From Front Desk to $100M+ Healthcare, with Alejandro Fernandez from Synergy Orthopedic Specialists, BOAC E55

0:00What I think is so interesting is that Alejandro started at the front desk in the early 90s and is now the CEO of all the desks in the group. So huge journey.

0:09Alejandro Fernandez: I learned early on when summers and weekends, we were in the store learning about entrepreneurship, about how you run an operation, sales, marketing, accounting, etc. What makes a business tick? I always thought, particularly living in Miami, Florida, going out on weekends, trying to meet girls and buy beer, it's not cheap. I always say I got an MBA and then I got another MBA when I went and did a private equity deal, particularly when we were the sellers. And today, probably the second or third largest gastroenterology group in the U.S. with over, I think there are like 600 physicians in that group.

0:43Alejandro Fernandez: And when people say, hey, how'd you got into healthcare? And I think about it. The first thing, all paper records. I had people running a 10 ,000 square foot office trying to look for one chart. And literally have to go one by one looking for the chart. The idea is that everything has changed. And I always say the only constant in healthcare is change. And now with AI, I forgot that. That just takes it to another world. The whole way that healthcare gets the business or the way healthcare gets managed, it's still the same. It's interesting. I was speaking to someone recently and they said healthcare is one of those really interesting industries where the innovation makes the exterior look like a sports car.

1:20But if you open up the hood, you still find someone on a bicycle underneath.

1:23Alejandro Fernandez: A lawyer charges$700 to$1 ,200 an hour, and a physician has to charge somewhere around$300, about a quarter or a third. I would say doctors, surgeons get educated and spend a lot more time in school and have skills that are not illegal, keep me out of a lawsuit or keep me out of jail versus, oh, I'm going to die. You can automate everything out of healthcare that you want, but at the end of the day, you've got a human somewhere in the journey. I think injecting that empathy, making it very human-centric, even if what's sitting under the hood is a machine that's running at full speed, that top layer, it's got to feel like flesh.

2:09So we are back for another episode of The Business of a Clinic. We are here with Alejandro Alex, goes by both, who is currently the CEO of Synergy Orthopedic Specialists in the U.S., 30 years in healthcare operations of different sizes and shapes, which he'll take us through in a couple minutes. What I think is so interesting is that Alejandro started at the front desk in the early 90s and is now the CEO of all the desks in the group. So huge transition, huge journey, interested to dig into that as well. And I think on the larger side, worked with groups and led groups of 100 plus providers. So there's probably some interesting learnings that you have from that experience as well.

2:49And I know that early on in your career, you built a gastroenterology group into one of the bigger players in the space. So I think we've got a lot of ground to cover. Thank you so much for joining. I wonder if you can maybe start us off with just a quick intro. Obviously, we're getting to know each other, but others do not know you. Give me a sense how people understand where are you right now. It's early morning for you in California, but tell us a bit about how you got here.

3:13Alejandro Fernandez: Yeah, excellent. Jared, first of all, thank you for the invite. Thank you for having me on your show. A lot of insight that I've learned by looking at the different shows over the year. And so basically, like you stated, my journey in healthcare is kind of interesting because I don't have physician parents or I don't have any family that there were in healthcare. My family actually was in the retail industry for most of their life. My brother, my younger brother's also in the same industry kind of took over my parents' business. But I learned early on when summers and weekends, we were in the store learning about entrepreneurship, about how you run an operation, sales, marketing, accounting, et cetera, what makes a business tick.

3:58Alejandro Fernandez: And then I was going to college, putting my way through school. My parents didn't necessarily have the college fund as we do for our own kids. And I had to pay my way through school. So I needed money. And I always thought, particularly living in Miami, Florida, going out on weekends, trying to meet girls and buy beer, it's not cheap. I said, I need to get a part-time job. I need to do something. And I got a job in a doctor's office, working medical records, working the front desk. But I knew a little bit about accounting and bookkeeping. So that gave me a step up. And later on, I learned how to do billing and coding and basically the whole revenue cycle management program.

4:35Alejandro Fernandez: And then over the years, I got my advanced degree and got my bachelor's and got my MBA in healthcare administration and grew groups from five, six doctors to 10, 15, and then 15 to 18, and another group from 18 to 60. And then now, wow, almost 10 years ago, we went through a journey with basically getting the group in an exit to private equity. It was extremely exciting, extremely... I always say I got an MBA and then I got another MBA when I went and did a private equity deal, particularly when we were the sellers. And then later on, I started acquiring with private equity. did almost 30 transactions in gastro health took gastro all from originally it was 18 doctors when i started when we did the deal we're around 50 when we when we by the time i exited personally i left the organization we're about 150 providers or excess of 100 million dollars in revenue uh so a journey of taking a business that was double digit million in revenue or low numbers all the way to basically you know hundreds of millions of dollars and today probably the second or third largest gastroenterology group in the U.S.

