The past several weeks have brought about new decisions that clinics never thought they’d have to face. Pausing treatments for almost all patients, furloughing or laying-off staff because of that pause, and so many other never-before-seen challenges. Hopefully, the light at the end of the tunnel is coming and clinics can get back to business as (almost) usual. But what about all the doctors in limbo? Doctors are coming out of fellowship, ready to make a difference in the lives of thousands of patients, but will they have a place to go when restrictions are lifted? Can clinics support new docs in an economic downturn?
Continuing in our COVID-19 Business Response Series on Inside Reproductive Health, Griffin was joined by Dr. Ruben Alvero of Stanford University Medical Center, Dr. Angie Beltsos of VIOS Fertility Institute, and TJ Farnsworth of Inception Fertility Ventures. Together, they take a look at what will happen once clinics reopen: Will they be able to operate normally? Will contracts from fellows be honored? Will more staff be needed if a backlog of patients is ready to start treatment? These questions and more are discussed among the panelists, hopefully shedding a positive light on the future of clinics after COVID-19.
This episode was recorded during a live webinar. As the COVID-19 Pandemic continues and new issues arise, we are putting out new information to help you and your fertility business. Follow us on social media for updates on upcoming webinars and how to join them live. Find this information helpful? We’d love it if you’d share with a friend or colleague in the fertility space.
Need help navigating marketing through this unprecedented time? Check out our COVID-19 Toolkit from Fertility Bridge.
***
Welcome to the Coronavirus Business Response Series of Inside Reproductive Health. Here, you'll be updated on the latest insights on managing and owning a fertility business or IVF center during the COVID-19 pandemic. We put out free podcasts, webinars and articles as soon as new topics arise, so make sure to subscribe to stay updated. The best way to help us in return is to share this episode with someone in the fertility field that would find it useful. Now here's the founder of Fertility Bridge and the host of Inside Reproductive Health, Griffin Jones.
GRIFFIN JONES 0:50
I'm trying to keep these webinars as topical as possible. And this came up as a question that people have been asking me about and so we're putting them together as they're happening, and we're pretty well diversified here. TJ Farnsworth is the CEO of Inception Fertility Ventures, which is the largest fertility network in North America. Dr. Beltsos is the CEO and founding physician of VIOS Fertility is one of the fastest-growing independent practices in the continent. And Dr. Alvero is at Stanford, but he's also the Vice President of SREI. So while we don't have--while we can't speak for every group, and we can't speak for every possible circumstance, we might be able to speak to the groups of the folks that are here. And we have insight fairly well-represented missing, maybe the solo practitioner or the smaller group. Maybe I kind of want to just start with you, Dr. Alvero with respect to what you've been may or may not be hearing from SREI. No small part of the reason why we're having this discussion is because I'm getting a lot of emails from fellows asking if they're still going to have a job in the fall or if things are going to be pushed back,or things are going to be different. So what are you seeing if anything from an aggregate level.
RUBEN ALVERO 2:21
You know, this is a pretty fast paced situation. Everything is evolving pretty quickly. Since I only found out about this last day or two, I did try to reach out to the SREI membership and really didn't get much of a response. But over the past 24 hours, I have had a chance to talk to a lot of the fellowship directors, as well as a lot of chairs, both through the ASRM webinars that we’ve had and other meetings that we've had, and near as I can tell, there are not going to be a lot of changes in terms of hiring that nobody had heard about any declination of hire or delay in hire, or anything like that. Maybe it was a very biased population sample, so it may be that they're out there, but I have not heard of anybody at this point in time that gotten a communication from their purported new place and say, Well, you know, we're going to push things back. If anything, what I'm hearing more is that everybody's kind of starting to ramp up for what we expect to be in the next few weeks, the startup of cycles. And in addition to the startup of cycles, we're going to be pretty busy, because we're going to have a pretty big backlog, all of us--private and in academic--in terms of the patients that were cancelled at the very end. So what I'm hearing is that people are anxious to have more manpower as things progress. Obviously, there's a bit of uncertainty as to what happens--are there going to be flare ups in terms of, you know, new cases, or surges in cases, as people kind of relax the restrictions. Nevertheless, I think the anticipation is that things are going to be busy come the summer and fall.
JONES 4:01
Dr. Beltsos, are you planning on ramping up? Are you planning on keeping the same onboarding time frame that you were? What's it like from your vantage point?
