm announcement in June that Goldman Sachs is merchant banking arm was buying them for four times revenue, 18 times EBITDA and what they don't, I mean, these are smart people.

But they see optometry as a sleep be under managed healthcare light got this retail aspect. We can do a better job managing the retail. We'll have these doctors seeing more patients and every patient is going to be worth X cause we're going to do a better job of. Following up on the patient in the optical part of the practice.

And that's what my doctor has done. And apparently they've done it fairly well. But again, getting back to my experience at Concentra, Chris, as we started out. We were buying multi location businesses. Just like my act, my eye doctor probably was when they got started, and typically something we're at one doctor owns eight locations.

There are opportunities to make them better. That was our experience, of course, and for the employed physicians as we did that, their life was actually better. Because they were becoming part of something that was more sophisticated, something that had 50 102 hundred physicians, career paths, better systems, better measurement, outcome measurements, et cetera.

So, but once we got done, once we had Concentra got done with those large multisite groups around the country, and we started buying Dr. Wolfe and Dr. Brown and Dr. Smith, you've already consumed all the big ones. Yup. And. Even though we were, we really prided ourselves on having great relationships with our physician partners and having an environment where the physicians were happy.

The single docs who sold went from being owner to employee, and a year later they were gone. Yep. Because things change as you know, these people who romance the seller and say, nothing's going to change. Well, that's so much baloney. Yep. Yeah, things are going to change. They have to change. They have to have, you go from 18 patients to 25 patients a day to continue that trend, or the business can be sold to the next private equity firm and then the next private equity firm, and as a seller, you might like the people you're talking to today, but you're going to have very little, if any control.

Over who they sell it to. So I asked for it and consideration on your age. Yeah, I, and I asked, I asked David about that. I said, David, how do you know that when they flip it the next time, you're going to be happy with the people that own that practice? And he said, I don't know. I can't know. And, and, and I think the bottom line with that, from, from my perspective for him, was that.

Um, at least he's accepted that at least he understands that's the risk. He's at a point in his career that probably in three to five years he would be okay being done. But I think also he's, he's savvy enough in the profession. He's sharp enough that he can do a number of other things as well. And, and so I, I respect him for all the stuff that he's done, but I, then I asked him that, which was really interesting to me, is I said, so David, if I'm a young doctor, I'm coming out of school.

And I want to come in and I want to be a partner because essentially the way he described Kepler to me was that, that if they buy your practice and you have a partnership path, and um, and I said, but let's say I don't already own a practice. I haven't built a practice that you want to buy. Can I become a partner over time?

I'm a young doctor, I want to be partnership. And he said, I don't think we have a path for that. So that's very interesting. So, so then, you know, here I am 38 years old. I'm 11 years, 11 and a half years into growing my practice. Of course, I'm, I'm purchasing the practice from my dad and who's not ready to step away yet, which I don't want him to step away anytime soon, but the, um, but I think, okay, well, you know, we've got an young associate and she might want to buy into the practice at some point.

Well. She wouldn't have that option. She'd be always an employee forever if she was with one of these groups. And so that's a challenge with minimal, if any, real upside. So how are you going to attract the best and brightest to serve your patients 10 years from now? You probably not. If you look at dentistry, there's so tiny about 75 private equity backed dental organizations this, but they've been at it for 20 years, Chris and very few.

Are deemed to be success stories and the turnover of the dentist. Oh yeah. Crazy isn't in like the 20% range. They just don't last. They don't like the empire. There are one offs. You know, there'll be here on Monday, they're on Tuesday, they're on Wednesday. That the continuity of care that we've enjoyed in our practice could not be had.

I'm in mass with me being in 130 second and Dodge on Monday and Elkhorn on Tuesday and Papillion on Wednesday, and you know, uh, Gretna on Thursday. I mean, they're just, you know, the, the type of care that we provide for our patients just wouldn't work that way. And the buyer wants to separate you, the selling doctors from your patients.

I mean, it's just, it's good business. If you're the buyer and I write you a check for $1 million and your 42 years old and for that million dollar check, you have a five-year non-compete. Well, if I don't separate you from your patients year six I do something to make you think about starting again. You could open up across the street.

