David Saltzman: 0:00

Muskula's skeletal claims represent a disproportionate amount of spend. The question is what's being done to bring that under control while providing a better employee experience at the same time? We'll find out on this episode of Shift Shapers.

Host: 0:16

This is the Shift Shapers podcast, connecting benefits advisors with thought leaders and entrepreneurs who are shaping the shifts in the industry. Now here's your host, David Saltzman.

David Saltzman: 0:30

And to help us answer that question, we have invited Dr Mike Briwy. He is CEO of OrthoLive. Mike, welcome to the program.

Mike Greiwe : 0:37

Oh, thank you so much for having me. David Glad to be here.

David Saltzman: 0:39

It's my pleasure. Tell us a little bit about your journey, a little bit about your background, how you ended up doing what you're doing.

Mike Greiwe : 0:45

Yeah, actually, you know, i grew up in Tampa, florida. My family grew up here in Tampa, my grandfather was a pediatrician and so, you know, started getting interested in medicine and how we could help people, ended up going to Notre Dame for undergrad and made it into medical school, came back to Tampa and then ended up in Cincinnati where I did my residency in orthopedic surgery. I went to Columbia University, at their shoulder and elbow fellowship there, and then came back to Cincinnati After several years of being, you know, a surgeon. I thought there was, you know, just a better way to reach out to patients, to be able to connect with them that might be traveling from a far distance Around that same period of time, virtual healthcare was coming on board and so I thought, you know, there needs to be a better way for orthopedic surgeons to be able to reach out.

Mike Greiwe : 1:40

I wonder if there's an orthopedic telemedicine company out there. And I looked and researched and just couldn't find anything that really fit the need for surgeons to be able to see their patients. And so I decided you know what I'm going to form a company, as crazy as that sounds, and try to help surgeons reach out to their patients And in doing so hopefully create a network of surgeons around the country that could take care of patients, and so that was the impetus for OrthoLive. And here we are. That was 2017, and here we are, you know, six years later, and I'm so happy I did and so happy we've got such a great network of surgeons and companies that we take care of now.

David Saltzman: 2:24

You know, it's been amazing to me, especially in the last several years, the rise of the physician entrepreneur And in almost all cases it's folks like you who see a problem from the inside, where patients don't generally see it. And you know there's got to be a better way to do this and go out looking your exact story. Go out looking, can't find anything and went well, okay, i'm a pretty smart fellow And the problem is I'll build something. So kudos to you for doing that. When we talk to folks, we know that musculoskeletal is a huge part of spend. How big is the problem?

Mike Greiwe : 2:58

Well, the problem is is quite large. I think when you look at the average employer, musculoskeletal is usually in the top three in terms of their total spend And many times it's number one. You know people need musculoskeletal health care And unfortunately, particularly in the commercial space they need, you know, total hips and total knees is very common types of procedures that happen And so that spend can be quite high. And I think when you, when you look at the total numbers, it's it is quite a large percentage of the musculoskeletal spend out there. You know the numbers. For me, from what I've seen, one in eight people have a chronic musculoskeletal condition that they deal with on a daily basis, and the average number of people that visit their doctor and miss days for work because of that musculoskeletal problem is somewhere in the 20% range. So you talk about missed work time because of that chronic musculoskeletal condition. It's it's very prevalent, so it's it's it's a very big problem across the US and only getting bigger as the baby boomers are coming of age here.

David Saltzman: 4:11

Guilty as charged. You know it. It it's interesting, i wonder. You know, there's one school of thought that says that there's there's far too and I I understand, i'm asking a surgeon this but there's there's far too fast, uh a course to jump to surgery when there are other modalities that might be better, other treatment plans. Um, is that something that you encounter or is that just kind of the rumor that goes around those of us who pay claims? You know it's a great question.