5:43Alejandro Fernandez: with over, I think there are like 600 physicians in that group. There's a lot to pick out of that journey. Two things that resonate with me personally, I also don't come from a family of doctors. It's always nice to hear about people's journey into healthcare who don't necessarily have it in the DNA, as it were. And the other thing that resonated is that I also started at the front desk when I opened clinic, spent a lot of time at effectively reception. And then this sort of went from there. So that makes a lot of sense. I guess we start picking into the different parts of the journey. 1990s is when you found your way into the space.

6:22Now we're in 2026. I was going to check the date 2026. Now what's changed in that period? A lot of things. What are the sort of I mean, just think about it.

6:34Alejandro Fernandez: Yeah, I always reminisce about this. When people say, hey, how'd you got into healthcare? And I think about it. The first thing, all paper records. We use the computer, even bookkeeping back then, Excel. I think it was Lotus 1, 2, 3, not Excel. And it's like just the technology around healthcare from a business perspective. and then the technology, which I don't necessarily speak around clinical aspects, but living with doctors for so many years, the advances in technologies. I was in gastroenterology for many years. The event of biologics coming into Crohn's, colitis, and many other today, we don't think twice before saying, well, I'm going to get an injection and I'm going to give it to myself, or I'm going to go get an infusion, whether it's IV therapy or you're going to get a medication that needs to be introduced through IV.

7:27Alejandro Fernandez: The technology, the advancements around pharma, the advances around imaging, the advances around just the flow of information. I remember having, we would do medical records, so therefore they're on paper, and we were trying to look for a chart or somebody needed a chart. And I had people running a 10 ,000 square foot office trying to look for one chart. And literally you have to go one by one looking for the chart or claimed. I I remember claims when we were still printing claims. I remember when I, at the beginning, I had to do for Medicare these blue cards in Florida, these blue cards because I guess Blue Shield managed Medicare at the time.

8:03Alejandro Fernandez: And you had to bubble in things. Basically, it was ready to be scanned through their computers. I remember we started doing coding and then later on through the computer and then the computer allowed through a dial-up modem because I'm AOL age. it was B and whatever, and basically just dial up modem your claims to whoever the provider was, Medicare or Blues or United, where now you would never even think of having to print out a paper claim for anybody. Granted, insurance companies want to go back to that so that way they could delay payments a little bit. I'm a little towards the physicians. I think that they get a bad rap.

8:40Alejandro Fernandez: That's why I really love working in the medical group physician space versus I could probably I've gone run hospitals or be in the nursing business or be in any other business for that matter. I could run and I have run other businesses other than health care organizations. So the idea is that everything has changed. And I always say the only constant in health care is change. It's always changing. Literally every year or something, every month, every couple of days or something. And now with AI, I forgot that. That just takes it to another world where we're going to little by little transform the way that healthcare is perceived and just the experience itself.

9:18So it's interesting. On the one hand, I totally agree with you. A lot of things have changed. I was not in healthcare in 1990. But a lot of things have changed, even in the times that I have been in the industry, the last 10, 12 years. And yet, I often feel like healthcare is one of the slowest sectors to change. it feels very fast and at the same time if you look at other parts of the market in other industries it's fast when you compare it to shipping it's very slow when you compare it to actually don't know if it's fast when you compare it to shipping i don't know that much about shipping but it can feel very fast and very slow but now you're saying hold on we're going someone just moved the car up to fifth gear we were in third year now we're in fifth year ai is here it's starting to accelerate where are you seeing that that sort of acceleration that pace around change, how are you feeling at day to day?

10:08You run as a large provider operation right now. How do you, where does it show up in your nine to five or in your eight to eight or whatever hours you work? Where does this show up? Where do you feel it the most?

10:20Alejandro Fernandez: Yeah, I think right now in particular, like we evaluate practices that we're looking always to acquire or merge into our enterprise. And I still go to offices, five, six doctors that are, there's still paper records in those locations. I'm like still astonished that we're still there. They're using, there's ASCs, there's ambulatory surgical centers that are basically still running on paper. Many parts of the process have transformed and gone to the next level where the technology is fully embedded into the business. You need a computer in order to interact with the patient, interact with the payers.