ANGIE BELTSOS 4:12
We are on the same schedule as we were for onboarding our new physicians and our strategic plans to grow. That remains the same.
JONES 4:22
TJ, you're in a number of different markets, does it depend on the market?
TJ FARNSWORTH 4:26
Yeah, I think--we're 70+ clinics across the country, so I don't know how many fellows have signed with which practices but I can say unequivocally, that quite a number of the new upcoming fellows are joining one of our practices from around the nation. And so what I can tell you is that for us, we look at human capital as the most important thing on our balance sheet and so there the right talented physician is critical for our long term growth in the business. I think all of us Angie, Ruben, everybody that is part of this industry and seeing this, that none of us question the long term viability of this industry, the growth trajectory that it's on, even if you look at the statistics of how the industry grew through the Great Recession--07, 08, 09--you know, I think we can all agree that the United States is going to be entering into or is in a recession as a result of COVID-19. But that does not impact, in our opinion, the opportunity for growth within our marketplaces. And we are a group of practices, but we are a business that is our doctors. I mean, without the doctors, there is no business and so without the right talented physicians, and they're hard to find, the right ones are really hard to find, and so if we found somebody that we want, and we feel like needs that grade in terms of being the right type of doctor for us, and one of our practices we are not showing off at all.
JONES 5:50
Dr. Harriton, a friend of mine who couldn't make it today, gave me a number of questions that I can ask if, in the event that I run out of any, and I'm not planning on it, but what one of the things that we're both wondering is, do we see the market shrinking or going flat in the 12 months after we reopen? We're not talking about 2020, because that will for sure be a decline, but the 12 months from when operations resumed. But I think what's really hard to define is what constitutes as operations resuming or what counts as reopening? Anyone want to take a stab at that?
BELTSOS 6:29
I think if you look at the lifecycle of a patient, from new patient visit to--and that includes calling or creating a new patient visit--so the moment they contact, whether it be electronically or by phone, that clinic, they come in, they do their evaluation, they enter into treatment, what you will see is there's always this lull between that moment where they contact the new patient visit and the time that they start doing things like retrievals and transfers. What I do think will happen around the world due to this pause is that it’s going to hit volume three to six months down the pipeline, depending on what your clinic does and how quickly patients go from that new patient visit into treatment. Some have a little bit longer delay, it may be related to mandates where certain insurances require certain things and also your group--so some clinics put people on birth control pills, etc. But in regards to that volume, what I anticipate will happen is that we'll see that dip, and then eventually, it'll come back into normal levels. Some of this is dependent on the fertility clinics, but a lot of it has to do with the economy-at-large and people being furloughed and having a certain amount of liberal cash in their pocket to do treatment, if they have to pay, whether they have job security, and at some point, this will become a priority for them one way or the other.
FARNSWORTH 8:05
I agree with that. I think that depending on markets, varying different percentages of patients are going to come through referrals from OB/GYNs. At least if the patients are not sitting there at the GYN, they're not getting referred to the fertility clinic. You will see some impact associated with that. But at the same time, that patient--unlike friends and neighbors, you might be in other other industries such as hospitality restaurants--with the same patient who wanted a baby on March 15, wants a baby on May 15. And so I think we're going to see a surge in patient volume that Ruben was referring to earlier coming out of this. And then, I think Angie’s probably right that we will see some level of a dip unless we see a surge in referrals coming from OB/GYNs and other places over the next weeks, which is yet to be seen. And I think we may see a dip three to six months in, but if you think about the compound annual growth rate of cycles being performed in the US, I don't think that we have any concerns of a leveling off or a decrease in the amount of IVF cycles being performed. It may just mean that we're not growing at the same percentage we would have otherwise for a year or so, but it's still going to be strong, healthy growth.
ALVERO 9:14
Well, I don't want to infer too much from our experience in 2008, when we had the Great Recession, there are some experiences and some data that we have from that, that I think is possibly going to inform how we respond. Now this is going to be I think, a recession that's more unpredictable and probably deeper than what we experienced back then, but if you can infer anything--one of the things that Mark [inaudible] actually had a really good paper that looked at the, essentially, the price elasticity. So even though there was an expectation with a deep dive in the economy, that there would be a greater than predicted decrease in the number of cycles seen, it wasn't. price elasticity stayed pretty much the same. And in fact anything if anything there, recovery was, after a few months was back up to close to baseline. Different recession, different times. But TJ is absolutely right, patients, this is something that's a very deep motivation in the patients that we see. And I think that they will be motivated to come back rather quickly.