Mike Greiwe : 4:40

I think to be completely honest and transparent here, um, too many procedures are being done that that are unnecessary, and I think that you know it serves up a little controversy amongst my colleagues when I say something like that, but if you want the honest truth, you know, when we're living in a fee for service environment, people get paid to do procedures And because of that, um, there are additional procedures being done that probably are unnecessary.

Mike Greiwe : 5:05

Across the US, marty McCary's written a great book, um, sort of outlining, uh, some of these things that happen in all industries, not just musculoskeletal, but you see it in vascular surgery, you see it, um, you know, you know in in cardiovascular, you see it, um, you know, in GI.

Mike Greiwe : 5:23

And so what we really need to do is is understand how value based care can effectively reduce these excessive, excessive, excessive, excessive, excessive use, these excessive procedures and utilizing a system like telemedicine, where surgeons really aren't holding a knife in our, in our virtual environments, right, we are truly trying to do what's best for the patient.

Mike Greiwe : 5:51

Um, that, you know, takes away all the conflicts, all of the things that might make us want to do a procedure, when you know there there may be other competing interests out there. It helps us, i think, to to really cut through all the, all the things that might have swayed us in one direction and, um, get really to to treating the patient the right, the right way. So, um, it certainly is not, you know, super common, but I know that it happens. And, um, and some of the research shows that there are, are certain percentage physicians that, um, that don't go the conservative route. So, uh, it's an important topic And I think it's one that, um, you know, if you align the incentives properly, you're going to get to the right, the right answers.

David Saltzman: 6:37

I think there are a lot of people who maybe feel that telemedicine and orthopedics is kind of a contradiction, in terms that what folks do with orthopedic problems or musculoskeletal problems is more of a hands-on proposition. What kinds of things do your folks see most frequently and what are they able to help with most frequently?

Mike Greiwe : 6:59

That's a great question and the way I answer that question. I think if you go to medical school, your first year of medical school, you sit down in a classroom and you listen to the professor tell you about how you're supposed to diagnose and treat. And diagnosis is really based on the history and 90% of problems are history alone. You could close your eyes, listen to the story, listen to the patient tell you the story and nine times out of ten, eight times out of ten you're going to have a differential diagnosis. That gets you in the right ballpark. And so when we train our physicians, our nurse practitioners, our physical therapists all the people that are part of OrthoLive we talk to them about listening first and then using that to help them make a differential diagnosis. And then we use telemedicine in certain ways, with physical exam through modification, so we might make a modification to an existing test, for instance, like the McMurray's test in the knee. It helps us to look at, like meniscus tears. Well, what we do is we take that and we say you know, mr and Mrs, so-and-so, do you mind? you know, squatting down and twisting on your knee, we'll watch you do it. But we're using the ground as sort of the, the hands of the physician, and we were able to pick up a lot like that. So there's a lot of modifications to tests that we've done. That gets us so far.

Mike Greiwe : 8:24

But the key here is we have a wonderful tool in MRI that allows us to find that 10% that maybe we couldn't quite get our hands on, couldn't quite feel. In those circumstances we'll order an MRI to understand a little bit better and most of the time we're doing that anyway in clinical practice. You're going to order an MRI when you think you need one because of a potential surgical problem. So something's really significant. We're going to go ahead and order that, those advanced imaging to understand the problem better. So I think we really do cover all bases quite well. And when people challenge me on you know whether or not we might be able to diagnose something, i always say you know, give me your history and let me see if I can figure out what happened to you. You know, 95 times out of 100 we're going to give them the right answer.

David Saltzman: 9:08

When your folks are sending people for MRIs, are they probably are they less likely to send somebody to a hospital than to a freestanding imaging center?

Mike Greiwe : 9:18

Absolutely. We really focus on value-based care and so, as you know, hospital MRIs can be quite astronomical. You can look at those charges and it's just unbelievable. Sometimes we have some remote locations and I think we paid last year worth of a lot of pays cash for these MRIs. We had an MRI that cost us somewhere around you know $3,000, $3,500 or something, and it was a hospital system and you know we knew we were going to take a hit there. But the bottom line is that most of the time, we're seeking out independent imaging locations, whether that's with an orthopedic group or an independent you know radiology location. That you know will keep the cost low. And you know, i think, when you look at the average cost for an MRI, what we can initiate. It's usually around you know $400, $450, maybe $500. So we're really keeping those costs down.