10:58Alejandro Fernandez: But at the same time, think cost. There's two ways to look at the cost. Some physicians look at the additional cost of technology, but they don't necessarily bring them any additional leverage when it comes to growth or revenue or, for the matter, contracting. Because, again, those things are still, some things have advanced and, again, some things have not. When we think about the way we get paid today, it's the same way that we did 30 years ago based on a percentage of Medicare. And Medicare kind of dictates everybody's numbers unless you're, and we do a lot of workers' comp. So we have worker comp fee schedules that are derived by the state.

11:32Alejandro Fernandez: and even those are pretty archaic as well. The whole CPT code system, the whole IC10 system, the whole way that healthcare gets the business or the way healthcare gets managed, it's still the same, we still have, they were moving to, I wouldn't even say now health systems or health enterprises where you have at Aetna and CVS that own medical practice and clinics and pharmacies and health insurance payers and so on, or an Uptum that's in the similar bandwagon. But the majority of the health care gets, the exchange happens with a doctor. You feel bad, you're ill, you get sick, you engage with a provider, or again, whether it's a nurse practitioner, a PA, or a physician, but you engage with typically a physician, and then that person provides orders, sends scripts, and thankfully now they're all electronic, So you show up at your pharmacy of choice and usually is there.

12:32Alejandro Fernandez: The insurance already verified. The pharmacy verified the insurance. The doctor verified your insurance. Hopefully they charge you a copay or your coinsurance and we know what to charge you. And so on. So I think we've come a long way, but the complexity of health care still exists. We just come up with other tools to go around. If we think about it from a, if we were saying, hey, we want to lean the process or develop some type of Six Sigma process with healthcare. There would be tons of workarounds that we're doing. There's lots of failures points that we have. So as much as we've come forward, we're still very complex business.

13:14Alejandro Fernandez: And the technology has not really advanced us, just allows us to develop more workarounds to try to facilitate the complexity and make it seamless or more seamless, just simpler. It's interesting. I was speaking to someone recently and they said, healthcare is one of those really interesting industries where the innovation makes the exterior look like a sports car. But if you open up the hood, you still find someone on a bicycle underneath. At its core, there is this structural inefficiency that you can... Blue rings. Exactly. Total blinstones. It looks great. It looks like a car, moving really fast, but But there's something structurally that prevents some of that acceleration.

13:54So you can work around faster, but you're ultimately still working around. It's very interesting. One of the things I'm curious about, so you said at the end of the day, you're still interacting with a physician. You're still coming in, or maybe it's a PA, maybe it's a nurse practitioner. That patient-provider relationship, there's an element that will never change. Some people will say, here come the AI doctors. I personally don't, I don't buy it yet, but maybe at some point, maybe at some point it will, but I don't buy it yet. But a huge amount of the care continuum happens when the patient is not physically there.

14:26So they may come in for a question for help, then they leave. I'm curious, in the time you've been in industry and how do you think about it today in your role, when someone comes in to see you, how do you think about providing 360 degree care provision where you're giving that five-star experience when someone is physically on site with you, but also when they then walk out the door, it's not like there's someone else's problem. So what does that look like for you? How do you think at an operator level about providing that patient support in and outside the clinic?

14:58Alejandro Fernandez: Yeah, I think the question is even more basic than that because you're already assuming that somebody got in. So I think the biggest problem in healthcare, it's truly access. There's limit access due to narrow networks, limit access due to your lack of insurance and high cost of healthcare. So there's first, the idea is access, entry points. If you're a new physician, you start your new practice, you'll get a Medicare number, Medi-Cal number, and you'll be able to see those to type of patients in cash. If you're lucky, you'll be able to get added to a couple of PPOs or general programs at a very discounted rate where basically it almost, it's extremely hard to live or make a living as a physician.

15:48Alejandro Fernandez: And then you have, then as you, time goes by and you develop some expertise or maybe some type of boutique type practice, maybe you say, I'm going to be a concierge type physician. So therefore, I'm going to provide 24-hour care. I'm going to go ahead and call me on my mobile number if something comes up, etc. The problem with that is that the business of healthcare does not provide a payment for the whole episode of care. It provides payment for specific interactions with the patient. For example, you come into the office, you see your doctor, he prescribes some medicine, you're supposed to come back, let's say in a year.