Yeah. And you still have those relationships and guess what the patients are going to follow and what I paid 10 times for. To your earlier point. Nothing. Zero. Yep, that's right. Yeah. So this why they want to separate you from your patients. It's interesting. We've seen in Nebraska, we've had one group come in so far that I know of one group that is bought to multi location practices, and each of them are about five locations.

One of them. So. Um, and it's a group that, um, that a, uh, a prior, um, vision source. Uh, he must've been a DND. Um, yeah, I D and D is kind of working with that group now. And he, uh, so director of network development, he's helping him by practice. He's helping them by practice. And so they bought a practice, uh, recently that had a location in a smaller town that they hit acquired maybe two or three years before the private equity firm bought the larger group or the five, five or six location group.

And. Um, I just, I was at a, um, a Christmas dinner in no, in December. And that, that the doc that started that practice that sold to the larger group a few years ago that now sold to the private equity firm got word in November. They're closing the office. He's done out of a job. And, and, and he, you know, he was mad.

He was not happy. Um, and I said, well, you know, I won't use his name, but I said, well, you know, what, what kind of recourse do you have? Because why? I've got early retirement. I have no, you know, I don't know. I didn't have any say in the deal. And, and essentially what happened is they looked at the profitability and all those practices, and they said, look, this is not worth us opening the doors every, every day, and we're just going to shut it down.

Now I'm not saying that to be alarmist. It's just the reality of like. You don't have the control anymore. Even when, like you said, even when you sell to this group that you do trust, the first group. Even in the second spinoff, it's like you have no, you don't have any idea of the culture of that group or, or what their values are or how they're going to generate different revenue.

And it was like, it was really shocking to me. And then that same group, um. There's a doc that's been really involved over the years and the association is with that group. And what we're seeing, and I won't even just mention this particular story, but what we're seeing in general is that these docs that were like super, super involved are, yes, they're taking a step back.

And, um, and on the one hand, I think, uh, that I'm like, why is that the case? Well, I think it's true. Okay. So we have a testimony next week in the legislature, and I own my practice and if I want to cancel days on the patient, or, you know, cancel patients on a day so I can be at the legislature and provide testimony.

Then I can do it. I don't have to take my vacation days. I mean I essentially, I am right. You have to be approved by somebody that it's done right. I get it. I get to say, look, Kelly, I need my patients cleared that day. And yes, do I lose money? Yes. But, but I, that's, that's something I get to decide to do.

We're seeing that, you know, um, that, that PA, um, I'm trying to be careful cause I don't want to disclose things that are privy. But. People don't necessarily have that. You know, they, they might have vacation days, but they're finite. Oh yeah. You're an employee. Yeah, that's right. That's right. You're making us money.

[00:26:05] You get, you know, four weeks a year. That's it. And if you want to collect your salary and stay on, did collect maybe that other 30% two or three years from now, you follow our rules as an employee. I was in Iowa recently, in the fourth quarter of last year, and I heard some stories about people who'd sold in Iowa.

[00:26:29] And guess what, all of a sudden the donations that they made to the boys scrub to the little league totally right, to whatever. They couldn't make those decisions, even if it was in the best interests of their practice. Yeah. It was hard to get the money to continue making those donations. It's just little things like that that you don't think about.

[00:26:47] Yes. The decisions you make as a business owner, there are going to be different. Yes. And again, and I can't blame anybody. I've, I've said this before, you know, if I were, if I were 65 years old and I couldn't find it. And that's the, that's the challenge. And I, I love you for you to talk about some of the, um, some of the, uh, things that vision sources doing for this.

[00:27:07] But you know, the challenge is that if I'm 65 years old and I'm, and I'm having somebody offer me, let's say eight times EBITDA. And, uh, maybe I could get five or four, you know, uh, from, from a young doctor coming up. I see. I get it. I still think fundamental. I'm idealistic enough to think that in the longterm, I think patients are best served by private practice.

[00:27:36] But, um, I S I S I can understand that aspect of it. What I, I just, um, so what, what sort of programs are in place that you had developed over the last five years or so that you've been involved in helping develop with vision source to help plug those other students in so that they. Ken have an opportunity, and doctors don't just have to say, look, I can get so much money.