David Saltzman: 10:14

Yeah, we've spoken on the program with people from green imaging and a couple of other places and it's just amazing. And what's even more fascinating is that the patient satisfaction scores are through the roof. It's a nicer environment, it's quieter, you know it's. People take more time and more care, as you know your folks who are on the phone are able to do, because they're not, they don't have to punch a clock where they see a patient every seven minutes or eight minutes. So it's, and I'm sure that employers appreciate you know. You going to the freestanding centers and the independent center imaging centers first Is speaking of plans. Are your services more typically tacked into a fully insured plan or a self-insured plan, or is it an equal mix of both?

Mike Greiwe : 11:01

It's typically self-insured.

Mike Greiwe : 11:02

We say about 80% of our companies are self-insured and we have 20% that are fully insured. But the amazing thing going back to the point that you made this like better ambiance or better service you know we're able to get an MRI within 24 to 48 hours And what our group does that I think is really great is, you know, we try to expedite healthcare and we try to make it, you know, sort of like Amazon, and so you call someone up and say I need XY or Z and they send, you know, whatever product to you and you get it within 24, 48 hours at your doorstep. We're trying to do the same thing in healthcare right now. We're trying to expedite services and the fact that we pay cash allows us to get those services done immediately, because many of these imaging centers they have openings for cash-paced you know patients, and so we get patients right in. They love it And these imaging centers really do know how to take care of patients well, just as you mentioned. So it is a huge win-win for the patient and for the provider.

David Saltzman: 12:02

Yeah, we just a couple of episodes ago spoke to another physician entrepreneur named Paula Moodo. Paula is a surgeon And she saw the same problem. Somebody needs care and they try to get an appointment and it's six to seven to eight weeks And you know they won't tell you the price of upfront because they're billing the insurance company and all that normal tap dancing on quicksand stuff. That goes on. And she's built a new business where you can use their portal, get an appointment within generally 48 hours with somebody who's board certified And it's a cash pay system And you know it's interesting. Are you finding any pushback from folks when there's a cash payment? that's necessary?

Mike Greiwe : 12:40

You know, what's interesting is that goes to the employer. When we work with the employers, we are not only, you know, so we work on the work comp side and we also work on the commercial side. On the work comp side, you know we have cut down so significantly on their spend. If you look at, you know, the average spend of someone that gets injured on the job, the costs that are associated with those injuries are typically around $5,000 to $6,000 in direct injury spend per injury. The average cost, after orthoLive takes care of the entirety of the spend, is about $500. And so you're talking about a 90% reduction in the total cost of care for that patient on a direct injury basis And that's all in on all work comp injuries spend. We had a recent employer that spent $800,000 in the last quarter of 2021 and then went and utilized our system. We were able to cut that spend down to about $50,000. So you're talking about 90% reductions in cost. And so there's no pushback when we talk about, you know, cash-paced, you know payments, and on the commercial side we have two you know models. One is to guarantee or basically go at risk, you know, with the spend. So when we pay cash and it's an at-risk model. no one's batting an eye, everyone's on board. because we've guaranteed savings, essentially because we're so confident in putting the experts up front.

Mike Greiwe : 14:19

You know, many times I think the way that healthcare works is you're always trying to sort of avoid getting to the surgeon, avoid, you know, sort of expert avoidance. But if you put the surgeon at the front end of musculoskeletal care, you're getting an accurate diagnosis, taking the scalpel out of their hands by doing it virtually. And now you have a way of ordering physical therapy when that's necessary and getting that done either digitally or virtually. You know, making sure that when someone needs a surgery they get right to surgery instead of that delay of potentially three, four, five months, and initiating the right type of conservative treatment. when someone just has what I call a boo-boo where they're going to get better, we just need to kind of give them some time right.