16:30Alejandro Fernandez: But within that period of time, within that year, other things come up. And the only way to interact with a physician based on the current payment model is that you actually have to come into the office or do a televisit in order to interact with the physician and have a conversation. I mean, in truth, no different that if you were interacting with a lawyer or interacting with an accountant or interacting with a web developer or anything like that. You're basically charging by the hour. But I always say, if you think of what the reimbursement is for a gastroenterologist, when you have, maybe you're constipated and you feel bad, your stomach aches, and you need to go and you don't have insurance, and typically you're going to get charged$300 to$400, depending on the market, depending where you're at, but somewhere in the ballpark for a visit.

17:19Alejandro Fernandez: Maybe with insurance, it might be a$100 crope or a$50 crope or something like that. But if you had, for your house, if your stock got stuck, your toilet got stuck, and you have to call the rapid-rooter-type individual plumber to come into your house and do that, the first thing they would say, that's great, but for us to go to your house, we have to charge you a$150 visit. And if everything goes well and we end up doing some more stuff, maybe we'll throw in that$150 into a credit and the other thing. And the next thing, they take out your kid's toilet. The kid went in and dumped through the toilet and unplugged your toilet and charged you$500.

17:59Okay.

17:59Alejandro Fernandez: I don't know. Something's wrong with that. Something's really wrong with that because you have the physician that's going to charge you$300 for, and then people say, it's really hard. Doctors need to only see me for five, 10 minutes. The system is set up that way. You know, a lawyer charges$700 to$1 ,200 an hour, and a physician has to charge somewhere around$300, about a quarter or a third of what a, somebody that's somewhat educated around the same life cycle, I would say doctors, surgeons get educated and spend a lot more time in school and have skills that are not legal, illegal, keep me out of a lawsuit or keep me out of jail versus, is, oh, I'm going to die, or I'm going to, something really bad is going to happen to me.

18:49Alejandro Fernandez: And I don't know, I think there should be greater value to the equation of equity of healthcare versus other professions. Again, lawyers, accountants, there's a lot of professions that are really good. So not really batting on them, but just trying to use that analogy, a plumber, et cetera. And going back to, we talked a little bit about it in regards to AI. I truly feel that the COVID time period where we started using telemedicine as a way to interact with patients at their home changed things significantly. But at the same time, there's been over and over, year after year, trying to reduce or basically cut back on the reimbursement and utilization of telemedicine by payers, by the government, and so on, trying to get patients back into the office instead of trying to have healthcare provided to them.

19:38Alejandro Fernandez: So a lot of people that want that almost feel like they have to pay out of pocket for that cost and not use their insurance or not use their government-funded programs. In addition to that, if you look at that perspective, there is a much higher, I would say there's a much higher opportunity or engagement with a patient when they're physically in front of you. You can't, if you have a stomachache, the doctor can't touch your tummy and see if it's rigid. If you have a knee issue, they can't ask you to bend your knee and see and touch where hurts and try to figure out if it's an ACL tear or if you just have inflammation and arthritis in your knees.

20:18Alejandro Fernandez: And then you have to get the MRI or the x-ray and all the other things happen. So eventually you still have to come in. So I think that there's going to be opportunities where AI will play a role in providing medicine. I'm not sure what it is today because I think that it's still too early on and I think physicians want to continue controlling it. But I do know a lot of that are trying to figure it out themselves to try to see how they expand their practice of medicine and they could provide more care to more people. Because again, going back to the first thought that I had, access, I think it's the biggest problem.

20:51It's interesting. Obviously, I'm in the UK now, book group in the US, so I'm familiar with both health systems. I think there are similarities in the UK. I always say that the easiest way to think about the sort of value chain is if you just assume everyone is self-paying or cash pay for the time being, just to get rid of the complexity. It's really interesting. You said something. The plumber example is interesting, right? It's when you're getting charged by the plumber, you're being charged for the end-to-end logistics and operational delivery to get there, to fix it, and then maybe to come back and fix it again.

21:23And when you said that, I found myself thinking, when I go to the doctor or when I think about paying for healthcare, I very much index to the specific moment of intervention. And I don't think about the fact that fee model actually needs to cover the entirety of the pre, the post. And I think you're right. I don't think that providers could get away with charging that way. But it's interesting, certainly from an insurance perspective, I guess there isn't coverage for the plumber getting out to your house. That's not the value moment is take the toy out of the toilet. That's the aha moment. That's what we're going to pay for.