[00:28:01] I got up, I gotta be out. The vision source brand was virtually unknown with optometry students. So over the last two or three years, there's been a tremendous investment. In elevating the brand, elevating the vision that, Oh, I can go work in private practice when I graduate. I might not be ready financially to start a practice or to buy into a practice, but I don't have to go work in a setting where I'm not necessarily utilizing everything that I've learned.

[00:28:38] So the pipeline that vision source had been able to build and it is building, is creating opportunities for those graduates to go work for vision source clinicians across the country. And once you get a taste of that. As a 25 year old, 20 or 23 year old. Yup. Yeah, you can, you can see the quality of the care.

[00:29:06] You can see the ability to make your own decisions. Versus going to work in a setting where you're told what to do and how many patients you need to see and what products you're going to use and what equipment you're going to be allowed to use. And I was, again, from the beginning back in 2013 when I joined, I was just so impressed with the medical orientation of most of our membership.

[00:29:31] And there's real, there's gold in those Hills in terms of, yeah. Utilizing the medical aspect. There's just such a need and it's a shame that some of these graduates may not get the chance to see that. So through vision source, next doing that. And then Chris trying to have administrators around the country, uh, hu identify members who are innovators and, and want to invest.

[00:30:00] And my dream would be that. Those little clusters buy out the 65 year old and put in a young doc as an employee. Initially. And those are the investors and they're, they're helping coach and, yes. So tell me, so, so that that transition happened, and I'm not, I'm not trying to put words in your mouth or, but this is very interesting because it's a question that I, that I, that comes up often just in private conversations is, look, we understand how to run a business, right?

[00:30:30] Collectively, you're going to see. You know, 40 docs here tonight that I trust, I trust to open my practice, to I trust to ask them about their opinions on how I'm going to manage patients and how I'm gonna run my practice better. And, and largely they trust my opinions as well. And so, um, so with that, the, Mmm, hi, is there a mechanism, what's your vision for a mechanism whereby we could get together and say, look, this is.

[00:30:58] This makes sense for us to partner to buy this practice, you know? So it doesn't wind up in private equity. And then just as part of an IPO mean, what are your thoughts about that? Know my, my dream, and as I threw out 2019 my vision that I was sharing with our parent company was to provide opportunities to have access to capital.

[00:31:28] Through the S lower Lexotica strength, their balance sheet to allow groups of doctors to come up with their own equity, but then also to borrow it, competitive rates and terms to be able to. Provide that exiting doctor a fair value for their practice and to do some of the things that we're talking about here that that's still a dream.

[00:31:54] I would hope that the SLR, uh, leadership ultimately embraces that and provides a pathway for vision source to self perpetuate. And to have those transitions. I mean, we have so many quality doctors who could be investors. And maybe 10% of that practice with eight or 10 of your friends and you put that new, that young Odie into practice and you're coaching them and you're equipping them, and then they're buying in there.

[00:32:30] They're buying you at over time. That's the dream. Yeah, that that is so, okay. So we just need to keep our foot on the gas for that. Yeah. So, um, so let me ask you this question. More people that are mentioning that as an effective solution, the better, in my opinion. Mine too. I think, you know, I think that, um, that we have an opportunity when you get to a point where, you know, on the one hand, I look at my practice and I think to look, I'm happy, I'm content, I love my practice, but I, but I also really believe in the vision of private practice over time.

[00:33:05] And I hate to see. That you know that you have these practices that are going to die on the vine or they sell any, ultimately they're gonna. They're going to be a, my vision. Again, this is jaded by me, but my vision is that private equity is going to ultimately wind up as just another commercial location that's going to be, uh, you know, another vision works or, um, or you know, name, Walmart or whatever.

[00:33:31] Right? So the, um, that name, it's not gonna happen in five years. It's probably gonna happen in 10 or 15 years. And essentially it's just one other Avenue for people to see patients that they're not able to, to provide the highest level of care. Um, that they possibly could. So the, um, I, I, I promise you there will be some dramatic failures.