FARNSWORTH 10:18
Yeah, I mean, my wife and I went through a two and a half year journey with infertility. And I can tell you, we would have leveraged everything to be able to have our family and I think many of our patients are in that position.
JONES 10:29
I am, too--I share your caution with comparing this economic downturn, the one that we're upon right now, with the last one, because a recession is when you lose 35% of your business in six months, not when 100% of it gets shut down in a week. This is really something different. And so and that also means that recovery might be very different and there might be spikes as well, but I wonder if this is also the eve of a disruption of referral patterns. So what we see, what we know from our data--this is coming from our own clients, an aggregate of our own clients and it's also coming from an abstract we're putting together for ASRM this year--it's 60% of IVF patients chose their REI based on referral from their physicians. 60%, not 100. But that’s still a really big chunk. And now they're not seeing their OB/GYN at this time. They're not going for the visits that they had. And that's probably at least a two to three month chunk, and maybe it's a four month chunk, maybe it's a six month chunk. And to your point TJ, you people will do anything, the demand doesn't go down. But what's already a long pathway, maybe two and a half years by the time somebody decides to go see their OB versus when they finally get pregnant from treatment is--do you see referral patterns changing?
FARNSWORTH 12:08
I think a lot can change in the short term. I think that in the long term, patients have a relationship with their OB/GYNs, they have trust with them and they'll continue to rely on them for referrals. Now, we are seeing, just generally speaking, an increase in the amount of self-directed patient referrals, period, separate from COVID-19. I think that trend will continue. I don't think that we're going to see a sea shift and an acceleration of the end of the OB/GYN referral. I don't see that I think that may be the case for a period of time where they’re not visiting their OB/GYN. But I think it'll return to that and then return to its already existing pathway towards less and less reliance on the OB/GYN referrals and more and more self-directed patients.
JONES 12:52
So none of you are seeing a delay in--from your vantage point--not seeing a delay in bringing in new doctors that perhaps, let's say, were supposed to start in August, but what if there's a continuation in the lockdowns or the stay-at-home orders or we're able to return and treat patients, but we're only doing IVF for patients with real DOR or 40 over 38, or only a segment. And you know, you're a group with 12 REIs doing the work of five or six. Why would you bring on the one or two that were supposed to start in the summer?
FARNSWORTH 13:36
I think it's about whether you’re playing the short-term game or the long-term game.
ALVERO 13:38
On the academic side, it’s a little bit different because we are part of an institution and that institution has a say in it. And so in our case, and this is something that I've heard of other academic practices as well, is that if they have an offer letter, the plan is--to Angie's point, long term planning continues--then we are still continuing to assume that the future will ultimately, it maybe after two years, or maybe sooner, we'll be pretty close to where we are right now, once a vaccine comes around and so forth. So the planning right now is to try to be careful in the short-term, but really assume that the long-term is going to go back to, if not the same way we practiced before, we're going to be socially distancing or right now, we're remapping the clinic so that everybody's at least six feet apart, even with full component and you have to be clever to do that. And then--but then ultimately, we're going to be able to continue to take care of the patients. Those one in eight couples that are infertile, are not going away with COVID-19. And I think that that demand, that push to have a family is going to continue, whether in the short term or certainly in the long term.
JONES 14:54
So that makes sense if we're talking about doctors--I guess because we're all competing for 40 docs tops that come out of fellowship each year, and there's a lot of people on this call right now that have not been able to recruit new doctors. You have to have the markets and the scheme that TJ has, you have to have the brand that Angie has built, you have to just be the right program in the right city for a lot of people. And there's a lot of smaller markets, smaller programs, especially, that have not been able to recruit those docs. So you've just seen such high demand for REI fellows over the last three to five years that it can afford to go--that demand can afford some relief and still have everybody sign. What about other staff? What about nurses? What about IVF coordinators? What about MAs? What's it going to be like for them Dr. Beltsos?