21:58but everything else. But actually, it's everything else that enables that to be really high quality. It's interesting. Yeah, it's an interesting way to look at it. I'm curious, in your own experience, people who work in healthcare, if they don't come from background in healthcare or families in healthcare, I think you start to develop your own ethical compass, moral compass around the rightness, the wrongness. What are the gray areas? What are the black and whites? I'm curious if you think about the billing model, the patient versus customer conversation. On the one hand, you have to provide clinical care.

22:29On the other hand, you have to provide good customer experience. Those two things together working to result in ultimately a sustainable business. How do you balance the care provision and profitability equation? What are the sort of internal heart and headstrings that you sometimes pull on to do the best for the patient, but also to do the best for the provider? And likewise, if you've done stuff in private equity, so there's obviously a very strong commercial mandate and agenda as well. So quite curious to how you balance those things as a healthcare leader.

23:00Alejandro Fernandez: Yeah, I think that as a leader or particularly a leader that's an operator, not necessarily a clinician, I think I look at it in a different way or a different scope. The actual, my job, in my opinion, is more around developing a biosphere, a program, a network of positive and procedures and interactions and opportunities so that the clinician can provide the most optimal care at the highest level of specificity, provide excellence in the experience, and for sure, outstanding medical care. Quality has to be there. I think all physicians want to provide the best care for their patients. They also want to get renumerated fairly for the work they do.

23:51Alejandro Fernandez: Granted, the programs that exist today, they feel like, for example, they're told if you overcode, it's fraud and you're going to go to jail. So it's easier for them to say, maybe it should have been a level five, but I'm not sure. So let me charge a level four because I prefer undercode than overcode. I feel like most providers tend to undercode or underbill for their services. In addition to their physicians, their clinicians, they're not business people. They were not taught business. They were not taught coding. They were not taught how an enterprise works, how a financial cheat, basically a P &L works.

24:28Reviewing income statements, reviewing the metrics of organizational management and figuring out how many employees they need, they don't.

24:36Alejandro Fernandez: They look at us, do I have money in my bank account? and can I pay for my kids' school? And can I pay for the car and can I buy a home? They're just like everybody else. They're just trying to make a living. They went through a lot of schooling because somewhere in their life they thought, hey, I want to be able to provide medical care or surgical care or whatever type of care they had to the community that they serve. That's really what they want to do. Everything else in my job is to make sure that I develop a system and people around them to make their life easier so they can provide that great experience and that great medical quality medical care.

25:17I wonder in the journey from front desk to CEO, I guess it's, as you're saying, it's about enabling. So how do we almost take away the non-clinical components of the role so that the clinical components can shine through from those who are qualified to deliver that high quality care. I'm thinking on a journey you would have initially done and now presumably direct and enable and empower and convene others to do a lot of that work. Yeah. If you had to list out bullet points, the top five things, top three things, top two things, whatever number, top things that result in bang for your buck leverage for your clinical care what do you need to take away from clinicians what are the truths that you've learned things that people assume oh the people the clinical team needs to do this actually what have you learned about creating that capacity that breathing room that you maybe didn't know when you started or you didn't know where to look and then suddenly you realize, ah, it's actually here.

26:26When we pull this away or when we restructure this admin, this back office's enablement function, suddenly the headroom really starts to open up and things get a lot easier and that clinical care shines through. Do you have your sort of your top two, your top three? Maybe keep the top one as a trade secret for yourself. Maybe you top number two and three. Yeah.

26:46Alejandro Fernandez: I think that there, the first thing when you mention it for me is empathy. It's really interesting. It's not about what you take away, but more what you add into the program. I think that doctors, again, go in with a very altruistic view of what they want to do in providing medicine. They want to have their own business. They want to be entrepreneurs. I don't know that any doctor says, I'm going to go and become a doctor because I want to go and work for so-and-such hospital. Maybe they might say Cleveland Clinic or Mayo or NYU or something like that. But in reality, at the end, they're like, I want to be doctor, name, last name.

27:27Alejandro Fernandez: That's really what they want. They want to be this physician, this thought leader, this person that's going to be healer. So if one thing we can add to it is providing empathy to the patient, and I don't think it's from the doctor's perspective. It comes more from the staff perspective. It comes from the operations. I think the operations need to set up more empathy, more emotional intelligence towards the patient. They are sick. They are hurting. They are in vulnerable states where they need somebody the most. And when you answer the phone, hello, you want an appointment? it? What's your date of birth?