Mike Greiwe : 15:07

So that is kind of the key And the way that we've structured our models. no one really cares about the cash payment because we've guaranteed it. on the commercial side And on the work comp side the savings are so significant that everyone loves what we're doing and is happy about it. So we've been very, very lucky. I think we've tried to align our incentives with the employer, with the employee and with the patient, you know, and they really like it and it's worked out well.

David Saltzman: 15:36

Well, and that's key. I mean, we talk so much on the program about misaligned incentives up down and sideways, and you know it's funny. I have a standard answer when people say to me you know the healthcare system is broken, and the answer is it's not really broken at all, it's working perfectly. It just never had you in mind when it was built. So it's not working perfectly for you, but for the people who designed it it's working great.

Mike Greiwe : 15:59

Yeah, it's so insightful because really, you know, our healthcare system was built around, you know, insurance companies and around pharmaceutical companies, pbms And we have a transparency issue and we have a justice issue in healthcare today And we need to solve for justice, we need to solve for transparency, we need honest providers, we need you know those are the things that are going to solve healthcare And if we don't get transparency and justice and proper providers, they're going to do the right thing for the patient and align things in the right way And I think, aligning them in a value-based way we're going to still continue to languish in the healthcare system of you know, the past 30 to 40 years, but things are changing. I see a lot of employers now signing up with the value-based system and understanding that that's the right way to go, and we need more providers that'll guarantee their services, guarantee the fact that they're going to save money in the long run by taking risk. That really will change how we do things.

David Saltzman: 17:10

Yeah, there's no question about that. Do you think that part of that change in attitude is generational? I mean, i go back to people my age it was almost unheard of to question a doctor. You know you had that white code authority and whatever, yes, doctor, whatever you say doctor, and I think you know folks like my kids age are going well, okay, but let's talk about that. You know, is that really the best course of action for me? Are there alternatives? And I see it as part generational. Are you guys seeing it on your side as well?

Mike Greiwe : 17:40

Absolutely. I was sort of brought up in a time where there was this transition happening where you had maybe the older generation which always would say yes, whatever you say, doctor, you know, whatever you know, just give me a treatment plan, right. So I sometimes still encounter this in my practice. Someone will ask me well, what do you think you know we should do? and I'll outline what I think they should do. And they really don't want necessarily a shared decision making, right, but most people now want shared decision making and the way I find my practice works the best is asking the patient what do you think? we have several options. I'm going to outline them, but I really want to know what you would like to do here, because this is your body and here are the options and let me give you the data to support each of those options and then come back. And I agree with you.

Mike Greiwe : 18:33

I think there is some generational differences here where it wasn't just you know, yes, doctor, so, and so you know, this is what I'm going to do. People have taken healthcare into their own hands a little bit more and understand that. Maybe it's the information age, i don't know, but people have a lot more knowledge and in that power to be able to say to their physician you know what, why don't we try something different? this is kind of what I was thinking, and I think that's for all physicians out there. You know, we need to be open to understanding what our patients want and need.

David Saltzman: 19:08

We've got about a minute left and the follow-up question is with that kind of a model, do you find generally better compliance?

Mike Greiwe : 19:15

100% shared decision making will give us better compliance. Patients really believe that. Once they kind of, you know, digest what you said and also add their own color commentary to it, and you come together and you make a plan, people really do stay consistent with what you've asked them to do and they believe it and I think that transforms the outcomes. It really changes that and makes that better.

David Saltzman: 19:42

And that's a great place to end our conversation for today. Mike Riewe, doctor CEO at OrthoLive. Mike, thanks for sharing your expertise and, as this grows along, we hope you'll come back and share your progress with us.

Mike Greiwe : 19:55

Thank you so much for having me.