BELTSOS 15:52
The support staff that people have in their team are sometimes more important than the doctors. And TJ's right what the machinery is of this particular business is all on the ability to provide clinical fertility care. And that's on the shoulders of the care providers and the physicians and our equipment. If you go to sell your practice someday, it has nothing to do with the fact that your desk was really nice and you have a nice incubator. It's really about the ability of your physician to practice very good medicine and create volume. However, our team is essential to us and being able to still provide the care--I know a lot of our clinics in Chicago have let some of their team members go or furloughed them and as we ramp back up, they're going to be critical to the success of the practice. So when you look at your clinical team that includes your phlebotomist, includes your ultrasound techs if you use them, your nurses, your MAs, your coordinators, they're all part of the fabric of the support net that we have as physicians. So I think that's going to be very important. As you are--some of the docs on the call are owners of their own practice or physician leaders and some of you are fellows--so I think if you're one of the docs, then we need to be thoughtful that we have our team when we ramp back up. And that's a delicate balance because you need to manage the financials and as you said, how are we going to know what that number is going to be? So I think those are going to be important when you look at your own clinic.
JONES 17:47
Would either of you gentlemen care to add?
FARNSWORTH 17:51
No, I think Angie’s exactly right. I mean, speaking on behalf of the patient, you know our relationship with our IVF coordinator, our nurses, were just as important if not more so, than the relationship we had with our physician. As time goes on in the journey, the patient relationship with the support staff becomes more and more important. You get there because of the doctor, you stay there because of the staff.
JONES 18:11
They're important, right, but if we don't have the demand for them, how can practices continue to hire for them?
FARNSWORTH 18:20
I think this goes back to our--I think all of our assumptions, the net demand is going to continue to grow. If you're talking about a scenario where we have stay at home orders that extend in October or something like that, then you're talking about something in a different environment. I don't think anybody's predicting that. So I think that is assuming the demand is going to continue in a way that I think all of us, at least on this panel are thinking it will, we will need to have talented people in support of our physicians.
JONES 18:44
Agreed. But it seems like in a normal time, if we've got this type of growth, we're bringing on support staff at this type of speed. And now we've got this and we think it's going to do this for a little while and then we think it might do this again, but we don't have that same level of consistency and more than half of the people on this call have at least furloughed their staff, some have laid-off staff and made more permanent cuts, at least half, it's probably closer to three quarters, have done at least some level of furlough. How could we possibly--as an aggregate, how can we possibly expect to see the same level of new people coming in? Because at least for a while, we need to bring the folks who are furloughed back?
FARNSWORTH 19:33
Sure.
ALVERO 19:34
I mean, I think that one of the things that we have to think about is the fact that we're not going back to business the way we've done it before in terms of how the practice functions on a day to day even that granular basis. There are many things that are going to have to change. We're going to have to do more testing and the question becomes, do we test the patient at the beginning of the cycle, right before the retrieval or both? We need to make sure that the patient has consented well, and they understand that there's a risk that we don't know COVID-19, we don't know if it's dangerous to babies or not, but we don't think so. But you know, this is still early in the whole cycle. I think that the way we manage the patients on a day-to-day basis is gonna have to change, but I think that most places are starting to come to that conclusion that--and given that, I think that eventually patients will be coming back and that eventuality I think we're already starting to plan! Lucile Packard Children's Hospital has already told us that May 18, tier one procedures--which you know, retrievals are considered tier one procedures or elective--will be starting to be done, which means that we are in the process right now of figuring out how that happens, how we do that. And the assumption is that beginning, it's going to be a lull. We have 230 people on our list that had plans at the time that this all happened. And those are the first folks that are going to come through in the first wave. We're figuring out how to do that, but I think we will be able to do that unless something substantially changes, everything dramatically changes to the point where, you know, this is it becomes more virulent, or any number of other uncertain things happen, then all bets are off. I just don't know. But assuming that things--we were figuring this thing out, we're getting it done, then, you know, we can start seeing patients if not at the same level, but at a fairly, fairly brisk pace.
FARNSWORTH 21:28
Yeah, I would add that, I think that we're seeing the light at the end of the tunnel like everyone else's that our centers according to plan for coming back online and being fully operational again--we hope to be mostly fully operational by the end of May into June. And a lot of that, Griffin, a lot of the growth, you're talking about or growth that we were experiencing before and any one of our operations was oftentimes limited by having the appropriately talented staff. And so think about wanting to grow in your market, there's plenty of patients for all us. Angie, Ruben, and I, we all have clinics in the same exact market with one another and there’s plenty of patients for all of us. And the reality is that meeting the needs of those patients’ needs means that we need quality talented staff. And it’s the question of whether or not you’re playing the short game. But I think that if you're thinking about this as a short term problem, and having the right talented person, whether it be an MA, or a nurse, or embryologist, or lab director, or a physician, that is critical to being able to grow and serve your patients in the marketplace, and that is oftentimes a rate limiter to your growth in any given time.