28:14Alejandro Fernandez: That's not it. That's not what we want to achieve for. You know, in our organization, we say, thank you for choosing Synergy Orthopedics. We start there because we know they have a choice. They could have gone anywhere else. They could do, they could be provided healthcare anywhere in the community. Any other doctor, in our case in San Diego, there's 200 something orthopedic surgeons. Our group has 25. Fantastic. We're one of the largest groups in the market, but we're still a little bit over 10 % of the market share. So they still have 90 % of all the doctors in the community to choose from. We need to let the patient know we care that we're we emphasize that they're not happy that they're not ill that they're ill that they're in pain particularly orthopedics people are in pain when they come in there it's not they're not coming in because oh my i have a headache or my belly rubs that's primary care when people are coming to us something tore something broke something's in arthritis some major pain the bone and bone is touching with the other there's some major issues they barely can walk in some cases.

29:28Alejandro Fernandez: I see patients coming into our clinic and they're with their walkers. These are young people. They shouldn't be on walkers. They're not 90 years old. Granted, nowadays, 90 years old can be running marathons. I know a physician that's in his 80s and this guy is a triathlon. It's just like the body can do so many more things that we can allow it to. But I think the staff require, we need to provide the best customer service that we can. man. Our patients are a customer. And I feel that if one thing is lacking in healthcare overall, whether you go to a pharmacy, you go to a pharmacy, it's the first thing.

30:03Alejandro Fernandez: It's like, oh, you're here to pick up your meds. Okay. I have your date of birth and your first name and last name. What happened to thank you? But then again, there's a queue with 40 people waiting in line, try to get in to pick up their meds. If you have an app, maybe you could skip the line and show with the little app, the little thing, and then you go ahead and scan it. And then they go get your meds and they don't talk to you. That one's like, let me now talk to you so I can provide you faster medicine. Somewhere along the line, we lost it. We need to get back to the normality of being human beings.

30:35We're providing human care, not IT.

30:39Alejandro Fernandez: We're not doing coding here. I feel very redeemed right now by everything you're saying. So Coherent, where I'm now with the Coherent team, I think we celebrate what you just said, which is that you can automate made everything out of healthcare that you want, but at the end of the day, you've got a human somewhere in the journey. Even if it's just the patient, at some point you've got robo-doctor, it's still the patient, it's still a human. That human should be treated like a human. They should feel like they're being looked after as if they were going to a five-star resort, not as if they're buying shoes online.

31:11And you use the IT example. It's another great example of this lack of service and support. And for us, we take a technology-based approach and saying that actually the tools aren't there to let providers provide that kind of support. But I think it's interesting, you said in response to what do you I asked the question, what do you take away? And then your answer is you don't you add as the first thing you add. And I think you're right. I think injecting that empathy, making it very human centric, even if what's sitting under the hood is a machine that's running at full speed, that top layer, it's got to feel it's got to feel like flesh, it's got to feel it's got to feel human.

31:49If you put that against the comments you made earlier, here comes AI and now things are getting fast. Obviously, there's a lot that AI does in both admin and clinical context, but let's just say the admin context for a second, given the examples you gave, where suddenly more time and space might exist. How do you make sure, what are you thinking about as an executive leader and healthcare exec operator? What are you thinking about to not let it disappear? How do you balance this thing that many of the AI vendors today will say, actually, you can get rid of people. You can, no one has to talk to anybody anymore.

32:27How do you balance that? How do you resist that pressure from the market and from making more efficient, making more efficient? What are you thinking about when that's going on?

32:35Alejandro Fernandez: No, but I do feel that we have to make it more efficient because we're one of the few industries that has number one, we're cap. When it comes to revenue, we're cap, or we're actually put on pressures. Medicare, particularly around orthopedics, is looking to do a 3 % cut next year again, which has been doing for the last, I don't know, 30 years has been cutting reimbursement. And then particularly for joint replacement, which again is a big expenditure in Medicare because typically the patients that get joint replacements are patients that are over 65. In most cases, just the body just wears down.

33:10Alejandro Fernandez: They're looking to do a close to a 12 % cut. So when you think of a 12 % cut and you look at a typical orthopedic practice runs at a 50 % to 60 % overhead, that's a much bigger cut to the doctor. You're talking about a 30 % cut in take-home pay. Granted, people don't look at it that way. They just like, healthcare is really expensive. On the other hand, you have drugs that cost thousands of dollars every month that everybody wants. Of course, they want the insurance to pay, and the insurance kind of has to do this. Do I pay for that, or do they pay for this? In reality, instead of trusting the doctors, which are the ones I went to, 18 years of school and training and advancements and have to continually educate themselves and continue to keep their medical license active in order to do what they do every day, we are now trusting, and we have trusted for many years, the government, insurance payers, big conglomerates in regards to how care needs to be delivered.