[00:33:56] Oh, of course. Of course. yeah. When I joined vision source, AOS had been out there and that, I think they had 80 locations in 15 States and a couple of vision source optometrists had sold to them. And in the first six months I was here. I get a phone call from a doctor Chris, who had sold to AOS and they had completely, you know, screwed up, accounts receivable went bankrupt.

[00:34:24] Weren't paying the landlords. So this doctor who had sold to them his door was locked in his practice. He couldn't get in to see patients to fund his own salary because of their mismanagement. So yeah, and not everyone's going to sell. There's some percentage that are going to sell, but independent optometry.

[00:34:47] You know, through this beautiful model that vision source has sustained for nearly 30 years, is here to stay. In my opinion, there's the , the abundance and the need of patients to see a optometrist is only going to grow. Uh, there's no more Optum. You know, ophthalmologists are gonna stay flat there. There's a tremendous need.

[00:35:07] Great opportunity. And, uh, another thing that we haven't talked about that I think is just is high on my list is all the rural practices that we have. Goodness, the private equity firms well, are 700 vision source locations in rural settings. Auburn, Nebraska, and the private equity firms are not going to buy those because it's hard to recruit to those small towns of 3000 people.

[00:35:33] But as those ODS near retirement age. If we can embrace tele optometry and have somebody from Nashville, Tennessee, buy a practice that's a hundred miles away and keep the real estate, keep the staff in place, use the equipment, allow the patients to keep going to that practice in that small town. Yeah.

[00:35:56] And use tele optometry to quote unquote see the patient from Nashville, and then maybe send an optometrist there once a week to see the patients who need face to face engagement. I love that. Yes. And I hope that the vision source team embraces that going forward. Cause there's 700 of our colleagues who need an exit of some kind.

[00:36:19] Yeah. If they can't do that, then they may just end up shutting the doors and so many do in small towns. So yeah. I mean, Mike Rothschild is. Yeah. You know, um, I talked to him and I'll probably have him back on the podcast about tele-health until optometry because it's pretty striking when you see what we can do and it's just becomes an extension of really excellent care as opposed to, you know, the, what people automatically, you know, think about, um, one last question cause I want to be respectful of your time.

[00:36:51] Um. What, so when I was talking last week to David, the comment that he made was that. Um, I, I'll just throw out the number 200 practices across the country. I think that's low. It's high, but we'll just use that as a number. He said that, that Kepler had owned 200 practices across the country and that their goal was that, um, that they would be able to negotiate with, because they own the practices, they can negotiate with payers.

[00:37:20] And so I immediately thought in Nebraska, what is the critical number that you have? Because in Nebraska we had a independent physician association that was about 120 members large, and we still found it challenging to negotiate with payers. So I thought 200 across the country doesn't seem critical enough.

[00:37:39] And in your experience in healthcare in general, with Paul Williams and all those other sorts of things, what are you seeing? What's the critical mass? Is vision source close? I mean, what. Well, the problem is healthcare is so state specific and even beyond that market specific, Chris. Um, in addition to what I've done in the past, I serve on boards of.

[00:38:02] A dermatology business, a primary care physician, business and autism business, and you need to have 30 to 35% market share of all the clinicians in a specialty, in a market to get the attention. Of the health plan? 35% yeah. So some of the, some of the business models that have succeeded in that are Aniston.

[00:38:27] Anesthesiology is a great example because if you have a third of all anesthesiologists in Omaha, and you go to United healthcare or blue cross and say, Hey. You know, give us a 20% raise or we're out. Yeah. That gets their attention. Cause surgeries have to happen. But most specialties are really at a competitive disadvantage.

[00:38:50] Jim Greenwood: [00:38:50] Even if you get to 35% market share, the health, the hospitals can do that. You need hospitals and you need anesthesiologists. But when it comes to most other aspects of provider world, it's really challenging. Yeah. I wouldn't count on it is my point. All right. Well with that, thanks Jim, so much for coming on the podcast and being here with us tonight.

[00:39:14] Um, I really appreciate it. I hope to do it again soon. Thanks for all your work. I can't thank you enough for what you're doing. This is fabulous and awesome. Thanks Chris. Thanks a lot. Appreciate it.