JONES 22:33
Is there a question of timing though? I mean, part of my natural tendency to root for the underdog, my natural tendency to see David beat Goliath in many ways, and I'm thinking of the small practitioners in small markets, is there a chance for them to maybe get is there a question of timing involved where some groups might say, Yes, okay. We know we need to bring people back, we also need to keep recruiting in order to meet the eventual growth. But is there a question of timing that someone might be able to take advantage of saying, You know what, I'm going to come back maybe just a couple weeks sooner than my pocketbook says we should in terms of hiring, because I might not have the access to the type of talent that's available right now. Will we see that?
FARNSWORTH 23:29
I hope not. I mean, I think the idea that--I hope that we have a collaborative enough industry, that we're not thinking for ourselves, I'm going to get open a couple of weeks faster in this market so I can steal the staff from my competitor. We're not doing that. And I sure hope that others aren't either.
BELTSOS 23:48
Yeah, I think some of that inadvertently can happen. And I agree with you, that those are not the ways to grow your business and to help the world go around. But there are gonna be--and you see it already, some people that have been let go and are looking for a position. I do agree with the comment that this, I think Ruben, you said, this is our new reality. And it's going to be this way because COVID is not going away in two weeks, nor two months. And so we're looking at months and years of this. If you're a fellow, and you’re in this precarious position of either not having secured quite exactly what you're doing, or you want to know what might be going on, understanding some of the questions that are being brought up here: Will your location that you signed up for will that be the same location as the leaders that you've got a couple on the call here today--is that their strategy short term to get you--to keep your business afloat? I would expect some lower volumes and you're to start, if you're a fellow graduating now, you're going to start in the midst of the dip, and so we expect to see lower volumes. So if you were expecting a bonus, I expect that may be less going into your first year. One of the things we've learned, too, is just a good--I don't know if the words reality check--but also to understand that as you graduate from your fellowship and whether you go academic, whether you go private practice, you are now part of a team. And no matter if you're a shareholder or a part of your academic group and leadership, we as the doctors on this call and the leaders on this call--but also you can expect it at any new job--that it works really well when you come into this with rolling up your sleeves and say what can I do to help. You are part of ground zero. This will be something that you'll tell your grandchildren about, and ground zero for a clinic that may have been shut down for a period of time. So we are going to ask you to help. And what I tell people that join VIOS is what's your job, whatever it takes, right? Low silos, high teamwork, and with that, you'll create a vibe with your career and your team members wherever you go to be successful, but it's going to be a little bit of some work that you didn't expect maybe that you'd be helping with, depending on the circumstances of your job and location.
ALVERO 26:29
I couldn't agree more. I think that's an excellent point, Angie. When you are graduating and become an Associate Fellow and then get boarded and so forth, you're part of about 1300 people around the country. It's not a big group. And so we all know each other, we all support each other and it really is significant that we can do this because we are relatively small, but we also have well organized--ASRM and SREI are really well organized to help folks. So I think I would encourage you to become involved because whether through this or any other challenge that we face, it's good to be part of a group and making those decisions.
JONES 27:10
I hope it happens at least a little bit. I hope some of you all let go a marketing director or senior PL or a pharma rep because I've been looking for a Director of Client Success for six months, and I need a good one and I'd like to see a little bit more robust candidacy! So selfishly, I'm hoping at least one or two positions. I do plan to take advantage of this if I can. That might sound really callous, but I think that there are people on that this might be their opportunity to get nurses or doctors or other staff that they just simply wouldn't be able to.
**COMMERCIAL**
Hi everyone, it's Griffin. This is the break in the show where normally, I do a little commercial for our small engagement. And we do have a small engagement that's relevant to the COVID-19 business response. If you're cutting marketing. if you're trying to bring back your people as quickly as possible. If you're trying to build a cache of treatment ready patients. We do have that, but I would rather use this break to just ask if you find this useful if you would share it with a colleague, either via email or on social media. We're doing everything we can to put out as many webinars, articles, free podcasts, all free resources to include as many people from the field as we possibly can to give you resources on how to manage and operate a fertility business or an IVF center during this time. And it's changing so quickly.
So if you find this useful, I would really appreciate it if you would please share it with a colleague via email or via social media and help us grow the audience, but only if you find it valuable, and hopefully you are. Now, back to your program.