34:11Alejandro Fernandez: The reality is, yes, physicians through now a mouse click or a Signature on their pen control 90 % of the spend of healthcare. But my understanding, altogether, they all receive, all of the doctors, the hundreds of thousands of doctors together don't add up to 5 % of the expenditure of healthcare. It's a very small number. So going back to your question, AI or being able to be more efficient in the practice in order to do more, to reduce costs, is a necessity. I don't think a doctor is going to say, hey, I'm going to use an AI scribe and get rid of my staff because he wants to. He would prefer to have somebody there assisting him in the exam room with the patient and taking notes and helping him document.

35:03Alejandro Fernandez: In truth, they would prefer not to have to develop a three-page note in order to bill their services, which, again, going back to the plumber example, he doesn't do any three-page note. He doesn't go ahead and show you the video camera and the proof and how he got the little toy out of the toilet. And no different than the doctor, the gastroenterologist shows you the operative report with the pictures on how he removed your polyps that could have grown into cancerous lesion, which would have killed you with colon cancer. I don't know. I feel like that part is really what has me messed up. I feel I get on a a pulpit around that.

35:40Alejandro Fernandez: But at the same time, we do have to embrace AI. Like for example, about a year and a half ago, we worked with GE on a project that somebody developed with them to with our MRI magnet to speed up the processing time of an MRI and the quality and the clarity of the imaging capture of the MRI using AI. That allows us instead of doing, I think we were doing somewhere around 12 to 13 MRIs a day, we went up to 17 to 18 So being able to do 30 % to 40 % more MRIs in the given day with a physical infrastructure that is already paid for and staff that's already paid for allows to bring a significant amount of opportunity and EBITDA to the bottom line, to the physicians, the shareholders that own that MRI.

36:26Alejandro Fernandez: If you're the hospital, it goes back to the hospital. If the hospital's not for profit, it goes back into infrastructure. Maybe they use the money to pay their doctors, nurses, and staff, and so on. So I think that there's really good opportunities with AI, whether again, using an AI scribe. I still have a lot of doctors that don't like it. They still have staff do it, or they use voice recognition, which again, it's a technology that's been around for a long time, but now with AI, it's getting way better than it was 15 years ago. And outside of that, we're twinkering and just still starting to do where we're answering the phones.

37:00Alejandro Fernandez: Like if you want to cancel your appointment, instead of pressing one, two, and three and forward for reach the operator, reach the appointment people, reschedule your medicine and so on. There's some really easy give me's that you can use AI for in regards to going ahead and speeding the delivery of that healthcare, particularly the healthcare you don't get paid for because you don't get paid anything extra for renewing a prescription or for canceling an appointment or for making an appointment. You only get made if the appointment is made. Granted, everybody in healthcare wants to get paid by the doctor, by the minute, by the hour, by the month, by the whatever.

37:38Alejandro Fernandez: Nobody gets paid on success. The only people that get paid on an event or an encounter are the providers. And then that payment has to cover the whole delivery of healthcare in that experience. So I do feel that we have to include AI. it's interesting when you think think about consolidation more generally or private equity or sort of group movement into traditional service-based businesses healthcare being one of them i know that this this idea that healthcare has a or has historically had a revenue cap based on the physical facility or the site footprint is a very real constraint but it's interesting that you're saying actually it's not that suddenly you've added 10 rooms and bought a new building it's actually that the theoretical capacity of your existing asset of your existing infrastructure goes up because now you're able to do 30 40 uplift and mri completion in a given week that's you might as well have another mri machine that that is a material change to the revenue footprint and the profitability of the practice and some of the groups that we work with i think have a similar view which is actually if i can if i can change throughput or patient service efficiency and or triage differently, then suddenly I don't need new buildings and new staff and new rooms.

38:51I can just move the journey through more efficiently. Obviously, that moves the needle as well. I'm conscious of time. I'm also conscious that you are currently in a role where you're on the very front line of making decisions around all things healthcare operations, but particularly technology adoption. I'm curious when you think about bringing in new stuff, tech or otherwise, new stuff. What is your guidance recommendation from the years that you've spent being the user, being the adopter, being the buyer, being all the different roles you've had? How do you know snake oil from substance? How do you know, what's your sixth sense on that feels right, that feels like the right direction of travel versus that looks shiny, but actually I'm not so sure about what's underneath the wrapper.

39:47How do you establish that? Part of it is probably just pattern recognition and experience, but if you had to say, okay, I've got scars for making those decisions the wrong way, I've seen people make those decisions the wrong way, when did it go bad and how do you make sure it doesn't happen again given how much new stuff is available? The last five years, it's like 25 years of innovation compressed, how do you make good decisions about what suppliers or what vendors are going to work with?

40:14Alejandro Fernandez: Yeah, I compare this whole era of AI a lot to when I implemented electronic medical records 15, 20 years ago. Back then, maybe you had the billing system and then people have paper records. At least the technology was there from a scheduling perspective, a registration perspective, you needed it. It gave you something to send our claims, but the medical record was living somewhere else. And I, many times I've had practices that have two, basically two separate systems that talk to each other or interface with each other. And people have to have two screens and they have to work with the practice management software, the EMR.

40:49Alejandro Fernandez: And back then it was, we don't have this feature, whether it's, oh, show me your, the next available appointment to schedule a patient. And it's like, oh, we don't have this feature, but in our next release, we'll have that. And I kind of hear that now with AI is like, we have this, we use, let's say, scheduling or telephony AI so we can replace the people that answer your phone and make appointments. And I say, that's great. Inbound or outbound? Oh, we do inbound. Okay, great. And can it do outbound calls? Can it call people? Oh no, we're not there yet, but we're developing that. That's coming soon in our next release.

41:27Alejandro Fernandez: And I do feel that they're not lying. I think the difference back then, coding, the way you handle things just took a lot longer to develop, where now you can sit down with any of the models and open computer and build a story, write a book, develop, I don't know, some thesis. You want the thesis to become a program? Click on code, and all of a sudden, the thing has a program, and you click on it, and it goes to the internet, and it has pictures and video. Oh, you want it to talk to you? Add some type of clinging eye or some other animation. And all of a sudden there you have a person talking to you.

42:03Alejandro Fernandez: It's incredible the things you could do today compared to what it was 15, 20 years ago. I almost feel sometimes, I remember my grandmother passed away a couple of years back. I don't know, she would probably be like 120, 130 years old today if she were alive. But I remember her, me trying to explain this person that was born in the early 1900s, how a fax machine worked. You know, for her, it was, what do you mean if I write a letter and I put it in this machine, it's going to show up somewhere else and they're going to see my handwriting? You mean I don't have to use the mail and put a stamp? Because she came from that age of having to write a letter and mail a letter to a friend, and that's how you communicate it.

42:49Alejandro Fernandez: Where right now, we went from letters to phone calls, some more telex came and died. The fax machine is only living in healthcare organizations. I still don't know why, because it's incredible that we still have fax machines to communicate with each other. It's like the weirdest thing. Then keep on going computers till today. Basically, we talk to our phones with a chat, with AI is talking back to us. It's like, it's the weirdest thing in the world. If you think about it from where we were literally a hundred years ago, it wasn't that far off what I'm saying. So I kind of think I went on a tangent, but I think that for sure there's a lot of space and opportunity to grow in healthcare.

43:30Alejandro Fernandez: And again, I go back to it. I think access is number one. And I would say number two is providing empathy to the patient, caring about them. And then add all the technology you want. You need to. But for sure, the bells and whistles will get there. Things will work. I do see people say we can do your billing or manage your RCM with it. I'm like, you probably cannot. But I will say maybe in five years, you will. Maybe in five years, the hardest part, and everybody's seen these statistics, the people that we're going to have to hire AI agents. And the question is, how are we going to train our current workforce to do something else or train our current workforce to be the ones that are managing these AI agents.

44:20Alejandro Fernandez: Because at the end, they can't do everything, at least today. There's a lot of gaps in the process, so you need somebody to manage that. So start with access, develop empathy for the patient through your staff, and then finally add technology wherever you can because it's going to help you survive in this ever-shrinking and stressful business that we're in healthcare. I had another question, but that felt like such a nice, a nice outro that I think I'm going to probably call the question back. Alejandro, thank you so much for sharing a bit of the story, the journey you've been on, which is very enormous range of responsibilities.

44:57You've seen probably more sides of the healthcare experience than most. For those interested, you can follow up directly. Alejandro is very findable through his work. So you're very welcome to reach out. And thank you everyone for joining.