JONES 28:59
Dr. Beltsos, I want to piggy-back on the point that you mentioned by bastardizing Brian Miller’s question. Brian had a question about how clinics will modify operations in order to mitigate the risk of the transmission of the virus. Brian, I'm going to switch up your question a little bit because we are going to do a separate webinar on SOPs and bringing clinics back online during the pandemic. And I want to stick to the topic of bringing staff in, but Angie had concluded her last point with saying that our job is to do whatever it takes. Is this something that we can expect new staff to see that are starting, whether they be doctors or support staff, that their job descriptions are going to change? How significantly in the next six months?
BELTSOS 29:48
In my opinion, cross training, creating easy overlay of responsibilities when people are cross-trained, standard operating procedures, creates a nimbleness in your organization. And these are going to be very important that--you know, I don't do blood draws unless it's Wednesday and the sun is shining, but otherwise I can do it. But you know, those kinds of real tight boxes of what my job is, is not going to be acceptable. The reason for that is you're going to want to open up and you're going to do that safely and responsibly. So the more that teams can help each other, do each other's jobs and split them up, social distancing, less time in the office, those kinds of things help you execute those maneuvers. So I do think we're all in this together. And if today's your day to empty the garbage in all the rooms, well get at it!
ALVERO 30:46
One of the things that we've experienced actually, as we do this remapping and figuring out how we're going to redo everything, is that it actually has been a really good opportunity for people who were leaders--I used to be Army so small group leaders, you know, small squad leaders--to step up. And they've been probably the most creative and the most helpful in terms of saying “Why don't we do it this way?” And that'll minimize time motion stuff so that we don't infect each other. So it's been really a good opportunity, in a strange way, a good opportunity for a lot of folks to step up, step outside of their comfort zone and really come up with some very good ideas. And it's really, kind of for me, heartening to see that on a day-to-day basis.
JONES 31:25
So a common theme that the three of you each have, a common vision, I guess, is that demand will come back to--I mean, we've had so much demand and there are so many patients to serve. We do have some others in the comments and in the questions--Dr. Gordon and Dr. Magarelli saying that in the last recession, there was significant hits to physician income for some--
BELTSOS 31:54
Yeah.
JONES 31:55
Some folks have seen cancellations and asking for refunds because they're unsure of their future in the next year or two--that there might be a lot of people going down to one income households.
BELTSOS 32:09
It’s a good point.
JONES 32:10
How much of this will vary by market and by practice, because I still see the overall demand being so high that even a reduction just maybe meet the capacity that we have. But where do you suppose we might see an imbalance in both market and practice type?
FARNSWORTH 32:28
I think it's hard to predict. I mean, there's never been in history--even in going back to the Depression era--the loss of employment that occurred as quickly as it has over the past five weeks, and so it's hard to know how fast that will snap back. You know, the difference of today versus 07, 08, 09, the Dot Com Bust, Black Monday, all the things we can remember--this didn't start with a fundamental underlying flaw in the economy. It wasn't a fundamental underlying issue now, we may have self inflicted one, rightfully so to protect ourselves from this outside force, but it'll be interesting to see once that outside force has gone, how quickly this does stand back. And I'm not making the argument that it will because I think it's a ripple effect. We're already starting to see large businesses file bankruptcy. Those people who are unemployed, they don't spend money--obviously consumer spending is the largest driver of US economy--they stop spending money. How does that continue? It is interesting though, if you read the consumer confidence indexes, they've held relatively strong, much more so than I would have thought they would have. But it'll be an interesting economics business school case to be written here. How fast is this--does this look like a L shape recovery, or does this look like a V shape recovery in terms of how fast this goes back?
JONES 33:48
Dr. Payne is from a group that's not totally representative smaller independent practice well, five doc group in the Carolinas, and he echoes the sentiments, saying that they took a dip for a while, are starting to see it come back, and that they also plan to honor all the hires that they made, including a new doctor starting in June. So thanks for contributing that, Dr. Payne. I'd also like to pose a question to the three of you that I got before this webinar was from a fellow, this person is third year, they are joining a large group in a fairly large city, and this person's lawyer advised them not to contact the group that they're joining. This person wants to ask the group Hey, is everything still normal? I'm supposed to start in August, this person said that their lawyer counseled against it. And I'm not sure if there's any reason for that. That to me, that seems like the exact opposite advice I would give. I asked if there was legal concerns. Angie, you've been in business meetings with me and you've said, “Griffin, we get it. You've said that three times,” it's because I--and anyone who's on this call who does business with me knows that I communicate expectations until it annoys the other person. And so I can't ever empathize with mutual mystification and not reaching out. But I told this person before they do so, I'd ask the three of you, is there any reason why they wouldn't reach out to their group to see what's going on?
FARNSWORTH 35:26
No, I’m not a lawyer, but for us for a lot of ways, we would probably assume that it goes on said that we're going to honor any agreement we've entered into so if we haven't communicated with someone--. And you know, a lot of people have a lot of anxiety right now, whether it's related to their professional life or personal life, they're cooped up in their house, their stressed, and so if there's a way in which we can alleviate some of that anxiety by letting them know that no, they had nothing to worry about. I would want them reaching out to us.
ALVERO 35:56
Yeah, I can't think of a situation where candid honesty is not the best solution.
FARNSWORTH 35:59
That’s right.
ALVERO 36:01
Yeah, I think they should talk.
BELTSOS 36:04
And again, it's being part of the team, even before you get there to say--you know, the fear is that you're gonna just poke a bear. But the reality is that the team is already thinking about you, they're already preparing for you to arrive. And they're thinking about strategies to survive. Some of the things that people have said, like Paul was saying on one of the Q&A that people are down to a one or zero income family that used to be a two income family and that's going to have an impact on the short term business. However, be part of the solution. What really brings success is that, not just identification of a problem, which is clear, low value, less is available, but being part of the solution and being committed to the long term health of the practice that you're going to join. And I think those are going to be really important. If you are risk averse, this is a tough time for you. For those that are Lieutenant Dan and Bubba Gump when the hurricane hit, and we are out at the sea, you know, grab ahold and push forward, be innovative, creative, thoughtful. I think being able to offer some of the solutions that can help couples later be successful by programs that may be a small deposit now to secure less costs later on when they can afford it and jobs return. There's lots of ways to bring solutions and you bring a brand new set of eyes and sometimes that fresh angle can be very helpful to the team. And simultaneously, follow your leadership, too. They've been doing this for years and listen to what they know about their practice.
JONES 37:46
We have a question about states with mandates. And do you think it'll be different in regions that are mandated versus those that aren't? And your group is in both mandated and non-mandated states. And Farnsworth’s are in non-mandated and mandated states. What do you think?
ALVERO 38:05
Yeah, I think in terms of mandates, obviously, they make a difference. And there's great data, largely from Massachusetts, but from many of the mandated states that it just there's greater access, greater demand for folks that have the mandate. Having said that, it's not just the mandate, it's also what's negotiated. Increasingly, it's not just those states, but we all know, like Progyny and many similar kinds of covered entities are around the country and it really depends on, sadly, a little bit the socio-demographics of the patient, but it's whatever they have covered. And so, it's not just state-by-state anymore. I think that there's a lot of coverage in states you might not expect, depending on what the individual workplaces negotiate with insurance. So that's going to be a little bit different. In our neighborhood here in Silicon Valley, it's you know it's the Googles, and the Ciscos and everybody else in that neighborhood that really will probably, for us anyway, keep us going to the beginning before, you know, the economy hopefully ramps up and the rest of folks pile in.
BELTSOS 39:11
Yeah, these are great questions. It is very geographical. And I think that will impact a lot of things. And being in a small town where there's a lot of farms compared to downtown Manhattan where people are taking public transportation, COVID is much more of an issue. And again, recovery will depend on states that are mandated versus self pay, and how that will impact volume as well as being able to retain staff.
JONES 39:41
Ruben had the point of there's a lot more coverage even in non-mandated states and still see sometimes half of patients having coverage because--
FARNSWORTH 39:48
We actually have some markets that are non-mandated areas that have just as much insurance coverage as some of our mandated markets.
JONES 39:55
What do you think happens with that, TJ? I mean Progyny’s been on a sales rampage in the last few years, just one big company after another. I don't see that speed happening. I'm not sure if companies will shed those benefits. But like any other benefit, it becomes the requisite for competing for talent. I don't think it is if unemployment is at 10%, or whatever it might go to. Is that going to slow down these large companies offering fertility benefits? And then two, do you think that any might even shed it?
FARNSWORTH 40:29
Yeah, I wouldn’t anticipate a lot of the large employers that have signed on to provide the benefit, shedding the benefits. I do think that you may see some slowing of it. But you know, for some of these companies, they're targeting an employee population that is limited and will remain limited even at a high employment rate market. That said, this goes back to what I said before, how fast the employment market snaps back will dictate a lot of this in mandated and non-mandated markets. I think certainly if there's a prolonged recession, the markets in areas of the country with higher incomes that have more resiliency to the recession will see better outcomes for those clinics. But that's the same for any business. I mean, that's not just unique to ours.
JONES 41:15
Maria Ming brings up a good point--can any of the three of you offer insight on markets with international patients? And we know of certain practices, especially on the West Coast, where more than half of their patients are coming from Asia. Do you have suggestions on how to rebalance that patient flow and in order to retain highly trained employees that may have been there for that purpose, especially if their marketable skill is a particular language?
ALVERO 41:46
You know, we have a fair amount, here at Stanford, of demand from the People's Republic, but we don't necessarily have specific skill set of folks, MAs and so forth, nurses, that speak the language. I mean, I think the access to languages through IT is so easy these days that I think we've had very little trouble communicating. And then in addition to that many of these individuals already speak English. So it's for us, we haven't really found a struggle, nor do we have a highly skilled subset of our workers that are in a skilled language or otherwise.
JONES 42:22
So this is sort of jumping back to the topic we were talking about before, but I think it also goes for those that might have coverage to their company or just being a mandated state. Those that are losing jobs in mandated states, or they're losing a job because they work in Facebook or in Google, not that those companies are cutting back, but are you seeing an increase in those patients seeking treatment before their insurance runs out? We talked a little bit about that with Andy Swan and Dr. Adamson on the last webinar, are any of the three of you seeing that?
BELTSOS 42:53
Absolutely, I have.
ALVERO 42:55
Yeah.
FARNSWORTH 42:56
Yeah, we’ve got a handful of phone calls from patients frustrated about the fact that we're not open because they're either furloughed with the concern they might lose their position. And so they have three months of benefits and one of those benefits obviously being a fertility benefit, or they're just concerned that they're going to lose their job and want to get their process started.
ALVERO 43:12
Yeah, so have we. And we actually, we do take that into account in terms of the queue, you know, as they come through again, as we're lining up the folks that are going to start coming through, because that's important. We want to take care of them as well. And if they're going to lose our benefits in two months, then we want to get them through sooner.
JONES 43:28
Dr. Gordon, you're going to get the last word on this for this question, so I'm okay with veering off topic just a little bit, but I think it's still pretty relevant to staff because of how the workflow is maintained. And the question is, I think that patients will not be happy to go back to the days where we had 25 to 50 patients in the waiting room. I don't think they were happy when there was no Coronavirus! I especially agree with that now. I wonder if the panelists can comment on if we will truly be practicing for a prolonged time in a new way in terms of patient flow in the office.
FARNSWORTH 44:04
I think we can assume that the new normal is the new normal for an extended period of time.
BELTSOS 44:09
Yeah and necessity is the mother of invention and I'll say innovation, and as we re-explore efficiencies, this will be part of how we practice for now. Hopefully, for a long time to become more effective and efficient.
FARNSWORTH 44:25
With telemedicine and everything, yeah, absolutely.
ALVERO 44:27
Yeah, one of the things we've discovered is actually we like telehealth. Maybe we did 10 a month before and now we're doing a couple of hundred and so we actually discovered that it actually is something that's effective and works really well. So I think we're gonna decant the waiting rooms just by having a huge number of telehealth visits, especially in the return visits.
FARNSWORTH 44:47
Yeah, I think patients like it, they found it to be more convenient. The feedback we've had is really good. And I Ruben, I've had the exact same feedback from a lot of our physicians across the country, which is, you could have never talked me into trying this, but now that I'm forced to do it, I really like it!
JONES 45:02
Amen to that! For all the Fertility Bridge clients on here that complained when I forced them to open a Zoom account or to buy a webcam or set it all up for the last couple years is to do business with us. You're welcome. And a particular thank you to Dr. Alvero, to TJ Farnsworth, to Dr. Beltsos, thank you all so much for coming on and addressing this topic with us.
FARNSWORTH 45:28
Thanks.
ALVERO 45:29
Thank you. Take care.
BELTSOS 45:30
Thanks, Griffin. Thanks, Megan. Thanks, everybody.
You've been listening to the Coronavirus Business Response Series on Inside Reproductive Health. If you find our free resources to be valuable, we ask that you share this episode on social media or with a colleague in the fertility field. Subscribe for the latest insights on managing and owning an IVF center or fertility business during the COVID-19 pandemic at FertilityBridge.com or anywhere you listen to podcasts.